Transient ischemic attack and minor stroke
From IDWiki
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
