https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 23/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate 80. Arsava EM, Furie KL, Schwamm LH, et al. Prediction of early stroke risk in transient symptoms with infarction: relevance to the new tissue-based definition. Stroke 2011; 42:2186. 81. Maier IL, Bauerle M, Kermer P, et al. Risk prediction of very early recurrence, death and progression after acute ischaemic stroke. Eur J Neurol 2013; 20:599. 82. Arsava EM, Kim GM, Oliveira-Filho J, et al. Prediction of Early Recurrence After Acute Ischemic Stroke. JAMA Neurol 2016; 73:396. Topic 1088 Version 24.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 24/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate GRAPHICS Temporal behavior of symptoms in patients with transient ischemic attack (TIA) The probability density function curve of symptom duration for transient symptoms associated with infarction (TSI) indicates the absence of continuity within the first 24 hours. The probability density function is the probability that the variable takes a value in a given interval and is equal to 1 over its entire range of values. The area under curve is almost equal to 1 at around 200 minutes. Also note that the curves for TIA with or without infarction overlap (p = 0.82). The distribution of duration of symptoms as seen here suggests that symptom duration is not a reliable feature to be used for predicting whether a transient neurological spell is associated with infarction. DWI: diffusion-weighted magnetic resonance imaging. Reproduced with permission from: Ay, H, Koroshetz, WJ, Benner, T, et al. Transient ischemic attack with infarction: a unique syndrome. Ann Neurol 2005; 57:679. Copyright 2005 John Wiley & Sons. Graphic 82729 Version 1.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 25/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Anterior cerebral artery distribution and signs and symptoms of occlusion Reproduced with permission from Kistler, JP, et al, Cerebrovascular Diseases, Harrison's Principles of Internal Medicine, 13th ed. McGraw-Hill, New York 1994. Copyright 1994 McGraw-Hill Companies, Inc. Graphic 60945 Version 3.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 26/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Middle cerebral artery distribution and signs and symptoms of occlusion Reproduced with permission from Kistler JP, et al, Cerebrovascular Diseases, Harrison's Principles of Internal Medicine, 13th ed. McGraw-Hill, New York 1994. Copyright 1994 McGraw-Hill Companies, Inc. Graphic 81813 Version 2.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 27/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Posterior cerebral artery distribution and signs and symptoms of occlusion Reproduced with permission from Kistler, JP, et al, Cerebrovascular Diseases, Harrison's Principles of Internal Medicine, 13th ed. McGraw-Hill, New York 1994. Copyright 1994 McGraw-Hill Companies, Inc. Graphic 60416 Version 2.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 28/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Superior pontine syndrome Reproduced with permission from Kistler, JP, et al, Cerebrovascular Diseases, Harrison's Principles of Internal Medicine, 13th ed. McGraw-Hill, New York 1994. Copyright 1994 McGraw-Hill Companies, Inc. Graphic 53412 Version 1.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 29/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Anatomy of the cerebral arterial circulation Frontal view of the carotid arteries, vertebral arteries, and intracranial vessels and their communication with each other via the circle of Willis. Reproduced with permission from: U acker R. Atlas Of Vascular Anatomy: An Angiographic Approach, Second Edition. Philadelphia: Lippincott Williams & Wilkins, 2006. Copyright 2006 Lippincott Williams & Wilkins. Graphic 51410 Version 6.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 30/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Major cerebral vascular territories Representation of the territories of the major cerebral vessels shown in a coronal section of the brain. Reproduced with permission from Kistler, JP, et al, Cerebrovascular Diseases. Harrison's Principles of Internal Medicine, 13th ed, McGraw-Hill, New York 1994. Copyright 1994 McGraw-Hill Companies, Inc. Graphic 65199 Version 2.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 31/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate 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: 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 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 32/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate 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 2 ABCD score <4 and no relevant large artery stenosis or DWI lesion on MRI [if imaging 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: Moderate to vigorous exercise most days of the week for those capable Smoking cessation for recent or current tobacco users Mediterranean diet https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 33/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate 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/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 34/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Evaluation of patient presenting with acute symptoms of possible TIA or minor ischemic stroke This algorithm should be used in conjunction with UpToDate topics on the initial evaluation and management of TIA and ischemic stroke. CDUS: carotid duplex ultrasonography; CNS: central nervous system; CT: computed tomography; CTA: computed tomography angiography; ECG: electrocardiography; IV: intravenous; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; TIA: transient ischemic attack; TCD: transcranial Doppler. Patients who present within the appropriate time window after ischemic symptom onset and have a persistent neurologic deficit that is potentially disabling, despite https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 35/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate improvement of any degree, should be treated with intravenous thrombolysis and/or mechanical thrombectomy in the absence of other contraindications. Further management of these patients is similar to that of other patients with a potentially disabling stroke. Can begin aspirin and statin therapy while awaiting results of remaining diagnostic studies if imaging is negative for hemorrhage and other nonischemic cause of symptoms. Viable strategies include antihypertensive therapy, antithrombotic therapy, statin therapy, and lifestyle modification; select patients with symptomatic cervical internal carotid artery disease may benefit from carotid revascularization. Graphic 107065 Version 1.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 36/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Severity of carotid stenosis predicts stroke risk Relation between the degree of carotid artery stenosis and the annual risk of stroke. Data from Barnett, HJ, Eliasziw, M, Meldrum, HE, Taylor, DW, Neurology 1996; 46:603. Graphic 60048 Version 1.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 37/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Cerebral ischemia events with asymptomatic carotid artery bruits Incidence of ischemic events in 500 patients with asymptomatic carotid artery bruits according to the severity of carotid artery stenosis on initial Doppler ultrasonography. Patients with 75 percent stenosis were at significantly increased risk (P <0.0001). Data from Chambers BR, Norris JW. Outcome in patients with asymptomatic neck bruits. N Engl J Med 1986; 315:860. Graphic 66153 Version 3.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 38/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - 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/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 39/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Canadian TIA score Items Points Clinical findings First TIA (in lifetime) 2 Symptoms 10 min 2 History of carotid stenosis 2 Already on antiplatelet therapy 3 History of gait disturbance 1 History of unilateral weakness 1 History of vertigo 3 Initial triage diastolic blood pressure 110 mm Hg 3 Dysarthria or aphasia (history or examination) 1 Investigations in emergency department Atrial fibrillation on ECG 2 Infarction (new or old) on CT 1 9 Platelet count 400 10 /L 2 Glucose 15 mmol/L 3 Total score (-3 to 23) TIA: transient ischemic attack; ECG: electrocardiography; CT: computed tomography. From: Perry JJ, Sharma M, Sivilotti ML, et al. A prospective cohort study of patients with transient ischemic attack to identify high-risk clinical characteristics. Stroke 2014; 45:92. DOI: 10.1161/STROKEAHA.113.003085. Copyright American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 134718 Version 1.0 https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 40/41 7/6/23, 1:06 PM Definition, etiology, and clinical manifestations of transient ischemic attack - UpToDate Contributor Disclosures Natalia S Rost, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Erica Camargo Faye, MD No relevant financial relationship(s) with ineligible companies to disclose. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack/print 41/41