76 y/o Hispanic F with PMHx: of HTN, HLD, and vertigo. PSHx: cholecystectomy, C-section x3. Presents to the ED for evaluation of occipital headache, R sided weakness/numbness, and right facial droop x 25 hours. Patients last known normal about 25 hours PTA. Per daughter the patient experienced slurred speech and difficulty ambulating one hour after onset of initial symptoms. Patients reported that she was seen by her PMD a few hours after symptom onset, who advised her to go to the ED for a stroke evaluation. Slurred speech and facial droop resolved before she arrived at the ED. At time of examination patient had weakness and decreased sensation to right face/arm/and leg. Patient’s NIHSS score was =1. CT head w/o contrast was negative (no sign of ICH). Labs were all WNL with no sign of infectious process. B12 levels were normal. Finger stick glucose 106 mg/dl. Pt’s ABCD2 score was 5. We suspected the patient had suffered a TIA.

For the management of this patient I chose to use an article from the journal “Annals of Emergency Medicine. It is a systematic review of systematic reviews and does a great job in summarizing the available evidence on how to manage a patient with a suspected TIA and provides an easy to follow chart and algorithm.

According to the article the incidence of acute ischemic stroke within 48 hours of an ED visit for transient ischemic attack is 4.8% (182/3,814 patients; 95% confidence interval [CI] 4.0% to 5.6%). By providing rapid implementation of multiple interventions stroke outcome can be reduced the by as much as 80 percent.

The first step in risk stratification is the initial evaluation, since the diagnosis of transient ischemic attack is usually based entirely on the patient’s history. While the formal risk-stratification tool, the ABCD2 scale is the most commonly used, it does not accurately identify the patients with large vessel occlusion or atrial fibrillation. Atrial fibrillation accounts for approximately 20% to 25% of transient ischemic and can be treated with acute interventions such as ablation, cardioversion, or if stable with rate control medication. Patients with symptomatic carotid stenosis greater than 50%, also have a high risk for a stroke and risk can be reduced by urgent revascularization.

In order to identify most treatable causes of the transient ischemic attack patients should:

• Undergo basic laboratory testing.
• Get an ECG.
• Be placed on cardiac telemetry.
• Along with calculating the ABCD2 score get imaging done such as:

-MRI with diffusion-weighted imaging or CT w/o contrast

-CT angiography to look for large vessel and carotid ultrasonography to improve risk stratification.

Recommended Management:

• Admit transient ischemic attack patients with a cardioembolic cause, such as atrial fibrillation, cardiomyopathy, left ventricular thrombus, valvular disease without atrial fibrillation, and aortic arch atherosclerosis
• Patients with atrial fibrillation should receive full anticoagulation with warfarin.
• Admit patients with large vessel disease such as carotid stenosis, vertebral or intracranial artery stenosis or arterial dissections, and administer aspirin and have urgent neurologic consultation.
• Administer antiplatelet with aspirin unless contraindicated, and initiate statin therapy.
• Manage patients BP, and counsel on smoking cessation

Algorithm:

 

Managing Patients with Transient Ischemic Attack

Edlow, Jonathan A.

Annals of Emergency Medicine, Volume 71, Issue 3, 409 – 415

https://www.annemergmed.com/article/S0196-0644(17)30789-8/pdf