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Transient Ischemic Attack: an Evidence-Based Update

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Transient Ischemic Attack: an Evidence-Based Update January 2013 Transient Ischemic Attack: Volume 15, Number 1 An Evidence-Based Update Authors Matthew S. Siket, MD, MS Assistant Professor of Emergency Medicine, Alpert Medical School of Abstract Brown University, Providence, RI Jonathan Edlow, MD Professor of Medicine, Harvard Medical School; Vice Chair of Transient ischemic attack represents a medical emergency and Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, warns of an impending stroke in roughly one-third of patients MA who experience it. The risk of stroke is highest in the first 48 hours Peer Reviewers following a transient ischemic attack, and the initial evaluation Christopher Y. Hopkins, MD in the emergency department is the best opportunity to identify Assistant Professor of Emergency Medicine and Neurocritical Care, those at highest risk of stroke recurrence. The focus should be on University of Florida Health Science Center, Jacksonville, FL J. Stephen Huff, MD differentiating transient ischemic attack from stroke and common Associate Professor of Emergency Medicine and Neurology, University mimics. Accurate diagnosis is achieved by obtaining a history of of Virginia, Charlottesville, VA abrupt onset of negative symptoms of ischemic origin fitting a CME Objectives vascular territory, accompanied by a normal examination and the Upon completion of this article, you should be able to: absence of neuroimaging evidence of infarction. Transient isch- 1. Cite recent studies on TIA diagnosis and management and emic attacks rarely last longer than 1 hour, and the classic 24-hour practice their indications. time-based definition is no longer relevant. Once the diagnosis has 2. Using available resources, incorporate imaging-enhanced risk stratification tools in the early evaluation of TIA in the ED. been made, clinical risk criteria may augment imaging findings to identify patients at highest and lowest risk of early recurrence. Prior to beginning this activity, see the back page for faculty Early etiologic evaluation, including neurovascular and cardiac disclosures and CME accreditation information. investigations, allows for catered secondary prevention strate- gies. Specialized transient ischemic attack clinics and emergency department observation units are safe and efficient alternatives to hospital admission for many transient ischemic attack patients. Editor-in-Chief Medical Center, University of North Charles V. Pollack, Jr., MA, MD, Stephen H. Thomas, MD, MPH International Editors Carolina School of Medicine, Chapel FACEP George Kaiser Family Foundation Andy Jagoda, MD, FACEP Peter Cameron, MD Hill, NC Chairman, Department of Emergency Professor & Chair, Department of Professor and Chair, Department of Academic Director, The Alfred Medicine, Pennsylvania Hospital, Emergency Medicine, University of Emergency Medicine, Mount Sinai Steven A. Godwin, MD, FACEP Emergency and Trauma Centre, School of Medicine; Medical Director, University of Pennsylvania Health Oklahoma School of Community Professor and Chair, Department Monash University, Melbourne, Mount Sinai Hospital, New York, NY System, Philadelphia, PA Medicine, Tulsa, OK of Emergency Medicine, Assistant Australia Editorial Board Dean, Simulation Education, Michael S. Radeos, MD, MPH Jenny Walker, MD, MPH, MSW University of Florida COM- Assistant Professor of Emergency Assistant Professor, Departments of Giorgio Carbone, MD William J. Brady, MD Jacksonville, Jacksonville, FL Medicine, Weill Medical College Preventive Medicine, Pediatrics, and Chief, Department of Emergency Professor of Emergency Medicine, of Cornell University, New York; Medicine Course Director, Mount Medicine Ospedale Gradenigo, Chair, Resuscitation Committee, Gregory L. Henry, MD, FACEP Research Director, Department of Sinai Medical Center, New York, NY Torino, Italy University of Virginia Health System, CEO, Medical Practice Risk Emergency Medicine, New York Charlottesville, VA Assessment, Inc.; Clinical Professor Ron M. Walls, MD Amin Antoine Kazzi, MD, FAAEM Hospital Queens, Flushing, New York of Emergency Medicine, University of Professor and Chair, Department of Associate Professor and Vice Chair, Peter DeBlieux, MD Michigan, Ann Arbor, MI Robert L. Rogers, MD, FACEP, Emergency Medicine, Brigham and Department of Emergency Medicine, Professor of Clinical Medicine, FAAEM, FACP Women’s Hospital, Harvard Medical University of California, Irvine; Interim Public Hospital Director John M. Howell, MD, FACEP Assistant Professor of Emergency School, Boston, MA American University, Beirut, Lebanon of Emergency Medicine Services, Clinical Professor of Emergency Medicine, The University of Emergency Medicine Director of Medicine, George Washington Scott Weingart, MD, FACEP Hugo Peralta, MD Maryland School of Medicine, Faculty and Resident Development, University, Washington, DC; Director Associate Professor of Emergency Chair of Emergency Services, Baltimore, MD Louisiana State University Health of Academic Affairs, Best Practices, Medicine, Mount Sinai School of Hospital Italiano, Buenos Aires, Science Center, New Orleans, LA Inc, Inova Fairfax Hospital, Falls Alfred Sacchetti, MD, FACEP Medicine; Director of Emergency Argentina Church, VA Assistant Clinical Professor, Critical Care, Elmhurst Hospital Francis M. Fesmire, MD, FACEP Dhanadol Rojanasarntikul, MD Department of Emergency Medicine, Center, New York, NY Professor and Director of Clinical Shkelzen Hoxhaj, MD, MPH, MBA Attending Physician, Emergency Thomas Jefferson University, Research, Department of Emergency Chief of Emergency Medicine, Baylor Medicine, King Chulalongkorn Philadelphia, PA Senior Research Editor Medicine, UT College of Medicine, College of Medicine, Houston, TX Memorial Hospital, Thai Red Cross, Joseph D. Toscano, MD Chattanooga; Director of Chest Pain Scott Silvers, MD, FACEP Thailand; Faculty of Medicine, Eric Legome, MD Emergency Physician, Department Center, Erlanger Medical Center, Chair, Department of Emergency Chulalongkorn University, Thailand Chief of Emergency Medicine, of Emergency Medicine, San Ramon Chattanooga, TN Medicine, Mayo Clinic, Jacksonville, FL King’s County Hospital; Professor of Regional Medical Center, San Suzanne Peeters, MD Nicholas Genes, MD, PhD Clinical Emergency Medicine, SUNY Corey M. Slovis, MD, FACP, FACEP Ramon, CA Emergency Medicine Residency Assistant Professor, Department of Downstate College of Medicine, Professor and Chair, Department Director, Haga Hospital, The Hague, Emergency Medicine, Mount Sinai Brooklyn, NY of Emergency Medicine, Vanderbilt The Netherlands School of Medicine, New York, NY Keith A. Marill, MD University Medical Center; Medical Assistant Professor, Harvard Medical Director, Nashville Fire Department and Michael A. Gibbs, MD, FACEP School; Emergency Department International Airport, Nashville, TN Professor and Chair, Department Attending Physician, Massachusetts of Emergency Medicine, Carolinas General Hospital, Boston, MA Case Presentations Introduction A 59-year-old obese woman presents to your community A transient ischemic attack (TIA) may not seem hospital ED after experiencing a distinct episode in which significant to patients and providers, but it should her left hand felt “clumsy,” along with a left facial droop always be considered a true medical emergency. and left-sided numbness. She denies experiencing frank Caused by temporary focal central nervous sys- weakness and states that the symptoms resolved in less tem hypoperfusion, a TIA is often a warning of an than 10 minutes. She mentions a similar episode 2 weeks impending stroke. Patients presenting to the emer- ago and is concerned because both her parents and an gency department (ED) with TIA are at highest risk older sibling experienced significantly disabling ischemic of stroke within the next 48 hours,1 and thus, it is strokes. Her vital signs and point-of-care glucose were critically important for the emergency clinician to within normal limits, and her ECG showed sinus rhythm. recognize this opportunity to initiate primary stroke Her physical exam, including a detailed neurologic exam, prevention strategies. Since the 2008 issue of Emer- was largely unrevealing, with no facial asymmetry, uni- gency Medicine Practice on TIA was published, there lateral weakness, sensory loss, or dysmetria appreciated. A have been numerous studies focusing on improving noncontrast cranial CT scan of the brain was remarkable risk stratification and early management strategies only for nonspecific subcortical and periventricular white in TIA. This update will provide the best available matter changes without evidence of acute or old infarc- evidence on diagnosing and managing TIAs. tion, mass, or hemorrhage. Although she was relieved to For more information on current strategies for learn that she has not had a stroke, she is concerned that management of stroke, refer to the July 2012 issue of this may be a precursor of a more serious event. She does Emergency Medicine Practice, “Four Evolving Strate- not have a primary care physician and states that she has gies In The Emergent Treatment Of Acute Ischemic not seen a physician in several years. She asks whether Stroke,” the April 2012 issue of Emergency Medicine this was a “mini stroke” and, if yes, what the chances are Practice, “Carotid And Vertebral Arterial Dissec- that she will have a stroke in the future. tions In The Emergency Department,” and the May An 80-year-old man with a history of diabetes, 2012 issue of EM Practice Guidelines Update, “Current carotid stenosis status post
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