Transient Ischemic Attacks

Rodney W. Smith, MD


Clinical Assistant Professor
Department of Emergency Medicine
University of Michigan
Ann Arbor, MI
Rodney Smith, MD
Example Case
A 55 year old male presents to the
emergency department with acute
onset of
Left arm weakness: Unable to lift left
arm off of lap
Symptoms improved on the way to the
hospital
Rodney Smith, MD
Example Case
PMHx: Hypertension
Takes enalapril
ROS:
No headache
No other neurologic symptoms
Social Hx:
Smokes 1 ppd
Rodney Smith, MD
Example Case
Physical Exam
Overweight, in NAD
160/90, 80, 14, 37.5C
Right carotid bruit
Heart with regular rate and rhythm; No
murmur
Rodney Smith, MD
Example Case
Neuro exam
Oriented to person, place, and time
Fluent speech
CN II-XII intact
Motor 4/5 strength in left upper extremity
Sensory subjective decrease in pinprick in left
upper extremity compared to the right
DTR +2 except at left biceps +3
Gait steady
Cerebellar intact finger to finger and finger to nose
No extensor plantar response.
Rodney Smith, MD
Summary
Importance of distinguishing TIA from other
causes of transient spells
Essential elements include a careful history,
physical exam, and CT scan
ED treatment and disposition are directed
toward prevention of subsequent stroke
Incidence of early stroke after TIA justifies
hospital admission for further evaluation
Rodney Smith, MD
Risk Factors/Epidemiology
300,000 TIAs per year in US
5-year stroke risk after TIA 29%
43.5% in 2 years with >70% carotid stenosis
treated medically
Many stroke patients have had TIA
25% - 50% in large artery atherothrombotic
strokes
11% - 30% in cardioembolic strokes
11% to 14% in lacunar strokes
Rodney Smith, MD
Risk Factors/Epidemiology
Risk factors are the same as stroke
Increasing age
Sex
Family history / Race
Prior stroke / TIA
Hypertension
Diabetes
Heart disease
Carotid artery / Peripheral artery disease
Obesity
High cholesterol
Physical inactivity
Rodney Smith, MD
ED Presentation
What is a TIA?
Acute loss of focal cerebral function
Symptoms last less than 24 hours
Due to inadequate blood supply
Thrombosis
Embolism
Rodney Smith, MD
ED Presentation
Acute loss of focal cerebral function
Motor symptoms
Weakness or clumsiness on one side
Difficulty swallowing
Speech disturbances
Understanding or expressing spoken
language
Reading or writing
Slurred speech
Calculations
Rodney Smith, MD
ED Presentation
Acute loss of focal cerebral function
Sensory symptoms
Altered feeling on one side
Loss of vision on one side
Loss of vision in left or right visual field
Bilateral blindness
Double vision
Vertigo
Rodney Smith, MD
ED Presentation
Non-focal Symptoms (Not TIA)
Generalized weakness or numbness
Faintness or syncope
Incontinence
Isolated symptoms (symptoms occurring
alone)
Vertigo or loss of balance
Slurred speech or difficulty swallowing
Double vision
Rodney Smith, MD
ED Presentation
Non-focal Symptoms (Not TIA)
Confusion
Disorientation
Impaired attention/concentration
Diminution of all mental activity
Distinguish from
Isolated language or visual-spatial perception
problems (may be TIA)
Isolated memory problems (transient global
amnesia)
Rodney Smith, MD
TIA Symptoms Related
to Cerebral Circulation
Symptom Anterior Either Posterior
Dysphasia
Unilateral weakness Usually
Unilateral sensory disturbance Usually
Dysarthria Plus other
Homonymous hemianopia
Unsteadiness/ataxia Plus other
Dysphagia Plus other
Diplopia Plus other
Vertigo Plus other
Bilateral simultaneous visual loss
Bilateral simultaneous weakness
Bilateral simultaneous sensory disturbance
Crossed sensory/motor loss
Circulation Involved
Rodney Smith, MD
ED Presentation
Acute loss of focal cerebral function
Abrupt onset
Symptoms occur in all affected areas
at the same time
Symptoms resolve gradually
Symptoms are negative
Rodney Smith, MD
ED Presentation
Symptoms last less than 24 hours
Most last less than one hour
Less than 10 percent > 6 hours
Amaurosis fugax up to five minutes
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Migraine with aura
Positive symptoms
Spread over minutes
Visual disturbances
Somatosensory or motor disturbance
Headache within 1 hour
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Aura without Headache
98% Visual symptoms
30% with other symptoms
26% sensory
16% aphasia
6% dysarthria
10% weakness
Mean age 48.7 (vs. 62.1)
Fewer cardiovascular risk factors
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Duration of symptoms
0%
20%
40%
60%
80%
15 15 to 60 > 60
Time in minutes
Time to maximum
symptoms
0%
10%
20%
30%
40%
50%
< 1 1 to 5 6 to 30 >30
Time in minutes
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Partial (focal) seizure
Positive sensory or motor symptoms
Spread quickly (60 seconds)
Negative symptoms afterward (Todds
paresis)
Multiple attacks
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Transient global amnesia
Sudden disorder of memory
Antegrade and often retrograde
Recurrence 3% per year
Etiology unclear
Migraine
Epilepsy (7% within 1 year)
Unknown
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Transient global amnesia
No difference in vascular risk factors
compared with general population
Fewer risk factors when compared
with TIA patients
Prognosis significantly better than TIA
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Structural intracranial lesion
Tumor
Partial seizures
Vascular steal
Hemorrhage
Vessel compression by tumor
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Intracranial hemorrhage
ICH rare to confuse with TIA
Subdural hematoma
Headache
Fluctuation of symptoms
Mental status changes
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Multiple sclerosis
Usually subacute but can be acute
Optic neuritis
Limb ataxia
Age and risk factors
Signs more pronounced than
symptoms
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Labyrinthine disorders
Central vs. Peripheral vertigo
Mnire's disease
Benign positional vertigo
Acute vestibular neuronitis
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Metabolic
Hypoglycemia
Hyponatremia
Hypercalcemia
Peripheral nerve lesions
Entrapments
Painful quality
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Oxfordshire Community Stroke Project
52 (10%) Migraine 33 (6%) Vertigo
48 (9%) Syncope 29 (6%) Epilepsy
46 (9%) Poss. TIA 17 (3%) TGA
45 (9%) Funny turn 47 (9%) Other
317 Others 195 (38%) with TIA
512 Patients referred
for suspected TIA
Rodney Smith, MD
ED Presentation
Differential Diagnosis
Patient evaluation by senior
neurologists with interest in stroke
Agreement on 48 of 56 patients (85.7%)
36 with TIA
12 Not TIA
8 of 56 disagreement
4 of these, both listed firm diagnosis
Rodney Smith, MD
ED Diagnosis and Evaluation
History
Characteristics of the attack
Associated symptoms
Risk factors
Vascular Disease
Cardiac Disease
Hematologic Disorders
Smoking
Prior TIA
Rodney Smith, MD
ED Diagnosis and Evaluation
Physical Examination
Neurologic Exam
Carotid Bruits
Cardiac Exam
Peripheral Pulses
Rodney Smith, MD
ED Diagnosis and Evaluation
EKG
CBC, Coags, and Chemistries
Chest Xray
Head CT without contrast
Expedite if early presentation
Rodney Smith, MD
ED Diagnosis and Evaluation
Symptom vs. Disease
Significant carotid artery stenosis
Cardiac embolism
Admission vs. Discharge
Traditional approach
Trend toward outpatient evaluation
Rodney Smith, MD
ED Diagnosis and Evaluation
Stroke Rate After TIA
Percent (95% CI)
O x f o r d sh i r e R o c h e st e r
1 m o n t h 4 . 4 ( 1 . 5 - 7 . 3 ) 8 ( 4 . 2 - 1 1 . 8 )
6 m o n t h s 8 . 8 ( 4 . 7 - 1 2 . 9 ) 1 0 ( 6 . 7 - 1 4 . 3 )
1 2 m o n t h s 1 1 . 6 ( 6 . 9 - 1 6 . 3 ) 1 3 ( 8 . 1 - 1 7 . 9 )
5 y e a r s 2 9 . 3 ( 2 1 . 3 - 3 7 . 3 ) 2 9 ( 2 2 . 0 - 3 6 . 0 )
Rodney Smith, MD
ED Diagnosis and Evaluation
Stroke Rate After TIA
Johnston, et al. J AMA 284:2901,
2000.
Follow-up of 1707 ED patients
diagnosed with TIA
Stroke rate at 90 days was 10.5%
Half of these occurred in the first 48
hours after ED presentation
Rodney Smith, MD
Management
Goal: Prevention of Stroke
Expedited Evaluation
Carotid Artery Disease
Cardioembolism
Inpatient vs. Observation Unit vs. Outpatient
Antiplatelet Therapy
Risk Factor Modulation
Rodney Smith, MD
Management
ED Disposition
Discharge
Further testing will not change
treatment
Prior workup
Not a candidate for CEA or
anticoagulation
Rodney Smith, MD
Management
ED Disposition
Admission
Clear indication for anticoagulation
Severe deficit
Crescendo symptoms
Other indication for admission
Admission or observation unit
evaluation
All others
Rodney Smith, MD
Management
Diagnosis of Carotid Stenosis
Carotid bruit related to stenosis
0%
10%
20%
30%
40%
Normal 1 - 24 25 - 49 50 - 74 75 - 99 Occluded
Percent stenosis of symptomatic ICA
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No Bruit Bruit
Rodney Smith, MD
Management
Diagnosis of Carotid Stenosis
Carotid Duplex Ultrasound
Sensitivity of 94 - 100% for > 50% stenosis
May overdiagnose occlusion
Non-invasive
Rodney Smith, MD
Management
Diagnosis of Carotid Stenosis
Magnetic Resonance Angiography
Similar sensitivity to carotid
ultrasound
Overestimates degree of stenosis
Gives information about
vertebrobasilar system
Accuracy of 62% in detecting
intracranial pathology
Cost and claustrophobia
Rodney Smith, MD
Management
Diagnosis of Carotid Stenosis
Cerebral Angiography
Gold standard for diagnosis
Invasive, with risk of stroke of up to 1%
For patients with positive ultrasound
For patients with occlusion on ultrasound
First test if intracranial pathology
suspected
Rodney Smith, MD
Management
Cardiogenic Embolism
Major risk factors: Anticoagulation Indicated
Atrial fibrillation
Mitral stenosis
Prosthetic cardiac valve
Recent MI
Thrombus in LV or LA appendage
Atrial myxoma
Infective endocarditis (No anticoagulation)
Dilated cardiomyopathy
Rodney Smith, MD
Management
Cardiogenic Embolism
Minor risk factors: Best treatment unclear
Mitral valve prolapse
Mitral annular calcification
Patent foramen ovale
Atrial septal aneurysm
Calcific aortic stenosis
LV regional wall motion abnormality
Aortic arch atheromatous plaques
Spontaneous echocardiographic contrast
Rodney Smith, MD
Management
Echocardiogram
Yield < 3% in undifferentiated patients
Higher with risk factors
TEE preferred
Specific treatment of many
abnormalities unknown
Rodney Smith, MD
Management
Echocardiogram
Indications
Age < 50
Multiple TIAs in more than one arterial
distribution
Clinical, ECG, or CXR evidence suggests
cardiac embolization
Rodney Smith, MD
Management
TIA with Atrial Fibrillation
INR 2.5 (Range 2 to 3)
Aspirin if Warfarin contraindicated
Timing of onset of AC not proven in RCT
AC in other causes of cardioembolic
stroke not proven in RCT
EAFT Study Group, Lancet, 1993
Rodney Smith, MD
Management
Antiplatelet Therapy
Aspirin
Compared with placebo in patients with
minor stroke/TIA
Relative risk of composite endpoint reduced
by 13% to 17%
Dose of aspirin probably not important
Lower dose gives lower incidence of GI
side effects.
Rodney Smith, MD
Management
Ticlopidine
Small absolute risk reduction
compared with ASA
Side effects preclude use in up to 5%
Serious adverse effects
Neurtropenia
Thrombotic thrombocytopenic purpura
Rodney Smith, MD
Management
Clopidogrel
Similar to Ticlopidine in reducing
composite endpoint
Reduction in risk of stroke alone less
than with Ticlopidine
Similar side effect profile to ASA
Rodney Smith, MD
Management
Dipyridamole plus ASA
Small absolute risk reduction for
stroke compared with ASA alone
Risk reduction for composite endpoint
due to stroke reduction alone
Safe side effect profile
Rodney Smith, MD
Management
Discharged patients should receive ASA
50 - 325 mg/day
Based on cost and small absolute benefit of
other agents
Patients with TIA on ASA should have
change in agent
Dipyridamole plus ASA
Clopidogrel
Increase dose of ASA to 1300 mg/day
Rodney Smith, MD
Expected Outcome
70% stenosis or greater
Best medical therapy vs. CEA
Medical Surgical
Ipsilateral stroke 26.0% 9.0%
Major or fatal ipsilateral stroke 13.1% 2.5%
Stroke or death 32.3% 15.8%
Rodney Smith, MD
Expected Outcome
50 - 69% stenosis
Best medical therapy vs. CEA
M e d i c a l S ur g i c a l
I p s i l a te r a l s tr ok e 2 2 . 2 % 1 5 . 7 %
S tr ok e or d e a th 4 3 . 3 % 3 3 . 2 %
Rodney Smith, MD
Expected Outcome
TIA with Atrial Fibrillation
Rate of stroke
Placebo - 12% per year
Aspirin - 10% per year
Warfarin - 4% per year
Major bleed in 2.8% per year
No increase in ICH occurrence
EAFT Study Group, Lancet, 1993
Rodney Smith, MD
Future directions
Treatment of PFO in patients with TIA
ASA; Warfarin; Surgery
Ongoing trials of Warfarin vs. ASA
for secondary stroke prevention
Ongoing trials of carotid artery
angioplasty and stents
Rodney Smith, MD
Outcome of Case
Patient was evaluated in an Observation Center
Carotid ultrasound demonstrated 80% stenosis of R
ICA
Underwent R CEA, without complication
Patient discharged with plan for risk modification
Diet for weight reduction
Smoking cessation program
Optimized antihypertensive regimen
Rodney Smith, MD
Summary
Importance of distinguishing TIA from
other causes of transient spells
Essential elements include a careful
history, physical exam, and CT scan
ED treatment and dispostition are
directed toward prevention of
subsequent stroke
Incidence of early stroke after TIA
justifies hospital admission for further
evaluation