Transient ischemic attack and minor stroke

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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

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

Management

  • Dual antiplatelet therapy for medium- and high-risk patients for 21 days, followed by single antiplatelet therapy
  • 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