Ver el código de «Transient ischemic attack»

==Definition==

"Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction.” Stroke 2009;40[6]:2276

==Background==

1. Ischemic
* Thrombosis
* Vasculitis
* Dissection
2. Embolic
* Cardiac
* Carotids
3. Vasospasm
4. Hypotension/watershed

DDx==
* Hypoglycemia
* Infectious endocarditis
* Complex migraines
* Peripheral cranial nerve lesions
* Seizure
 
==Work-Up==

* Head CT
* Labs
** CBC
** Chemistry
** Coags
* ECG (a-fib)
* CXR
* ?MRI/MRA or ?Neuro labs (ESR?, lipids?)

==Treatment==

* Head of bed lowered
* Permissive hypertension
* NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded)
* ASA
* Heparin if cardiac embolic source/a-fib (usually different vascular territories)

==Disposition==

ABCD2 SCORE

Age > 60 (1 pt)
Blood pressure (SBP >140 or diastolic >90) (1 pt)
Clinical
* unilateral weakness (2 pt)
* speech disturbance without weakness (1 pt)
* Duration symptoms 10-60 min (1 pt)
* Duration symptoms >60 min (2 pt)
* Diabetes (1 pt)
 
Admit for score >3 and presenting within 72h of symptoms

(none with less had CVA within one week in study)

Only numbness with low score is low risk: outpt f/u with Neuro

Also admit:

Crescendo TIA
Duration >1h
Symptomatic carotid stenosis > 50%
Known cardiac source of embolus
Known hypercoaguable state

Literature:

Johnston, SC et al.  JAMA.  Dec 13, 2000.

    To determine which pts need to be admitted vs rapid outpatient evaluation.

    10% of pts with TIA developed CVA within 90 days. 

    50% (5%) within 2 days.

 

Kaiser Study

    Greater risk of CVA (admit any)

1.  Age >60

2.  DM

3.  Duration >10min

4.  Motor weakness

5.  Speech impairment (dysarthria/ aphasia)

 

Numbness is low risk:  outpt f/u with Neuro

(also, at increased risk of CVA if >4 TIA spells within last 2 wks, or escalating / crescendo TIA)

Transient monocular blindness (amaurosis fugax) more benign.

 

 

in Mayo Clinic Proceedings, Nov 1994.  33% of pts with TIA will have CVA within 5 yrs. 

    high risk... inpt w/u

    low risk... expedited outpt w/u

    ECG for a-fib

    Echocardiogram, TEE most sensitive.  prosthetic valves... DCM... mural thrombosis, SBE, post-MI.

    Carotid duplex, if +, cerebral angiogram, then CEA.

    ----ASA

    ----Heparin if cardiac embolic source/a-fib.  usually different vascular territories.

    ----if ASA intolerant or ASA failure, then Ticlopidine.  consider Coumadin.

    or,         Plavix alone.  

 

TIA ADMIT (nmlly neg sy; <1hr)

1) any Johnson criteria

2) <1 wk from onset 

 

==Source==


DONALDSON (Smith, Lampe, NEJM '07, Pani)




[[Category:Neuro]]