algorithm 6) and be treated with all available risk reduction strategies ( table 1). Effective strategies include treatment of hypertension, low density lipoprotein-cholesterol (LDL-C) lowering with high-intensity statin therapy, and lifestyle modification, including smoking cessation, exercise, low-salt and Mediterranean diet, weight control, and no or limited alcohol consumption. These interventions are discussed in greater detail separately. (See "Overview of secondary prevention of ischemic stroke".) Large artery disease Options for the secondary prevention of TIA or ischemic stroke caused by large artery disease include revascularization (mainly for symptomatic cervical internal carotid artery stenosis) and intensive medical therapy (ie, antiplatelet, antihypertensive, and LDL-C lowering therapy) for multifactorial risk reduction. (See "Overview of secondary prevention for specific causes of ischemic stroke and transient ischemic attack", section on 'Large artery disease'.) https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 12/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate Selected patients with recently symptomatic cervical internal carotid artery stenosis of 50 to 99 percent who have a life expectancy of at least five years are generally treated with revascularization via carotid endarterectomy or carotid artery stenting. A pooled analysis of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) found that early carotid endarterectomy (within two weeks of a nondisabling stroke or TIA) significantly improved outcome compared with later surgery [45]. Thus, early identification of symptomatic carotid disease is critical. (See "Management of symptomatic carotid atherosclerotic disease", section on 'Timing of revascularization'.) Patients with TIA or ischemic stroke having carotid endarterectomy are usually treated with aspirin monotherapy at a dose of 81 to 325 mg/day started before surgery, so clopidogrel should be stopped at the discretion of the surgeon if it was started as part of dual antiplatelet therapy (DAPT) prior to determination of carotid stenosis as the stroke mechanism. Patients having carotid artery stenting are treated with dual antiplatelet therapy prior to and continuing for 30 days after stenting. (See "Management of symptomatic carotid atherosclerotic disease" and "Carotid endarterectomy", section on 'Antiplatelet therapy' and "Overview of carotid artery stenting", section on 'Dual antiplatelet therapy'.) Symptomatic intracranial large artery atherosclerosis is associated with a high risk of recurrent stroke, but randomized controlled trials have found that endovascular treatment with stenting leads to harm. Recommended treatment includes short-term (eg, 90 days) use of DAPT with 2 aspirin and clopidogrel, regardless of ABCD score, followed by long-term single-agent antiplatelet therapy, and intensive risk factor management. (See "Intracranial large artery atherosclerosis: Treatment and prognosis".) Small vessel disease For patients with TIA or stroke caused by small vessel disease, medical management (see 'Intensive medical management' above) (ie, antiplatelet, antihypertensive, glucose control, and LDL-C lowering therapy) is the mainstay for secondary stroke prevention. 2 Patients with low-risk TIA (ABCD score <4) attributed to small vessel disease should continue on 2 long-term single-agent antiplatelet therapy, while patients with high-risk TIA (ABCD score 4) or minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] 5) should continue DAPT for 21 days, followed by long-term single-agent antiplatelet therapy. (See "Overview of secondary prevention for specific causes of ischemic stroke and transient ischemic attack", section on 'Small artery disease' and "Long-term antithrombotic therapy for the secondary prevention of ischemic stroke".) Atrial fibrillation For most patients with atrial fibrillation and a recent ischemic stroke or TIA, we recommend oral anticoagulation with warfarin or a direct oral anticoagulant (DOAC); once https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 13/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate anticoagulation is started, antiplatelet treatment should be stopped. (See "Atrial fibrillation in adults: Use of oral anticoagulants".) DAPT may offer an alternative to therapy with aspirin alone in high-risk patients with atrial fibrillation who cannot be treated with warfarin or a DOAC due to a strong patient preference, following careful consideration of the advantages of oral anticoagulation. However, DAPT is thought to have similar bleeding risk as oral anticoagulation. Although high-quality evidence is lacking, patients with an unacceptably high long-term bleeding risk may be treated with left atrial appendage occlusion if short-term anticoagulation around the time of the procedure can be tolerated. These issues are discussed in separately. (See "Atrial fibrillation in adults: Use of oral anticoagulants" and "Atrial fibrillation: Left atrial appendage occlusion".) Cryptogenic stroke Most patients with a cryptogenic TIA or ischemic stroke should be treated with antiplatelet therapy as described above (see 'Immediate antiplatelet treatment' above) and intensive risk factor management with blood pressure control, LDL-C lowering 2 therapy, and lifestyle modification. Patients with cryptogenic low-risk TIA (ABCD score <4) should continue on long-term single-agent antiplatelet therapy, while patients with cryptogenic 2 high-risk TIA (ABCD score 4) or minor ischemic stroke (NIHSS 5) should continue DAPT for 21 days, followed by long-term single-agent antiplatelet therapy. However, the optimal antithrombotic therapy of patients with cryptogenic stroke who have patent foramen ovale, atrial septal aneurysm, atheromatous aortic disease, or coagulation disorders is uncertain. (See "Cryptogenic stroke and embolic stroke of undetermined source (ESUS)", section on 'Secondary prevention'.) SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stroke in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 14/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topics (see "Patient education: Stroke (The Basics)" and "Patient education: Transient ischemic attack (The Basics)") Beyond the Basics topics (see "Patient education: Stroke symptoms and diagnosis (Beyond the Basics)" and "Patient education: Transient ischemic attack (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS TIA and minor, nondisabling ischemic stroke represent a neurologic emergency Patients with a time-based TIA (ie, symptoms lasting less than 24 hours) or minor, nondisabling ischemic stroke are at increased risk of recurrent and potentially disabling ischemic stroke, especially in the days following the index event. Accumulating evidence suggests that immediate intervention after a TIA or minor, nondisabling ischemic stroke can reduce the risk of recurrent stroke compared with delayed intervention. For patients who present with TIA or minor ischemic stroke, implementation of appropriate diagnostic evaluation and stroke prevention treatment should proceed without delay, preferably within one day of the ischemic event. (See 'Importance of early evaluation and treatment' above.) Immediate antiplatelet treatment For most patients with TIA who do not have a known cardioembolic source at presentation, we start antiplatelet therapy immediately while evaluating the ischemic mechanism ( table 1). We start aspirin alone for low-risk TIA, 2 2 defined by an ABCD score <4 (calculator 1). For high-risk TIA, defined by an ABCD score of 4, we start dual antiplatelet therapy (DAPT) using aspirin plus clopidogrel (or aspirin plus ticagrelor) for the first 21 days. Doses are listed above. Exceptions are patients who are on oral anticoagulation or have a clear new indication for anticoagulation. (See 'Immediate antiplatelet treatment' above.) Urgent investigations Urgent evaluation of suspected TIA and minor, nondisabling ischemic stroke is necessary for confirming the diagnosis of TIA or ischemic stroke, excluding stroke mimics, and determining the ischemic mechanism, which has important implications for directing targeted treatment for secondary stroke prevention. The https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 15/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate evaluation includes urgent brain imaging, vascular imaging, a cardiac evaluation, and laboratory testing ( algorithm 4). The evaluation proceeds in tandem with initiation of antiplatelet therapy; both should be implemented without delay, preferably within one day of the ischemic event. (See 'Urgent investigations' above.) Risk factor reduction Most patients with TIA or ischemic stroke should be treated with all available risk factor reduction strategies. Viable strategies include treatment of hypertension, LDL-C lowering with high-intensity statin therapy, and lifestyle modification, including smoking cessation. These interventions are discussed in greater detail separately. (See "Overview of secondary prevention of ischemic stroke".) Treatment for specific causes An overview of the treatment for secondary prevention of specific causes of TIA and ischemic stroke (eg, atrial fibrillation, large artery disease, small vessel disease, and others) is provided separately. (See "Overview of secondary prevention for specific causes of ischemic stroke and transient ischemic attack".) ACKNOWLEDGMENTS The UpToDate editorial staff acknowledges J Philip Kistler, MD, Hakan Ay, MD, and Karen L Furie, MD, MPH, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009; 40:2276. 2. Edlow JA. Managing Patients With Transient Ischemic Attack. Ann Emerg Med 2018; 71:409. 3. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369:283. 4. Perry JJ, Sivilotti MLA, mond M, et al. Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 16/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate attack: multicentre prospective cohort study. BMJ 2021; 372:n49. 5. Amarenco P, Labreuche J, Lavall e PC, et al. Does ABCD2 score below 4 allow more time to evaluate patients with a transient ischemic attack? Stroke 2009; 40:3091. 6. Coull AJ, Lovett JK, Rothwell PM, Oxford Vascular Study. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ 2004; 328:326. 7. Ois A, Gomis M, Rodr guez-Campello A, et al. Factors associated with a high risk of recurrence in patients with transient ischemic attack or minor stroke. Stroke 2008; 39:1717. 8. Coutts SB, Hill MD, Simon JE, et al. Silent ischemia in minor stroke and TIA patients identified on MR imaging. Neurology 2005; 65:513. 9. Fischer U, Baumgartner A, Arnold M, et al. What is a minor stroke? Stroke 2010; 41:661. 10. Re-examining Acute Eligibility for Thrombolysis (TREAT) Task Force:, Levine SR, Khatri P, et al. Review, historical context, and clarifications of the NINDS rt-PA stroke trials exclusion criteria: Part 1: rapidly improving stroke symptoms. Stroke 2013; 44:2500. 11. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; 370:1432. 12. Luengo-Fernandez R, Li L, Silver L, et al. Long-Term Impact of Urgent Secondary Prevention After Transient Ischemic Attack and Minor Stroke: Ten-Year Follow-Up of the EXPRESS Study. Stroke 2022; 53:488. 13. Lavall e PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the- clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007; 6:953. 14. Kernan WN, Schindler JL. Rapid intervention for TIA: a new standard emerges. Lancet Neurol 2007; 6:940. 15. Johnston SC, Nguyen-Huynh MN, Schwarz ME, et al. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol 2006; 60:301. 16. Cucchiara BL, Kasner SE. All patients should be admitted to the hospital after a transient ischemic attack. Stroke 2012; 43:1446. 17. Amarenco P. Not all patients should be admitted to the hospital for observation after a transient ischemic attack. Stroke 2012; 43:1448. 18. Molina CA, Selim MM. Hospital admission after transient ischemic attack: unmasking wolves in sheep's clothing. Stroke 2012; 43:1450. 19. Ranta A, Barber PA. Transient ischemic attack service provision: A review of available service models. Neurology 2016; 86:947. https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 17/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate 20. Amarenco P, Lavall e PC, Labreuche J, et al. One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke. N Engl J Med 2016; 374:1533. 21. Wu CM, McLaughlin K, Lorenzetti DL, et al. Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med 2007; 167:2417. 22. Rothwell PM, Warlow CP. Timing of TIAs preceding stroke: time window for prevention is very short. Neurology 2005; 64:817. 23. Edlow JA. Risk stratification in TIA patients: "It's the vascular lesion, stupid!". Neurology 2012; 79:958. 24. Shahjouei S, Li J, Koza E, et al. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta- analysis. JAMA Netw Open 2022; 5:e2136644. 25. Hastrup S, Johnsen SP, Jensen M, et al. Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke: A Cohort Study. Neurology 2021. 26. Stead LG, Bellolio MF, Suravaram S, et al. Evaluation of transient ischemic attack in an emergency department observation unit. Neurocrit Care 2009; 10:204. 27. Jarhult SJ, Howell ML, Barnaure-Nachbar I, et al. Implementation of a Rapid, Protocol-based TIA Management Pathway. West J Emerg Med 2018; 19:216. 28. Tuna MA, Rothwell PM, Oxford Vascular Study. Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis. Lancet 2021; 397:902. 29. Redgrave JN, Coutts SB, Schulz UG, et al. Systematic review of associations between the presence of acute ischemic lesions on diffusion-weighted imaging and clinical predictors of early stroke risk after transient ischemic attack. Stroke 2007; 38:1482. 30. Ay H, Oliveira-Filho J, Buonanno FS, et al. 'Footprints' of transient ischemic attacks: a diffusion-weighted MRI study. Cerebrovasc Dis 2002; 14:177. 31. Ay H, Koroshetz WJ, Benner T, et al. Transient ischemic attack with infarction: a unique syndrome? Ann Neurol 2005; 57:679. 32. Kidwell CS, Alger JR, Di Salle F, et al. Diffusion MRI in patients with transient ischemic attacks. Stroke 1999; 30:1174. 33. Ay H, Buonanno FS, Rordorf G, et al. Normal diffusion-weighted MRI during stroke-like deficits. Neurology 1999; 52:1784. 34. Saber Tehrani AS, Kattah JC, Mantokoudis G, et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology 2014; 83:169. https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 18/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate 35. Edlow BL, Hurwitz S, Edlow JA. Diagnosis of DWI-negative acute ischemic stroke: A meta- analysis. Neurology 2017; 89:256. 36. Felfeli P, Wenz H, Al-Zghloul M, et al. Combination of standard axial and thin-section coronal diffusion-weighted imaging facilitates the diagnosis of brainstem infarction. Brain Behav 2017; 7:e00666. 37. Sch nfeld MH, Ritzel RM, Kemmling A, et al. Improved detectability of acute and subacute brainstem infarctions by combining standard axial and thin-sliced sagittal DWI. PLoS One 2018; 13:e0200092. 38. Giles MF, Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2007; 6:1063. 39. Lee SH, Nah HW, Kim BJ, et al. Role of Perfusion-Weighted Imaging in a Diffusion-Weighted- Imaging-Negative Transient Ischemic Attack. J Clin Neurol 2017; 13:129. 40. Grams RW, Kidwell CS, Doshi AH, et al. Tissue-Negative Transient Ischemic Attack: Is There a Role for Perfusion MRI? AJR Am J Roentgenol 2016; 207:157. 41. Krol AL, Coutts SB, Simon JE, et al. Perfusion MRI abnormalities in speech or motor transient ischemic attack patients. Stroke 2005; 36:2487. 42. Choi JH, Park MG, Choi SY, et al. Acute Transient Vestibular Syndrome: Prevalence of Stroke and Efficacy of Bedside Evaluation. Stroke 2017; 48:556. 43. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364. 44. Flemming KD, Brown RD Jr, Petty GW, et al. Evaluation and management of transient ischemic attack and minor cerebral infarction. Mayo Clin Proc 2004; 79:1071. 45. Rothwell PM, Eliasziw M, Gutnikov SA, et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363:915. Topic 1123 Version 66.0 https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 19/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate GRAPHICS Transient ischemic attack (TIA) and minor ischemic stroke: Rapid overview of emergency management Clinical features Typical TIAs are characterized by transient, focal neurologic symptoms that can be localized to a single vascular territory within the brain, including one or more of the following: Transient monocular blindness (amaurosis fugax) Aphasia or dysarthria Hemianopia Hemiparesis and/or hemisensory loss (complete or partial) Atypical TIAs may present with transient isolated neurologic symptoms: Isolated vertigo Isolated ataxia Isolated diplopia Isolated speech disturbance (slurred speech) without aphasia Isolated bilateral decreased vision Isolated unilateral sensory loss involving only one body part Differential diagnosis Seizure Migraine aura Syncope Transient global amnesia Central nervous system demyelinating disorder (eg, multiple sclerosis) Peripheral vestibulopathy Metabolic disorder (eg, hypoglycemia) Myasthenia gravis Cranial/peripheral neuropathy Cerebral amyloid angiopathy Subdural hematoma Subarachnoid or intracerebral hemorrhage Transient neurologic attack not otherwise specified Immediate treatment while evaluating the ischemic mechanism For patients with TIA or minor, nondisabling acute ischemic stroke (and thus not eligible for thrombolytic therapy or mechanical thrombectomy), start antiplatelet therapy immediately while the evaluation is in progress: https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 20/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate Start DAPT (aspirin plus clopidogrel, or aspirin plus ticagrelor) for patients with one of the following: 2 High-risk TIA, defined by an ABCD score 4 Time-based TIA with a relevant large artery stenosis or DWI lesion on MRI (if imaging available at this stage) Minor, nondisabling ischemic stroke, defined by an NIHSS score 5 Start aspirin monotherapy for patients who do not meet the above criteria (ie, TIA with an ABCD score <4 and no relevant large artery stenosis or DWI lesion on MRI [if imaging 2 available at this stage]) Once the ischemic mechanism is determined, antithrombotic therapy can be modified as necessary Urgent evaluation Brain imaging with diffusion-weighted MRI (preferred) or CT to identify infarction and rule out nonischemic causes Vascular imaging of extracranial and intracranial large arteries with MRA or CTA to identify large artery cause Cardiac evaluation (ECG, cardiac monitoring, echocardiography) to identify atrial fibrillation or other cardioembolic source Laboratories: CBC, PT and PTT, serum electrolytes, creatinine, fasting blood glucose or HbA1c, lipids, and (as indicated for selected patients) ESR and CRP Targeted treatment by mechanism for secondary prevention Cardiogenic embolism due to atrial fibrillation: Stop antiplatelet agents and start long-term anticoagulation Symptomatic internal carotid artery stenosis: Carotid revascularization with CEA or CAS and long-term antiplatelet therapy Intracranial large artery atherosclerosis with 70 to 99% stenosis: Continue DAPT for 21 to 90 days, then switch to long-term single-agent antiplatelet therapy Small vessel disease, extracranial vertebral artery stenosis, intracranial large artery atherosclerosis with 50 to 69% stenosis, or cryptogenic: Continue DAPT for 21 days, then switch to long-term single-agent antiplatelet therapy for: 2 High-risk TIA (ABCD score 4), or TIA with a relevant DWI lesion on MRI, or extracranial stenosis not amenable to revascularization Minor ischemic stroke (NIHSS 5) 2 Continue long-term single-agent antiplatelet therapy for low-risk TIA (ABCD score <4), and TIA without a relevant large artery stenosis or DWI lesion on MRI Intensive risk factor management Antihypertensive therapy for patients with known or newly established hypertension LDL-cholesterol lowering with high-intensity statin therapy Glucose control to near normoglycemic levels for patients with diabetes Lifestyle modification as appropriate: https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 21/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate Moderate to vigorous exercise most days of the week for those capable Smoking cessation for recent or current tobacco users Mediterranean diet Weight reduction for patients with obesity Reduced alcohol consumption for heavy drinkers This rapid overview presents a general approach to the management of TIA and minor stroke. Please refer to UpToDate content for details, including descriptions and calculators for the NIHSS and 2 ABCD scores. 2 DAPT: dual antiplatelet therapy; ABCD : Age, Blood pressure, Clinical features, Duration of symptoms, and Diabetes; NIHSS: National Institutes of Health Stroke Scale; DWI: diffusion-weighted imaging; MRI: magnetic resonance imaging; CT: computed tomography; MRA: magnetic resonance angiography; CTA: computed tomographic angiography; ECG: electrocardiography; CBC: complete blood count; PT: prothrombin time; PTT: partial thromboplastin time; HbA1c: glycated hemoglobin; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; CEA: carotid endarterectomy; CAS: carotid artery stenting; LDL: low density lipoprotein; ICAS: intracranial larger artery atherosclerosis. Graphic 131201 Version 4.0 https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 22/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate Symptoms of transient ischemic attacks and the vascular territories involved ICA/MCA VA/BA PCA SVD Visual abnormalities Transient ++++ monocular blindness Hemianopia + +++ Blindness ++ ++ Motor abnormalities Hemiparesis + + ++ Quadriparesis ++++ Single part weakness Face + ++ + Arm/hand +++ + Thigh/leg/foot ++ + + Crossed weakness* ++++ Limb ++ ++ ataxia/weakness Gait ataxia +++ + Sensory abnormalities Hemisensory + ++ ++ Single part sensory Face + ++ + ++ Arm/hand ++ ++ + Thigh/leg/foot + + + + Crossed sensory* ++++ Cognitive abnormalities Aphasia ++++ + Amnesia + +++ Alexia +++ +++ https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 23/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate Abulia ++ + + Brainstem and cranial nerve symptoms Dizziness/vertigo + +++ Diplopia ++++ Dysarthria + ++ ++ Dysphagia ++ ++ Tinnitus/hearing loss ++++ ICA: internal carotid arteries; MCA: middle cerebral arteries; VA: vertebral arteries; BA: basilar artery; PCA: posterior cerebral arteries; SVD: small vessel disease. Crossed weakness or crossed sensory refers to one side of the cranial structures and the opposite side limbs and trunk. Graphic 71676 Version 5.0 https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 24/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate 2 ABCD score 2 The ABCD score can be used to estimate the risk of ischemic stroke in the first two days after TIA. The score is tallied as follows: Age: 60 years 1 point <60 years 0 points Blood pressure elevation when first assessed after TIA: Systolic 140 mmHg or diastolic 90 mmHg 1 point Systolic <140 mmHg and diastolic <90 mmHg 0 points Clinical features: Unilateral weakness 2 points Isolated speech disturbance 1 point Other 0 points Duration of TIA symptoms: 60 minutes 2 points 10 to 59 minutes 1 point <10 minutes 0 points Diabetes: Present 1 point Absent 0 points Data from: Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and re nement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369:283. Graphic 62381 Version 3.0 https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 25/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate National Institutes of Health Stroke Scale (NIHSS) Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (ie, repeated requests to patient to make a special effort). Instructions Scale definition Score 1a. Level of consciousness: The 0 = Alert; keenly responsive. investigator must choose a response if a full evaluation is prevented by such obstacles as 1 = Not alert; but arousable by minor stimulation to obey, answer, or respond. an endotracheal tube, language barrier, 2 = Not alert; requires repeated stimulation orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped). _____ (other than reflexive posturing) in response to noxious stimulation. 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic. 1b. Level of consciousness questions: The 0 = Answers both questions correctly. patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from 1 = Answers one question correctly. 2 = Answers neither question correctly. _____ any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues. 1c. Level of consciousness commands: The 0 = Performs both tasks correctly. _____ patient is asked to open and close the eyes and then to grip and release the non-paretic 1 = Performs one task correctly. 2 = Performs neither task correctly. hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (ie, https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 26/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. 2. Best gaze: Only horizontal eye movements will be tested. Voluntary or 0 = Normal. 1 = Partial gaze palsy; gaze is abnormal in reflexive (oculocephalic) eye movements will one or both eyes, but forced deviation or total gaze paresis is not present. be scored, but caloric testing is not done. If the patient has a conjugate deviation of the 2 = Forced deviation, or total gaze paresis not overcome by the oculocephalic eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a maneuver. patient has an isolated peripheral nerve paresis (cranial nerves III, IV or VI), score a 1. _____ Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre- existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy. 3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, 0 = No visual loss. 1 = Partial hemianopia. 2 = Complete hemianopia. but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut 3 = Bilateral hemianopia (blind including cortical blindness). _____ asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. 4. Facial palsy: Ask - or use pantomime to encourage - the patient to show teeth or 0 = Normal symmetrical movements. _____ 1 = Minor paralysis (flattened nasolabial raise eyebrows and close eyes. Score symmetry of grimace in response to noxious fold, asymmetry on smiling). 2 = Partial paralysis (total or near-total paralysis of lower face). stimuli in the poorly responsive or non- comprehending patient. If facial trauma/bandages, orotracheal tube, tape or https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 27/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate other physical barriers obscure the face, 3 = Complete paralysis of one or both sides these should be removed to the extent (absence of facial movement in the upper possible. and lower face). 5. Motor arm: The limb is placed in the appropriate position: extend the arms 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not falls before 10 seconds. The aphasic patient hit bed or other support. is encouraged using urgency in the voice and pantomime, but not noxious 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in _____ effort against gravity. the case of amputation or joint fusion at the shoulder, the examiner should record the 3 = No effort against gravity; limb falls. score as untestable (UN), and clearly write 4 = No movement. the explanation for this choice. UN = Amputation or joint fusion, explain:________________ 5a. Left arm 5b. Right arm 6. Motor leg: The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The 0 = No drift; leg holds 30-degree position for full 5 seconds. 1 = Drift; leg falls by the end of the 5-second period but does not hit bed. aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. _____ 3 = No effort against gravity; leg falls to bed immediately. record the score as untestable (UN), and clearly write the explanation for this choice. 4 = No movement. UN = Amputation or joint fusion, explain:________________ 6a. Left leg 6b. Right leg 7. Limb ataxia: This item is aimed at finding 0 = Absent. _____ evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, 1 = Present in one limb. 2 = Present in two limbs. ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests UN = Amputation or joint fusion, explain:________________ are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient https://www.uptodate.com/contents/initial-evaluation-and-management-of-transient-ischemic-attack-and-minor-ischemic-stroke/print 28/47 7/6/23, 1:08 PM Initial evaluation and management of transient ischemic attack and minor ischemic stroke - UpToDate who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick 0 = Normal; no sensory loss. when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial Only sensory loss attributed to stroke is scored as abnormal and the examiner pain with pinprick, but patient is aware of being touched. should test as many body areas (arms [not hands], legs, trunk, face) as needed to 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, accurately check for hemisensory loss. A score of 2, "severe or total sensory loss," should only be given when a severe or total loss of sensation can be clearly and leg. _____ demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best language: A great deal of 0 = No aphasia; normal. _____ information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes the items on the attached naming sheet and to read from the attached list of sentences. conversation about provided materials Comprehension is judged from responses here, as well as to all of the commands in difficult or impossible. For example, in conversation about provided materials, the preceding general neurological exam. If examiner can identify picture or naming card content from patient's response.