COVER ARTICLE

Transient Ischemic Attacks: Part I. Diagnosis and Evaluation NINA J. SOLENSKI, M.D., University of Virginia Health Sciences Center, Charlottesville, Virginia

Transient ischemic attack is no longer considered a benign event but, rather, a critical harbinger of impending . Failure to quickly recognize and evaluate this warning O A patient infor- sign could mean missing an opportunity to prevent permanent disability or . The mation handout on 90-day risk of stroke after a transient ischemic attack has been estimated to be approxi- and TIAs, writ- ten by the author of mately 10 percent, with one half of strokes occurring within the first two days of the this article, is provided attack. The 90-day stroke risk is even higher when a transient ischemic attack results on page 1679. from internal carotid stenosis. Most patients reporting symptoms of transient ischemic attack should be sent to an emergency department. Patients who arrive at the emergency department within 180 minutes of symptom onset should undergo an expedited history and , as well as selected laboratory tests, to determine if they are candidates for thrombolytic therapy. Initial testing should include complete blood count with platelet count, prothrombin time, International Normalized Ratio, partial thromboplastin time, and electrolyte and glucose levels. Computed tomo- graphic scanning of the head should be performed immediately to ensure that there is no evidence of hemorrhage or mass. A transient ischemic attack can be mis- diagnosed as , , peripheral neuropathy, or anxiety. (Am Fam Physician 2004;69:1665-74,1679-80. Copyright© 2004 American Academy of Family Physicians.)

ased on an increased under- than 50 percent of all adverse events standing of brain occurred within the first four days after and the introduction of new the TIA. Notably, of the patients with TIA treatment options, a working who returned to the emergency depart- group has proposed rede- ment with stroke (10.5 percent), approxi- Bfining transient ischemic attack (TIA) as mately one half had the stroke within “a brief episode of neurological dysfunc- the first 48 hours after the initial TIA. In tion caused by focal brain or retinal isch- 2.6 percent of patients with TIA, hospi- emia, with clinical symptoms typically talization was required for cardiac events, lasting less than one hour, and without including congestive , unsta- 1(p1715) This is part I of a two- evidence of acute .” This ble angina, , and ventricular part article on transient definition underscores the urgency of rec- . ischemic attacks. Part ognizing TIA as an important warning of II, “Treatment,” will impending stroke and facilitating rapid Clinical Presentation appear in this issue on evaluation and treatment of TIA to pre- The more common clinical presenta- page 1681. vent permanent . tions of TIA are described in Table 1. In general, a TIA presents as a syndrome This article Epidemiology rather than any one sign or symptom. exemplifies the An estimated 200,000 to 500,000 TIAs AAFP 2004 Annual occur annually in the United States.2 Pre-emergency Department Care Clinical Focus on caring 2 for America’s aging One study found that 25 percent of There is no reliable way to determine population. patients who presented to an emergency if the abrupt onset of neurologic deficits department with TIA had adverse events represents reversible ischemia without See page 1591 for defi- within 90 days; 10 percent of the events subsequent or if ischemia nitions of strength-of- were strokes, and the vast majority of will result in permanent damage to the recommendation labels. the strokes were fatal or disabling.3 More brain (e.g., stroke). Therefore, all patients

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Affected area Implications

Cranial nerves Visual loss in one or both eyes Bilateral loss may indicate more ominous onset of ischemia. Double vision If double vision is subtle, the patient may describe it as “blurry” vision. Vestibular dysfunction True is likely to be described as a spinning sensation rather than nonspecific lightheadedness. Difficulty swallowing Trouble swallowing may indicate brainstem involvement; if the swallowing problem is severe, there may be an increased risk of aspiration. Motor function Unilateral or bilateral weakness affecting Bilateral signs may indicate more ominous onset of brainstem the face, arm, or leg ischemia. Sensory function Unilateral or bilateral: either decreased If sensory dysfunction occurs without other signs or symptoms, sensation (numbness) or increased the may be more benign, but recurrence is high. sensation (tingling, pain) in the face, arm, leg, or trunk Speech and Slurring of words or reduced verbal output; If speech is severely slurred or facial drooling is excessive, there language difficulty pronouncing, comprehending, is an increased risk of aspiration. or “finding” words Writing and reading also may be impaired. Coordination Clumsy arms, legs, or trunk; loss of balance Incoordination of limbs, trunk, or gait may indicate cerebellar or falling (particularly to one side) with or brainstem ischemia. standing or walking Psychiatric or Apathy or inappropriate behavior These symptoms can indicate frontal lobe involvement and cognitive frequently are misinterpreted as poor volitional cooperation. function Excessive This symptom may indicate bilateral hemispheric or brainstem involvement. Agitation or psychosis Rarely, these symptoms may indicate brainstem ischemia, particularly if they occur in association with cranial nerve or motor dysfunction. or memory changes These rarely are isolated symptoms; more frequently, they are associated with language, motor, sensory, or visual changes. Inattention to surrounding environment, Depending on the severity of neglect, the physician may particularly to one side; if severe, patient need to lift the patient’s arm to check for strength, may deny deficit or even his or her own rather than rely on the patient to perform this task. body parts.

TIA = transient ischemic attack.

with symptoms of TIA should receive an tion, or severity are particularly ominous signs expedited evaluation. of impending stroke. Office staff should be trained to inform Most patients with possible TIA should be the family physician immediately if a patient sent immediately to the nearest emergency calls or presents with symptoms that could department. If they have had symptoms represent a TIA. Neurologic symptoms that for fewer than 180 minutes, they should be crescendo with increasing frequency, dura- sent to an emergency department that offers acute thrombolytic therapy. Patients should not drive themselves to the hospital. To The proposed redefinition of transient ischemic attack is “a speed evaluation, it is appropriate to activate the 9-1-1 Emergency Medical Service system brief episode of neurological dysfunction caused by focal for transport.2,3 brain or retinal ischemia, with clinical symptoms typically On presentation to the emergency depart- lasting less than one hour, and without evidence of acute ment, patients who have had symptoms for fewer than 180 minutes might be candidates

1666-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 7 / APRIL 1, 2004 TABLE 2 Relative Indications for Inpatient Evaluation of Possible TIA or Stroke*

Condition Implications

High-risk cardioembolic source: acute Consider anticoagulation. (especially if large and significant wall-motion abnormality is present), mural thrombi, new-onset TIAs manifested by major symptoms such as dense paralysis Possible evolving large hemispheric stroke with increased risk of or severe language disorder brain swelling Increasing frequency or severity of TIAs (crescendo pattern) Possible evolving thromboembolic stroke Evidence of high-grade Carotid artery evaluation for possible emergency intervention (surgery, stent, or ) Drooling, imbalance, decreased alertness, difficulty Increased risk of falling, or of aspiration and other pulmonary swallowing complications Severe , , stiff neck, recent syncope Possible : obtain emergency computed tomographic scan of the head; if the scan is negative but clinical suspicion remains high, evaluation or possible cerebral is needed.

TIA = transient ischemic attack. *—May require more than 23 hours of observation in the emergency department, or hospitalization for observation.

for treatment with tissue-type plasminogen 4,5 activator (tPA). If a patient is not a candi- date for tPA treatment, antiplatelet therapy should be initiated as soon as it can be deter- The most common imitators of TIA are mined that there are no contraindications.4-6 glucose derangement, migraine, seizure, post- [Reference 6: SOR A, rating of benefits] ictal states, and tumors (especially with acute hemorrhage). Inpatient or Outpatient Evaluation TIA typically has a rapid onset, and maxi- Guidelines issued by the National Stroke mal intensity usually is reached within min- Association7 recommend evaluation within utes. Fleeting episodes lasting one or two sec- hours of the onset of TIA symptoms, prefer- onds or nonspecific symptoms such as , ably in an emergency department. If appro- lightheadedness (in the absence of other cer- priate imaging studies are not immediately ebellar or brainstem symptoms), and bilateral available in the emergency department or out- rhythmic shaking of the limbs are less likely patient setting, the patient should be hospital- presentations of acute cerebral ischemia. ized for observation.7 [SOR C, expert opin- Distinguishing TIA from migraine aura ion] Relative indications for more extended can be difficult. Younger age, previous his- inpatient evaluation for TIA or stroke are tory of migraine (with or without aura), and listed in Table 2. associated headache, nausea, or photophobia Patients with symptoms of acute TIA for are more suggestive of migraine than TIA. In fewer than 24 to 48 hours should undergo general, migraine aura tends to have a march- diagnostic testing in the emergency depart- ing quality; for example, symptoms such as ment.8 [SOR C, expert opinion] Patients tingling may progress from the fingers to whose symptoms have resolved for more than the forearm to the face. Migraine aura also is 48 hours should receive urgent inpatient or outpatient evaluation. Neurologic symptoms that crescendo with increasing fre- Initial Work-Up for Suspected TIA quency, duration, or severity are particularly ominous signs of The first step in evaluating a patient with symptoms of TIA is to confirm the diagnosis impending stroke. (Figure 1).

APRIL 1, 2004 / VOLUME 69, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1667 Initial Work-Up for Suspected TIA

Confirm TIA history.

Acute (did transient symptoms occur < 24 to 48 hours ago)?

Yes No

Send patient to hospital emergency Urgent outpatient evaluation to identify department for evaluation. cause of TIA; if imaging studies are not available in a timely fashion, admit patient. Identify and treat stroke risk factors. Is patient a candidate for Begin medical therapy, including antiplatelet thrombolytic therapy? therapy, as soon as possible.

No Yes

Initiate therapy Perform certain tests (*) within 25 minutes of within 24 to 48 hours patient’s arrival in emergency department; screen (if no contraindications). for inclusion/exclusion criteria for IV tPA therapy.

Frequent vital signs, with attention to * and heart rhythm Head CT* Cardiac monitoring: ECG Medical and neurologic examination* Initial laboratory tests: complete blood count with platelet count*; electrolyte, glucose,* and renal function measurements; PT,* aPTT,* and INR* Carotid artery evaluation Head MRI and MRA of intracranial and neck vessels, if available and appropriate

Further testing in selected patients (see Table 3)

FIGURE 1. Initial work-up for the patient with possible transient ischemic attack (TIA). (IV = intravenous; tPA = tissue-type plasminogen activator; CT = computed tomography; ECG = elec- trocardiography; PT = prothrombin time; aPTT = activated partial thromboplastin time; INR = International Normalized Ratio; MRI = magnetic resonance imaging; MRA = magnetic resonance angiography)

more likely to have a more gradual onset and Special emphasis should be given to pos- resolution, with a longer duration of symp- sible symptoms of TIA (Table 1), and stroke toms than in a typical TIA. risk factors should be identified to determine If a patient has explosive onset of a severe the likelihood that the symptoms are caused headache, with or without photophobia, stiff by TIA. Modifiable risk factors for stroke neck, or syncope, acute subarachnoid hemor- include , , cardiac dis- rhage is a possibility. Rarely, TIA is mistaken ease, elevated blood lipid levels, carotid artery for the first presentation of multiple sclerosis stenosis, , sickle cell , excessive in young patients or for amyotrophic lateral alcohol use, obesity, and physical inactivity.7 sclerosis in older patients. Whether hypercholesterolemia is an inde- pendent primary risk factor for stroke remains HISTORY uncertain.9 However, hypercholesterolemia is A general should be a significant risk factor for coronary heart dis- obtained in all patients with suspected TIA. ease (CHD) and therefore can be considered

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an important risk factor for ischemic stroke. There appears to be a stronger data relationship Conditions that may mimic TIA include glucose derangement, between total and low-density lipoprotein cho- migraine, seizure, postictal states, tumors or, rarely, multiple lesterol levels, as well as a protective influence sclerosis and amyotrophic lateral sclerosis. of high-density lipoprotein levels, in cervical carotid artery atherosclerosis.10 Other important information includes a family history of stroke (including cerebral subarachnoid hemorrhage, intracranial hem- or hypercoagulable state), the use orrhage, or subdural . Urgent iden- of over-the-counter or illicit drugs, a history tification of these conditions is critical because of migraine or “severe ,” recent neurosurgical intervention or special manage- head trauma, previous systemic clots and, ment may be required. in a woman of childbearing age, a history of If hemorrhage is present, treatment with tPA spontaneous abortion. Certain findings may or that may worsen central ner- indicate the need for special diagnostic tests vous system should be avoided. Spe- (Table 3). cial measures may be needed to manage blood pressure if the patient is found to have hyper- PHYSICAL EXAMINATION tension-mediated intracranial hematoma, and Vital signs should be evaluated, includ- further testing may be required if the patient is ing blood pressures in both arms, to rule found to have subarachnoid hemorrhage (e.g., out stenosis of the subclavian artery, which to rule out aneurysm). may manifest as grossly asymmetric pressures. CT scanning also can identify conditions Auscultation of the heart and neck also should that mimic TIA, including tumors and other be performed. Carotid bruits, when present, masses (especially if hemorrhage occurs are neither highly specific nor highly sensitive acutely within a mass), as well as conditions for carotid artery stenosis. that are associated with or auras. All patients with possible TIA should A head CT scan can identify signs of early receive a detailed, documented neurologic brain damage or evidence of old strokes.11,12 examination, with emphasis on cognitive and Finally, CT scanning of the head with contrast language function, cranial nerve function, medium should be performed in the febrile facial and limb strength, sensory function, patient to rule out an infectious cause or in the deep tendon reflex symmetry, and coordi- patient with a suspected mass (e.g., metastatic nation. This examination can be helpful in carcinoma, abscess). determining whether a patient previously had Because of increased bony artifact in the an unrecognized stroke. It also can serve as a posterior fossa, CT scanning is not sensitive baseline examination if the patient’s neuro- for evaluating disease in the brainstem or logic status worsens or neurologic symptoms . In these instances, magnetic reso- recur. Occasionally, the neurologic examina- nance imaging (MRI) is the preferred study. tion may identify a nonischemic cause for Electrophysiologic Testing. All patients should an acute neurologic deficit (e.g., acute radial have a baseline electrocardiogram (ECG) with nerve palsy, isolated third-nerve palsy in a rhythm strip.6,12,13 If the ECG is abnormal or the patient with diabetes mellitus). patient has a history of cardiac disease, echocar- diography should be performed. Atrial fibrilla- DIAGNOSTIC TESTS tion and left ventricular hypertrophy (suggest- Brain Imaging. Computed tomographic ing unrecognized chronic hypertension) are (CT) scanning of the head without contrast important risk factors for stroke. Recent data medium should be performed to identify suggest that the 90-day risk for a cardiac event

APRIL 1, 2004 / VOLUME 69, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1669 TABLE 3 Further Diagnostic Testing Based on the History in Patients Undergoing Evaluation for Possible TIA*

History Implications Tests

Headache in postpartum Venous MRI with venography or cerebral angiography or dehydration setting Subacute or acute bacterial Blood cultures, head CT scan with and without contrast medium; endocarditis in selected patients with confirmed bacterial endocarditis, perform cerebral angiography to rule out a mycotic aneurysm. Confusion, headache, CNS vasculitis Cerebral angiography, ESR, (to look for elevation of seizure white blood cell counts in particular) Hypertensive encephalopathy Careful blood pressure monitoring in intensive care setting; consider MRI. Rheumatologic disease, CNS vasculitis Consider cerebral angiography, ESR, lumbar puncture (to look for sympathomimetic drug use elevation of white blood cell counts in particular). Recent myocardial infarction Cardioembolic source Transthoracic or esophageal echocardiography Head, neck, jaw pain, Carotid or vertebral dissection Consider cerebral angiography or other neck neuroimaging studies especially after trauma (see text). Abrupt onset of severe Subarachnoid hemorrhage Emergency head CT scan; if the scan is negative, evaluate headache with cerebrospinal fluid for elevated count or perform photophobia, or cerebral angiography to rule out aneurysm or arteriovenous recent syncope malformation. Confusion, stupor, , Vertebrobasilar ischemia Consider intracranial magnetic resonance angiography or cerebral other brainstem symptoms angiography; if basilar artery is significantly thrombosed, consider (poor prognosis) intra-arterial thrombolytic therapy (if available). Brain swelling, impending Immediate head CT scan; if the scan is positive, emergency herniation neurosurgical intervention may be required. No obvious risk factors “Cryptogenic stroke,” patent Consider cerebral angiography, transesophageal echocardiography, for stroke foramen ovale, intra-atrial and work-up for hypercoagulable state. septal aneurysm, valvular or aortic arch disease

TIA = transient ischemic attack; MRI = magnetic resonance imaging; CT = computed tomography; CNS = central ; ESR = erythrocyte sedimentation rate. *—The initial work-up for the patient with possible TIA is outlined in Figure 1.

is seven times higher in patients with TIA and that transesophageal echocardiography should abnormal ECG findings than in those with a be considered in patients without an identifi- normal ECG (4.2 versus 0.6 percent).13 able cause of TIA or known cardiac disease, If the ECG is unrevealing, cardiac moni- because it may detect a condition requiring toring in selected patients could help diag- therapeutic intervention (e.g., anticoagulation nose paroxysmal atrial fibrillation (or other for ). Aortic plaque, which has been in patients with syncope or pal- associated with stroke, can be visualized well on pitations). In patients with untreated atrial transesophageal echocardiography. fibrillation, echocardiography may identify Laboratory Tests. A complete blood count a thromboembolic source or left ventricular with platelet count should be obtained to rule systolic dysfunction, both of which are com- out polycythemia, thrombocytopenia, and mon predictors of ischemic stroke.14 thrombocytosis. It is helpful to know the pro- Transesophageal echocardiography is super- time (PT), activated partial throm- ior to transthoracic echocardiography for eval- boplastin time (aPTT), and International uating possible dysfunction of the left atrium Normalized Ratio (INR) before antiplatelet or (including thrombus) or a patent foramen anticoagulation therapy is administered; the ovale (an etiology for paradoxical emboli), PT, aPTT, and INR can be elevated in some atrial septal defects (including aneurysm), and hypercoagulable states. aortic plaque. Recent clinical trials15,16 suggest The glucose level should be determined to

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rule out hypoglycemia or and to resonance angiography (MRA) with contrast help diagnose occult diabetes. Blood urea nitro- medium or by CT angiography. If the work- gen and creatinine levels are important, because up demonstrates carotid or other large-vessel poor renal status may prohibit the use of con- atherosclerotic disease in the patient with TIA trast media in imaging studies. An erythrocyte and unrecognized CHD, coronary artery test- sedimentation rate (ESR) should be obtained to ing is recommended.19 potentially rule out vasculitis. Finally, a drug of MRI. Clear advantages of MRI of the brain abuse screen, a pregnancy test, a homocystine over CT scanning of the head include better level determination, or a blood alcohol level imaging of tissues (i.e., greater sensitivity for measurement should be performed in selected early edema), superior imaging within the patients. posterior fossa (including the brainstem and cerebellum), additional planes of imaging Follow-Up Evaluation (sagittal, coronal, and oblique), and no expo- LIPID PROFILE sure to radiation. After the initial more abbreviated evalua- A clear disadvantage of brain MRI is that it tion in the emergency department, risk factors may or may not identify hemorrhage. For this for stroke can be reassessed thoroughly later reason, although MRI can be helpful, it should in the evaluation. Recent data indicate that not replace urgent CT scanning of the head in treatment with (3-hydroxy-3-methyl- the initial work-up of patients with possible glutaryl coenzyme A reductase inhibitors) TIA. When cerebrovascular malformation, reduces the risk of stroke by about 30 percent aneurysm, cerebral venous thrombosis, or arte- in patients with CHD.17,18 Therefore, a fasting ritis is suspected, MRI or MRA is preferred. lipid profile reflective of the patient’s normal Diffusion-weighted imaging detects cellular eating habits should be obtained, and edema as early as 10 to 15 minutes after symp- therapy should be initiated if indicated. tom onset. However, this technique is not yet widely available. HYPERCOAGULABLE STATES MRA. This imaging modality is a noninva- Patients with known risk factors for stroke sive means of assessing intra- and extracranial and those with a history of migraine, sponta- vessels. Current MRA techniques use intrave- neous abortion, pulmonary emboli, or deep nously administered contrast medium (gado- venous thrombosis, or a family history of any linium) to visualize the vessels. of these conditions, should be evaluated for MRA with the administration of con- hypercoagulable states. Initial tests include trast medium also is effective in identify- ESR, antinuclear antibody test, rapid plasma ing vertebrobasilar stenosis, although recent reagent test, and antiphospholipid antibody data suggest that intracranial tests. Referral to a hematologist or neurolo- disease can be missed.20 Depending on the gist can ensure cost-effective evaluation of MRA acquisition technique, the percent- the multiple coagulation-factor abnormalities age of intracranial vessel stenosis can be and conditions that can cause embolic stroke. overestimated (sensitivity of approximately 85 percent compared with cerebral angiog- TESTING FOR ARTERIAL PATENCY raphy).21 Therefore, if accuracy is therapeu- AND BLOOD FLOW tically important, cerebral angiography is Carotid duplex ultrasonography should be necessary. performed in a reliable laboratory, preferably When near occlusion of the carotid artery one with validation against the results of cere- cannot be distinguished from complete occlu- bral angiography. Alternatively, cerebral and sion on MRA or carotid Doppler ultrasound cervical vessels can be evaluated by magnetic studies, cerebral angiography should be con-

APRIL 1, 2004 / VOLUME 69, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1671 sidered. Surgery generally cannot be per- tion. Because the technique requires venous formed on completely occluded vessels. injection of contrast dye, the patient’s renal Special consideration should be given to status should be considered before the test is patients who present with a history or symp- performed. toms that suggest arterial dissection. This con- Conventional CT scanning in combination dition can be diagnosed using neck MRI scans with CT angiography currently is being evalu- in certain sequences that can identify hemor- ated as an addition to the diagnostic imaging rhage within the vessel wall (T1-weighted tools for use in patients with TIA or stroke. images with fat suppression). This combination can provide useful infor- Patients with carotid artery dissection can mation about vascular anatomy (in the form present with acute or subacute unilateral of three-dimensional reconstructions) and neck, head, or jaw pain. These symptoms may the extent and location of infarction. It may be associated with visual or language deficits, allow rapid evaluation of patients with TIA or or with sensorimotor deficits, particularly in stroke in hospitals or institutions that do not the opposite arm. More typically, patients have MRI capability. with carotid artery dissection present with Cerebral Angiography. This technique con- only some of these features, such as temporal tinues to be the gold standard for complete headache with lateral neck pain and, possi- evaluation of intracranial and extracranial ves- bly, transient visual obscuration (amaurosis sels. With cerebral angiography, both arterial fugax) because of thromboemboli in the oph- and venous phases of cerebral blood flow can thalmic artery. be visualized (dynamic study). However, cere- Both carotid and vertebral artery dis- bral angiography is an invasive technique that sections have been described after trauma, can result in neurologic complications (total although spontaneous dissection also is com- rate: 1.3 to 4.6 percent),22,23 includ- mon. Patients should be evaluated for con- ing major stroke or death in 0.1 to 1.3 percent nective tissue disease because of the associated of patients, depending on the study.24,25 increased risk of dissection. Relative indications for cerebral angiog- If the MRI or MRA study is inconclusive, raphy include suspected carotid dissection cerebral angiography should be used to rule unconfirmed on a noninvasive neuroimaging out arterial dissection or better define the study, subarachnoid hemorrhage (to identify percentage of vessel narrowing. bleeding source), in CT Angiography. This modality is another the absence of hypertension, and vasculitis. If state-of-the-art technique for detecting one of these conditions is suspected, referral blood flow to the brain. CT angiography also to a neurologist can be helpful in obtaining is becoming a useful imaging modality for and interpreting the angiogram. identifying carotid or vertebral artery dissec- Special Considerations The Author VERTEBROBASILAR ISCHEMIA NINA J. SOLENSKI, M.D., is associate professor of and a staff member of the Typical signs and symptoms of ischemic Stroke Center at the University of Virginia Health Sciences Center, Charlottesville. Dr. syndromes involving the anterior and pos- Solenski received her medical degree from Jefferson Medical College of Thomas Jeffer- terior circulations are listed in Table 4. The son University, Philadelphia, and completed a neurology residency and cerebrovascular fellowship at the University of Virginia Health Sciences Center. brainstem and cerebellum are confined within the posterior fossa, a bony cavity with poor Address correspondence to Nina J. Solenski, M.D., Stroke Center, Department of Neurology, P.O. Box 800394, University of Virginia Health Sciences Center, Hospital tolerance of brain swelling or mass effects Dr., McKim Hall, Room 2055, Charlottesville, VA 22908 (e-mail: [email protected]). (e.g., from hemorrhage). Because brainstem Reprints are not available from the author. structures are essential for preserving criti- cal respiratory function and arousal states,

1672-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 7 / APRIL 1, 2004 TABLE 4 Typical Characteristics of Ischemic Syndromes Involving the Anterior and Posterior Circulations

Ischemic syndrome: circulation involved Signs Symptoms

Anterior circulation* Visual-field cut Inability to see well (i.e., difficulty reading or driving Language dysfunction (left hemisphere most Difficulty finding or understanding words, inability to read, often affected): aphasia garbled or slurred speech Motor dysfunction: contralateral face, arm, Dropping objects; depending on severity, inability to lift or leg weakness or move a body part or objects Sensory dysfunction: contralateral increased Tingling (paresthesias), numbness, or pain or decreased sensation to pain, heat, or cold Behavior dysfunction (right hemisphere): The patient usually reports no symptoms, but family inattention to surrounding environment, members or others report that the patient has difficulty particularly to one side; if severe, patient dressing, ignores half of food on a plate, or has poor may deny deficits or even his or her own attention to one side of the room or to someone speaking body parts to the patient on one side versus the other (most often, the left side is ignored). Posterior circulation† Nystagmus Vertigo (spinning sensation) Disconjugate gaze If subtle, blurry or double vision Homonymous visual-field cut Inability to see well, especially to one side Contralateral weakness Dropping objects, inability to fully lift or move the limb Incoordination of trunk or limbs () Clumsiness, falling, inability to coordinate an action (e.g., drink from a cup without spilling contents) Motor or sensory dysfunction on opposite For example, the patient may report double vision, side of cranial nerve deficits (crossed signs droopiness on the left side of the face, and dragging suggest brainstem involvement) of the right leg (because of weakness). Bilateral signs Abrupt weakness of both legs, falling Decreased mentation; stupor or coma Family members or others report that the patient has poor responsiveness or that they are unable to arouse the patient.

*—Includes the internal carotid artery, , and anterior cerebral artery, as well as the branches of these . †—Includes the vertebral arteries, basilar artery, and posterior cerebral artery, as well as the branches of these arteries.

patients with vertebrobasilar ischemia should or inflammation. be monitored closely. It also is crucial to search Because cardiac abnormalities are among for life-threatening , the most common causes of TIA in young such as basilar artery stenosis or thrombosis patients, a baseline ECG with rhythm strip or disease affecting multiple large vessels (e.g., should be obtained, and transthoracic and bilateral, vertebral, or carotid artery stenosis). transesophageal echocardiography should be considered. A toxicology screen for drugs TIA IN A YOUNG PATIENT of abuse (especially sympathomimetic com- When a TIA occurs in a patient younger pounds) usually is performed. than 45 years, particularly if there are no clear Several newly identified, genetically based risk factors for stroke, it is advisable to refer metabolic and hematologic syndromes have the patient to a neurologist for consideration been found to be associated with stroke. With of specialized testing. For example, it may be some of these syndromes, initial symptoms necessary to determine the utility of cerebral occur in the younger years (late childhood, angiography to rule out vasculitis, carotid adolescence, or early adulthood). Diagnosis artery dissection, and other forms of nonath- of these syndromes may require specialized erosclerotic vasculopathy, or lumbar spinal tests. Such testing could be important to bet- puncture with cerebrospinal fluid evaluation ter define treatment options and prognosis, as may be required to rule out chronic infection well as to identify family members who may

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