A transient ischaemic attack needs emergency assessment to help prevent a full-blown stroke. The new scientific statement offers a standardised approach to evaluating people with suspected TIA, specifically for GPs that may not have access to advanced imaging or an on-site neurologist.

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The American Heart Association (AHA) has released a new scientific statement that provides a standardised method for assessing patients who may have had a transient ischaemic attack (TIA), with consideration given to the difficulties experienced by low-resource settings.

There should be immediate medical attention for TIAs since they are warning shots of an impending stroke.

The purpose of this scientific statement is to provide clinicians with the tools they need to properly risk-stratify patients who have been diagnosed with TIA and decide which patients require hospitalisation and which may be safely discharged from the hospital if appropriate and prompt follow-up has been arranged.

Specifically, the statement discusses how we can recognise and be sure in identifying a TIA patient and what would imply an alternate diagnosis.

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Perplexing diagnosis

Nearly one-fifth of those who have a TIA will go on to have a full-blown stroke within three months, with nearly half of those strokes occurring within the first two days.

Although TIAs are rather common, they may be difficult to identify since many patients no longer exhibit symptoms by the time they reach the emergency room. Unfortunately, there is likewise no verification procedure. It's possible that these difficulties may be amplified by the lack of resources and stroke experts available in rural areas.

The statement also includes recommendations for recognising the difference between a true TIA and a TIA mimic.

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TIA and TIA mimics: Differentiating characteristics

TIA is often seen in elderly people who have vascular risk factors. Patients with TIA have symptoms that peak just after they start and last for around 60 minutes. The patient may have intact mentation, localised neurological symptoms, headache with ptosis/miosis, dizziness with cranial neuropathies, vision loss, difficulty with coordination and walking, truncal ataxia, and hypertension at presentation.

Patients with TIA mimics are often young and free of vascular risk factors, albeit they may have a history of epilepsy, migraines, or brain tumours. The symptoms may extend from the initial location and may be evidence of an alternate diagnosis such as migraine, changed mental status, or seizures (ie, positive visual phenomena, seizure-like activity, positional vertigo with focal symptoms).

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How to proceed?

To check for subacute ischaemia, haemorrhage, or mass lesions, a non-contrast head computed tomography (NCCT) scan should be performed immediately in the emergency room if one is available. The research group asserts that although NCCT has limited sensitivity for detecting acute infarcts, it is helpful for excluding TIA imitators.

The recommended approach for diagnosing an acute ischaemic infarct is multimodal brain MRI, which is often used after an NCCT and should ideally be acquired within 24 hours of the beginning of symptoms.

It is nevertheless feasible to establish a clinical diagnosis of TIA in the ED on the basis of a negative NCCT and symptom remission within 24 hours when MRI cannot be acquired promptly to definitely differentiate TIA from a stroke.

Admission to a hospital for an MRI, a full workup, and a neurology consultation might be the next move. Other possibilities include moving patients to a facility with cutting-edge imaging and vascular neurology training or scheduling an outpatient MRI promptly (preferably within 24 hours).

Additionally, the statement offers advice on the benefits, restrictions, and things to keep in mind while using doppler ultrasonography, computed tomography angiography, and magnetic resonance angiography to examine TIAs.

A cardiac work-up is suggested after a TIA diagnosis due to the possibility that heart-related issues contributed to the TIA.

Each centre is responsible for using the available resources and developing a route to guarantee the effective care and disposal of patients with a transient ischaemic attack (TIA), with the ultimate aim of minimising the risk of future stroke.

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Case 

A 56-year-old male presents 2 days after a brief (15-minute) incident of transitory visual loss in the left eye. The loss of vision was followed by a gradual recovery from the centre to the periphery. Afterwards, the patient claimed to feel exhausted. There are no additional neurological symptoms or indicators, such as headaches. BP for the patient was 150/100 mm Hg. No migraine history. Normal fundii examination and ophthalmic examination with normal vision and intraocular pressure.

Diagnosis- Brief monocular vision loss followed by complete recovery i.e. TIA

Risk of stroke in the next year after TIA- Approximately 2% of patients will develop a major stroke within 48 hours; up to 10% of patients within 90 days; and up to 22% within one year. Most TIAs cure within 60 minutes, and there is a less than 15% chance that they will completely recover if they linger longer.

The ABCD2 score of a TIA

• ABCD is an abbreviation used in clinical practice to identify TIA patients with the greatest risk of suffering a stroke. Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes.
• A points system is used for each of these risk factors, as per the below.

ABCD2 score

• Age: ≥60yrs (1pt)
• Blood pressure: Systolic BP ≥140 or Diastolic BP≥90 (1pt)
• Clinical features: Focal weakness (2pts) or speech impairment without focal weakness (1pt)
• Duration of symptoms: ≥60min (2pts) or ≤59min (1pt)
• Diabetes: (1pt)
• Advancing age, male gender, hypertension and diabetes = high risk.
• Higher ABCD2 scores are correlated with higher risks of impending strokes.

Risk of a stroke in 2 days

• 0-3pts = 1% risk
• 4-5pts = 4.1% risk ≥4pts admit to hospital
• 6-7pts = 8.1% risk

According to studies, TIA patients with an ABCD2 score of four or above had a considerably elevated risk of stroke in the near future. Those with scores lower than four were at a lesser risk. Guidelines for best practices suggest that patients with an ABCD2 score of 4 or above be admitted to the hospital promptly for diagnostic examination and treatment initiation. With low ABCD2 scores, the danger of imminent strokes is still quite significant, thus these patients must be sent to their primary care physicians within two days following a TIA for a comprehensive diagnostic assessment.

Review of the case:

ABCD2 score for this patient

• A 0 points
• B 1 point
• C 0 points
• D 1 point
• D 0 points
• Score 2
• Risk of a stroke in 2 days 1 % risk

Instructions and care plans for this patient:

1. Referred after complete evaluation of cardiovascular risk factors and control of blood pressure
2. Education regarding stroke risk, symptoms, and the need for immediate medical treatment

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.