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Transient Ischemic Attack

Transient Ischemic Attack. Nicholas J Okon, D.O. Billings, MT. Management of TIA. TIA represents the best opportunity to intervene and prevent stroke. Inconsistent approach to management in the ED throughout US

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Transient Ischemic Attack

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  1. Transient Ischemic Attack • Nicholas J Okon, D.O. • Billings, MT

  2. Management of TIA • TIA represents the best opportunity to intervene and prevent stroke. • Inconsistent approach to management in the ED throughout US • Recent refinement of short term-risk (48hr) allows for application of systematic approach

  3. How is TIA defined? • Classic definition of TIA: • sudden, focal neurologic deficit lasting < 24 hrs. • presumed to be of vascular origin • confined to an area of the brain or eye perfused by a specific artery

  4. Problems with classic definition of TIA • presumes that if symptoms resolve completely then no permanent ischemic damage has occurred suggesting that TIAs are benign • 24 hr criterion is arbitrary and assumes that if symptoms last >24 hrs an injury to brain parenchyma should be detectable by microscopy • numerous studies have shown (since 1958) that the majority of TIAs last < 1 hour

  5. New Definition of TIA The TIA Working Group N Engl J Med 2002;30(11):2502 • “A TIA is a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction”

  6. New Definition of TIA: further clarification The TIA Working Group N Engl J Med 2002;30(11):2502 • “Patients who have transient focal symptoms of brain ischemia -- and who, on diagnostic evaluation, are found to have an acute infarction-- would no longer be classified as having a TIA, regardless of the duration of clinical symptoms.”

  7. Risk of stroke following TIA is dependent on many factors • Symptom type (hemispheric or retinal) • Duration of symptoms • Risk factors/Comorbidities • Underlying cause

  8. Short-term prognosis after ED diagnosis of TIA SC Johnston JAMA 2000;284:2901-2906 • 1707 patients diagnosed with TIA by ED docs • 99% presented in 24 hrs • 50% had symptoms upon arrival to ED • 21% of strokes were fatal: 64% were disabling

  9. 1707 patients identified by ED docs with TIA among 16 hospital in HMO in northern California. SC Johnston JAMA 2000;284:2901-2906

  10. 90 Day Risk of Stroke After TIA Increases with Number of Risk Factors Risk Factors Age > 60 y Diabetes Symptoms > 10 min Weakness Speech Impairment

  11. Evaluation of TIA • Exam, EKG, glucose,lipids, homocysteine • CT head in ER • Carotid Duplex • MRI/MRA • TCD (diabetics, posterior circulation) • Echocardiography • Hypercoaguable labs

  12. Treatment dependent on underlying cause • Carotid stenosis 70-99% -- CEA • Carotid stenosis 50-69% -- CEA or Medical Tx +Neuro Consult • Intracranial stenosis > 50% -- Warfarin or PTA +Neuro Consult • Atrial Fib/Cardioembolic* -- Warfarin • Aortic Athero severe plaque† -- Warfarin • Aortic Athero < severe plaque -- Double antiplatelets • Lacunar stroke -- Double antiplatelets *AWMI/LVEF <35%/Thrombus †4mm thick, ulcer or mobile plaque

  13. Recommended admission • 4 or more risk factors (DM,>60,>10min,weakness,dysarthria) • Those requiring anticoagulation (new A-fib,recent AWMI) • Repeated or crescendo TIAs • Those where compliance with an outpatient evaluation is in question • Presumed Endocarditis

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