New Recommendation: Treat TIA Urgently

Abstract

Michele G. Sullivan is with the Mid-Atlantic bureau of Elsevier Global Medical News. Patients with a presumed transient ischemic attack should undergo a neuroimaging evaluation within 24 hours of their symptom onset, preferably with magnetic resonance imaging, according to new recommendations. The guideline, issued by the American Heart Association/American Stroke Association, redefines transient ischemic attack (TIA) as an urgent problem worthy of immediate treatment, rather than a minor issue that can be managed with watchful waiting. New imaging methods have shown that many TIAs are associated with new infarcts, and that up to 15% of patients will have a major stroke within 3 months of a TIA, with almost half of those occurring within 48 hours. TIAs have in the past been temporally defined as a focal cerebral ischemic event with symptoms lasting less than 24 hours. The new description defines TIA from a tissue-based stance, as “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.” The tissue-based description is important, according to the committee, because distinguishing TIA by a time limit is misleading and can be inaccurate. The committee recommended the following diagnostic evaluation, based on the new definition: ▸ Patients with TIA should undergo neuroimaging within 24 hours of symptom onset, preferably by MRI with diffusion-weighted imaging. If these are not available, computed tomography (CT) should be performed. ▸ Noninvasive testing of the cervicocephalic vessels should be included. ▸ Noninvasive testing of the intracranial vessels is reasonable when the knowledge of transcranial vessel disease would alter management decisions. This may be done by carotid ultrasound/transcranial Doppler, magnetic resonance angiography, or CT angiography. ▸ An electrocardiogram should be performed as soon as possible, especially in patients in whom the initial workup has shown no immediate cause of the TIA. ▸ Consider hospitalization of TIA patients if they present within 72 hours of the event with any of the following criteria: ABCD2 score of 3 or higher; ABCD2 score of 0-2 and uncertainty that a diagnostic work-up can be completed within 2 days; ABCD2 score of 0-2 and other evidence of focal ischemia. These are valuable recommendations, and they should be applied to our patients who are reasonably healthy and would be candidates for interventions such as tPA (tissue plasminogen activator), angiographic procedures, and surgery. Clearly, we also have some patients who suffer transient ischemic attacks who do not require imaging—although they may benefit from initiation or step-up of antiplatelet therapy. As with all of our patients, each clinical scenario should be considered individually, but this recommendation reminds us that a TIA should be considered a serious and urgent event and that immediate imaging should be our standard procedure. —Karl Steinberg, MD, CMD Editor in Chief