Transient Ischemic Attacks
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Transient Ischemic Attacks Rodney W. Smith, MD Clinical Assistant Professor Department of Emergency Medicine University of Michigan Ann Arbor, MI. 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

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Example case

Transient Ischemic Attacks Rodney W. Smith, MDClinical Assistant ProfessorDepartment of Emergency MedicineUniversity of MichiganAnn Arbor, MI


Example case

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


Example case1

Example Case

  • PMHx: Hypertension

    • Takes enalapril

  • ROS:

    • No headache

    • No other neurologic symptoms

  • Social Hx:

    • Smokes 1 ppd


Example case2

Example Case

  • Physical Exam

    • Overweight, in NAD

    • 160/90, 80, 14, 37.5C

    • Right carotid bruit

    • Heart with regular rate and rhythm; No murmur


Example case3

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.


Summary

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


Risk factors epidemiology

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


Risk factors epidemiology1

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


Ed presentation

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


Ed presentation1

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


Ed presentation2

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


Ed presentation3

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


Ed presentation4

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)


Tia symptoms related to cerebral circulation

TIA Symptoms Relatedto Cerebral Circulation


Ed presentation5

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”


Ed presentation6

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


Ed presentation differential diagnosis

ED PresentationDifferential Diagnosis

  • Migraine with aura

    • Positive symptoms

    • Spread over minutes

    • Visual disturbances

    • Somatosensory or motor disturbance

    • Headache within 1 hour


Ed presentation differential diagnosis1

ED PresentationDifferential 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


Ed presentation differential diagnosis2

ED PresentationDifferential Diagnosis


Ed presentation differential diagnosis3

ED PresentationDifferential Diagnosis

  • Partial (focal) seizure

    • Positive sensory or motor symptoms

    • Spread quickly (60 seconds)

    • Negative symptoms afterward (Todd’s paresis)

    • Multiple attacks


Ed presentation differential diagnosis4

ED PresentationDifferential 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


Ed presentation differential diagnosis5

ED PresentationDifferential 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


Ed presentation differential diagnosis6

ED PresentationDifferential Diagnosis

  • Structural intracranial lesion

    • Tumor

      • Partial seizures

      • Vascular steal

      • Hemorrhage

      • Vessel compression by tumor


Ed presentation differential diagnosis7

ED PresentationDifferential Diagnosis

  • Intracranial hemorrhage

    • ICH rare to confuse with TIA

    • Subdural hematoma

      • Headache

      • Fluctuation of symptoms

      • Mental status changes


Ed presentation differential diagnosis8

ED PresentationDifferential Diagnosis

  • Multiple sclerosis

    • Usually subacute but can be acute

      • Optic neuritis

      • Limb ataxia

    • Age and risk factors

    • Signs more pronounced than symptoms


Ed presentation differential diagnosis9

ED PresentationDifferential Diagnosis

  • Labyrinthine disorders

    • Central vs. Peripheral vertigo

    • Ménière's disease

    • Benign positional vertigo

    • Acute vestibular neuronitis


Ed presentation differential diagnosis10

ED PresentationDifferential Diagnosis

  • Metabolic

    • Hypoglycemia

    • Hyponatremia

    • Hypercalcemia

  • Peripheral nerve lesions

    • Entrapments

    • Painful quality


Ed presentation differential diagnosis11

ED PresentationDifferential Diagnosis


Ed presentation differential diagnosis12

ED PresentationDifferential 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


Ed diagnosis and evaluation

ED Diagnosis and Evaluation

  • History

    • Characteristics of the attack

    • Associated symptoms

    • Risk factors

      • Vascular Disease

      • Cardiac Disease

      • Hematologic Disorders

      • Smoking

    • Prior TIA


Ed diagnosis and evaluation1

ED Diagnosis and Evaluation

  • Physical Examination

    • Neurologic Exam

    • Carotid Bruits

    • Cardiac Exam

    • Peripheral Pulses


Ed diagnosis and evaluation2

ED Diagnosis and Evaluation

  • EKG

  • CBC, Coags, and Chemistries

  • Chest Xray

  • Head CT without contrast

  • Expedite if early presentation


Ed diagnosis and evaluation3

ED Diagnosis and Evaluation

  • Symptom vs. Disease

    • Significant carotid artery stenosis

    • Cardiac embolism

  • Admission vs. Discharge

    • Traditional approach

    • Trend toward outpatient evaluation


Ed diagnosis and evaluation4

ED Diagnosis and Evaluation

  • Stroke Rate After TIA

    • Percent (95% CI)


Ed diagnosis and evaluation5

ED Diagnosis and Evaluation

  • Stroke Rate After TIA

  • Johnston, et al. JAMA 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


Management

Management

  • Goal: Prevention of Stroke

  • Expedited Evaluation

    • Carotid Artery Disease

    • Cardioembolism

    • Inpatient vs. Observation Unit vs. Outpatient

  • Antiplatelet Therapy

  • Risk Factor Modulation


Management ed disposition

ManagementED Disposition

  • Discharge

    • Further testing will not change treatment

    • Prior workup

    • Not a candidate for CEA or anticoagulation


Management ed disposition1

ManagementED Disposition

  • Admission

    • Clear indication for anticoagulation

    • Severe deficit

    • Crescendo symptoms

    • Other indication for admission

  • Admission or observation unit evaluation

    • All others


Management diagnosis of carotid stenosis

ManagementDiagnosis of Carotid Stenosis


Management diagnosis of carotid stenosis1

ManagementDiagnosis of Carotid Stenosis

  • Carotid Duplex Ultrasound

    • Sensitivity of 94 - 100% for > 50% stenosis

    • May overdiagnose occlusion

    • Non-invasive


Management diagnosis of carotid stenosis2

ManagementDiagnosis 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


Management diagnosis of carotid stenosis3

ManagementDiagnosis 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


Management cardiogenic embolism

ManagementCardiogenic 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


Management cardiogenic embolism1

ManagementCardiogenic 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


Management echocardiogram

ManagementEchocardiogram

  • Yield < 3% in undifferentiated patients

  • Higher with risk factors

  • TEE preferred

  • Specific treatment of many abnormalities unknown


Management echocardiogram1

ManagementEchocardiogram

  • Indications

    • Age < 50

    • Multiple TIAs in more than one arterial distribution

    • Clinical, ECG, or CXR evidence suggests cardiac embolization


Management tia with atrial fibrillation

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


Management antiplatelet therapy

ManagementAntiplatelet 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.


Management1

Management

  • Ticlopidine

    • Small absolute risk reduction compared with ASA

    • Side effects preclude use in up to 5%

    • Serious adverse effects

      • Neurtropenia

      • Thrombotic thrombocytopenic purpura


Management2

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


Management3

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


Management4

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


Expected outcome

Expected Outcome

  • 70% stenosis or greater

  • Best medical therapy vs. CEA


Expected outcome1

Expected Outcome

  • 50 - 69% stenosis

  • Best medical therapy vs. CEA


Expected outcome tia with atrial fibrillation

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


Future directions

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


Outcome of case

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


Summary1

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


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