Transient ischemic attack and minor stroke

Clinical Manifestations

• Presentations are myriad
• Most classic is sudden loss of motor function and impaired speech
• Not typically progressive, repetitive, or stereotyped
• Symptoms are negative (loss of function) rather than positive

Investigations

Canadian TIA Score

• Canadian Transient Ischemic Attack Score (see MDCalc)
• Categorizes them into low (<1%), medium (1-5%), or high (>5%) risk for stroke within 7 days

Routine

• ECG for atrial fibrillation or flutter, possibly followed by Holter monitor for up to 14 days
• Consider echocardiogram, depending on clinical suspicion for cardioembolic source

Imaging

• Urgent CT brain, within 48 hours of onset
• Vascular imaging depends on risk
• Medium or high risk: CTA including for carotid stenosis
• Low risk: ultrasound with Dopplers as an outpatient

Differential Diagnosis

• Migraine, peripheral vertigo, syncope, somatization and seizure

Management

• Dual antiplatelet therapy for medium- and high-risk patients for 21 days, followed by single antiplatelet therapy
  • Aspirin 80-81 mg p.o. daily plus clopidogrel 75 mg p.o. daily
  • Loading dose is aspirin 160 mg and clopidogrel 300-600 mg
  • Ticagrelor is an alternative to clopidogrel
• Statin should be added in noncardioembolic strokes without contraindication
  • High-dose with atorvastation 80 mg or simvastatin 40 mg
• If atrial fibrillation is identified, use anticoagulation
  • Can be started immediately if no active bleeding and no large acute infarction (>1.5 cm in anterior or posterior circulation) on CT
  • If moderate-to-large infarction, repeat CT at 3 to 7 days before starting anticoagulation to rule out hemorrhagic transformation
  • Patients with hemorrhage can be started after 14 days
• Treat modifiable risk factors, including hypertension, smoking, dyslipidemia, and obesity
• Lifestyle modification including dietary changes and increased physical activity