Transient Ischemic Attack

Diagnosis:

  • Sudden neurological focal deficit of vascular origin lasting <24 hrs (usually lasts <1 hr), with normal diffusion weighted MRI (DWI).
  • PWI: may show decreased perfusion.
Investigations to Consider:

Blood tests:

  • FBC, Coagulation screen, Blood Glucose, Blood chemistry panel,
  • Fasting: Cholesterol, Lipids, glucose
  • ESR: vasculitides, giant cell arteritis.
  • Consider Homocystein, vasculitic screen, thrombophilia screen

Extracranial vascular evaluation:

  • CTA, MRA
  • Or carotid ultrasound if carotid territory (too  low sensitivity in posterior ciruclation TIA)

Intracranial vascular evaluation:

  • CTA, MRA: good screening tests, particularly CTA
  • Cathetera angiography: confirmatory test for intracranial stenosis

Cardiac evaluation:

  • ECG: Exclude AF
  • Transthoracic echocardiogram
  • Transoesophageal Echocardiogram TOE, especially if other tests don’t reveal the mechanism.
  • Consider implantable cardiac monitor or prolonged external monitor (>or=60 days) if clinically definite TIA

Consider:

  • DWI MRI: high signal indicates high risk of stroke

Treatment:

  • Emergent or urgent evaluation & treatment. [EXPRESS]
  • If admitting to the hospital, admit the patient to the stroke unit

Antiplatelets: Choose one

  • Aspirin +/-dipyridamole
  • Clopidogre
  • Cilostazol
  • Don’t use aspirin +clopidogrel, use single antiplatelt agent investigations confirm intracranial atherosclerotic disease with stenosis

Anticoagulation: if cardioembolic stroke (see cardioembolic stroke)
Manage risk factors for stoke & atheroma:

  • Hypertension control
  • Statin
  • Others: smoking, diabetes mellitus, diet, exercise

Revascularization if meets crteria for extracranial symptomatic carotid stenosis: by carotid artery stenting or carotid endarterectomy

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