Title: Transient Ischemic Attack (TIA): The Calm Before the Storm
1Transient Ischemic Attack (TIA) The Calm Before
the Storm
- Raymond Reichwein, M.D.
- Associate Professor of Neurology
- Penn State University College of Medicine
- Milton S. Hershey Medical Center
- January 8, 2009
2Disclosures
- Boehringer Ingelheim
- Genentech
- AGA Medical Corp
3OBJECTIVES
- Discuss the importance of TIA and future stroke
risk. - Discuss optimal TIA evaluation and management.
- Briefly discuss future stroke prevention, from
both an antiplatelet/anticoagulant therapy and
risk factor management standpoint.
4Stroke in the US
- 730,000 new or recurrent strokes each year1
- 167,366 deaths in 1999 (1 of every 14.3 deaths)2
- 4,600,000 stroke survivors alive today2
- Origin of strokes3
- 80 ischemic
- 20 hemorrhagic
1. Broderick J et al. Stroke. 199829415-421.2.
American Heart Association. 2002 Heart and Stroke
Statistical Update. 2001. 3. Pulsinelli WA.
Cerebrovascular diseases. Cecil Textbook of
Medicine. 1996.
5TIA
- Underrecognized
- Underreported
- Undertreated
6TIA Knowledge
- Among 10,112 participants
- 8.2 correctly related the definition of TIA
- 8.6 could identify a typical symptom
- Men, non-whites, and those with lower income and
fewer years of education were less likely to be
knowledgeable about TIA. - Johnston, et al, Neurology 2003
7TIA Definition
- Resolution of acute neurological/stroke deficits
within 24 hours. - No imagable acute ischemic stroke changes.
8TIAs
- The majority of TIAs resolve within 60 minutes,
and most resolve within 30 minutes. - Less than 15 chance of complete resolution of
symptoms if last gt1 hour (Levy). - NINDS IV t-PA trial data revealed only 2 chance
of complete symptom resolution _at_ 24 hours, for
neurological symptoms/deficits that didnt
completely resolve within 1 hour or rapidly
improve within 3 hours.
9(No Transcript)
10(No Transcript)
11TIA Epidemiology
- gt200,000 events per year (compared to gt730,000
strokes per year). - Approximately 10-20 of patients will experience
a stroke after a TIA within the first 90 days,
and in approx. 50 of these patients, the stroke
occurs in the first 24-48 hours. - Factors associated with increased stroke risk
advanced age, diabetes mellitus, symptoms more
than 10 minutes, weakness, and impaired speech.
Large artery atherothrombotic disease more likely
to present with a TIA before a stroke, versus
other etiologies.
12TIA Epidemiology
- Several recent studies reveal a gt10 stroke risk
in the 90 days after a TIA. - The risk of stroke within the first 48 hours
after TIA is approximately 5 (greater than MI
risk after presenting with acute chest pain
syndrome). - Blacks and men had higher stroke risk.
13Event Risk Within 3 MonthsAfter TIA
12.7
10.5
Event Rate
2.6
2.6
Cardiac Event
Recurrent TIA
Stroke
Death
Johnston SC, et al. JAMA. 200028429012906.
14TIA before Stroke by Subtype
- Large-artery atherothrombotic disease 25-50.
- Cardioembolic sources 10-30.
- Small vessel/lacunar disease 10-15.
15Symptomatic Internal Carotid Artery Disease
- NASCET Medical Arm Data (600 patients)
- Two-day risk was 5.5.
- 90-day ipsilateral stroke risk was 20.
- Degree of stenosis (gt70 stenosis) didnt confer
increased stroke risk. - Infarct on brain imaging and presence of
intracranial major-artery disease doubled the
early stroke risk. - Benefit from CEA declines rapidly over several
weeks, particularly in women (Oxford data).
16Cumulative Risk of Stroke
Post-TIA ()
Post-Stroke ()
3 10 5 14 25 40
4 8 12 13 24 29
30 days 1 year 5 years
Sacco. Neurology. 199749(suppl 4)S39. Feinberg
et al. Stroke. 1994251320.
17TIA and ischemic stroke pathophysiology are the
same.The only difference is transient versus
persistent neurological deficits. Certainly,
a TIA state is a much better clinical state to
intervene and prevent a future disabling stroke.
18Risk Factors for First Ischemic Stroke
Modifiable (value established)
Nonmodifiable
- Hypertension
- Atrial fibrillation
- Cigarette smoking
- Hypercholesterolemia
- Heavy alcohol use
- Asymptomatic carotid stenosis
- Transient ischemic attack
- Age
- Gender
- Race/Ethnic
- Heredity
Adapted from Sacco RL. Neurology 199851(suppl
3)S27-S30.
19Stroke in Young Individuals
- Clotting disorders
- Migraine
- Birth control pills
- Illicit drug use
- Arterial dissection
- Patent foramen ovale
- Autoimmune disorders (lupus)
20TIA Evaluation
- Prompt evaluation and intervention is the key.
- Most TIA patients should be admitted for
diagnostic evaluation and management (Observation
unit or equivalent) often significant delay if
done as outpatient. - TIA and ischemic stroke diagnostic evaluations
should be the same.
21Who should be admitted??
- Anyone with no prior/recent TIA/stroke diagnostic
workup new suspected etiology despite prior
workup. - Suspected large vessel (anterior or posterior
circulation) events. - Most suspected lacunar/small vessel events,
particularly if no prior workup (? calm before
the storm). - Recurrent/crescendo TIAs.
22ABCD2 Score
- Age 60 or older 1 point
- Blood pressure gt140/90 1 point
- Clinical
- - Unilateral weakness 2 points
- - Speech impairment 1 point
- Duration
- - 60 minutes or more 2 points
- - Less than 60 minutes 1 point
- Diabetes 1 point
23 24ABCD2 Score
- Score 4 or greater admit to hospital
(moderate-high stroke risk). - Score predicted risk similarly among all ethnic
backgrounds. - Best predictor of 2, 7, and 90 day stroke risk
among validated scales.
25Inpatient TIA Management
- Neurochecks follow blood pressures.
- ? Cardiac telemetry (paroxysmal a. fib).
- ? Intravenous Heparin for suspected high risk TIA
sources, pending completion of diagnostic
evaluation. - Diagnostic evaluation should be completed within
24 hours make decision regarding admission or
discharge at that point. - Potential IV t-PA use for recurrent event (acute
ischemic stroke) while hospitalized.
26Presumptive TIA/stroke etiology determines
optimal treatment, as well as risk for recurrent
events.
27Stroke Subtypes and Incidence
Hemorrhagic stroke15
Other5
Cryptogenic30
Atherosclerotic cerebrovascular disease 20
Small vessel disease lacunes 25
Cardiogenicembolism20
Ischaemic stroke85
Albers et al. Chest 2004 126 (3 Suppl)
438S512S.
28TIA BRAIN IMAGING
- Prior CT(brain) studies revealed a 15-20
incidence of cerebral infarction in a vascular
territory related to the patients
symptoms/deficits. - Newer MRI(brain) studies, using
diffusion-weighted imaging (DWI), reveal approx.
30-50 acute ischemic stroke findings, and about
half of these persisted on follow-up imaging.
Best correlated with prolonged TIA symptoms.
29MRI Diffusion Imaging
- Distinguish new versus old ischemic areas.
- Distinguish new ischemic areas even with clinical
TIA. - Differentiate stroke etiology (small vessel vs.
large vessel embolic sources).
30Acute Embolic Strokes
31Acute Ischemic Stroke