TIA

Classic definition: focal cerebral ischemic event with symptoms lasting < 24 hours

2009 AHA/ASA definition:  brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction

Why is there a new definition?

• A 24-hour duration of symptoms does not accurately demarcate patients with and without tissue infarction
• new definition focused on imaging rather than duration of symptoms
  

Implications

• Annual incidence of is about 200,000 to 500,000 with the population prevalence about 2.3 precent or about 5 million Americans.
• 10-15% of patients have a stroke within 3 months, with half occurring within 48 hours
• Data supporting early rather than delayed carotid endarterectomy for TIA patients with carotid stenosis

Evaluation

• History
• Duration ‐ <10min, 10‐60min, >60 min
• Evidence to suggest non‐vascular cause?
• Vascular risk factors?
• Symptoms to suggest potential causes?
• Exam
• Neurologic deficits?
• Carotid bruits?
• Cardiac abnormalities?
• Arrhythmia, Murmur – Symptoms reproducible with maneuvers?
• Testing
• ECG
• Cardiac Monitor
• Labs
• CBC, glucose, chemistries, PT
• Imaging
• CT-Head
  

ABCD^2 Score

• Risk of CVA in 2, 7, 90 days
• Higher score is higher risk
  

Medical management of risks

• HTN: BP below 140/90
• DM: fasting glucose < 126 mg/dl
• Hyperlipidemia: LDL < 100 mg/dl
• Stop smoking!
• Exercise 30‐60 min, 3x/week
• Avoid excessive alcohol use
• Weight loss: < 120% of ideal weight

Sources

Definition and Evaluation of Transient Ischemic Attack: J. Donald Easton, Jeffrey L. Saver, Gregory W. Albers, Mark J. Alberts, Seemant Chaturvedi, Edward Feldmann, Thomas S. Hatsukami, Randall T. Higashida, S. Claiborne Johnston, Chelsea S. Kidwell, Helmi L. Lutsep, Elaine Miller and Ralph L. Sacco. Stroke 2009, 40:2276-2293: originally published online May 7, 2009. doi: 10.1161/STROKEAHA.108.192218

Update in the Management of TIA and Stroke Patients. Michael A. Ross, MD, FACEP. SA-46. 10/15/2011. 3:00 PM - 3:50 PM. Moscone Convention Center







Stroke

BP Management

• Keep SBP < 180 mmHg and/or MAP < 120 mmHg
• Labetalol
• IV Bolus Dose
• 5 – 20mg IV q 20min
• Infusion
• 2 mg/min, titrate to effect (max 300mg/day)
• Nicardipine
• Infusion
• 5 mg/hr, titrate to effect (max 15mg/hr)