Transient Ischemic Attack: Reviewing the Evolution of the Definition, Diagnosis, Risk Stratification, and Management for the Emergency Physician

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Clinical presentation

When approaching patients with symptoms suggestive of a TIA, the physician's first objective is to determine whether the described episode is consistent with TIA or not. Misdiagnosis rates among emergency physicians has been reported to be as high as 60%,23 and discordance among neurologists in the diagnosis of TIA by history is thought to be between 42% and 86%.24, 25 Moreover, one recent study found that agreement in the diagnosis of TIA was low even among stroke-trained neurologists,

History

The diagnosis of TIA is clinical, although the new definition implies that brain imaging is negative for infarction. Although it can be challenging for patients to accurately describe neurologic dysfunction, the history should focus on establishing whether or not patients have the abrupt onset of focal neurologic deficits. A nationwide survey found that only 8% of laypersons were able to correctly define or identify one common symptom of TIA, so asking patients about specific associated

Risk prediction

There have been numerous attempts over the past 20 years to create a validated risk-stratification tool that is easy to apply and provides clinicians with a realistic estimate of stroke risk after TIA. The first seems to be the Stroke Prognosis Instrument published by Kernan and colleagues73 in 1991. This tool was followed by Hankey and colleagues74 in 1992, then the California Score in 2000,16 and the ABCD score in 2005.75 The ABCD2 score published in 2007 represents the combined efforts of

General Considerations

The primary goals in patients with TIA and TSI are to optimize cerebral perfusion to the ischemic tissue and to prevent a subsequent more disabling stroke. Positioning the patient with the head of the bed flat has been shown (by TCD) to increase cerebral perfusion by 20% compared with a 30° incline.100 This simple step should be done routinely unless contraindicated. As in ischemic stroke, it is generally a good idea to maintain euvolemia, and all patients with TIA should have intravenous

Disposition

Determining which patients to admit to the hospital versus observe in an observation unit or discharge with rapid follow-up is a source of uncertainty and frustration for many emergency physicians. Factors likely to contribute to varying admission thresholds include the ease of access to follow-up testing and neurology consultation, inpatient bed availability, patient expectations, and medicolegal concerns.

Some have advocated for admission policies based on the ABCD2 score. In reviewing the

Future directions

If recent history is any indication of future direction, then there will certainly be continued effort in improving stroke-risk prediction after TIA. It is clear that individual stroke risk is best estimated when the TIA cause is known and cerebrovascular disease burden has been assessed with advanced imaging studies. How to best improve risk estimation when imaging resources are limited in the short-term remains to be determined.

Serum biomarkers of cerebral ischemic injury would prove useful

Summary

The evaluation of TIA in the ED is a golden opportunity to prevent a disabling stroke. The greatest risk is in the first 48 hours after the TIA. Clinical risk stratification tools provide a partial estimation of short-term risk and may help differentiate TIAs from nonischemic events. The diagnosis is made based on history, a normal neurologic examination, and neuroimaging with absence of infarction. The 24-hour time window is no longer relevant, and most TIAs last less than 1 hour. Etiologic

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