Diagnosis

Transient ischemic attack

Etiology

Cause

• Atherosclerosis: carotid and vertebral or intracranial arteries

• Embolic sources: valvular disease, atrial fibrillation, aortic arch disease, paradoxical embolism via a patent foramen ovale or atrial-septal defect

• Arterial dissection

• Arteritis: vasculitis, drugs, irradiation, local trauma, connective tissue diseases

• Drugs (cocaine)

• Mass lesions (tumors or subdural hematomas)

• Hypercoagulable states (Protein C, protein S, and antithrombin III, Activated protein C resistance/factor V Leiden, Fibrinogen,Anticardiolipin antibody, Lupus anticoagulant, Homocysteine, Factor VIII, Von Willebrand factor)

• Causes in children: Congenital heart disease, cocaine, Clotting disorders, CNS infection, Neurofibromatosis, Vasculitis, Moyamoya, Fibromuscular dysplasia, Marfan disease, Tuberous sclerosis, Tumor, Sickle cell anemia, Focal arteriopathies

Pathophysiology [3m9]

1. Source of occlusion:

   • Cardiac embolism secondary to atrial fibrillation

   • Large artery atherothrombosis: Atherothrombosis --> occlusion (common)

   • Small vessel disease: Small vessel arteriolosclerosis with peripheral obliteration

   • Cryptogenic: Cortical pattern of ischemia without any identifiable source

2. TIA can be considered a serious warning of an impending ischemic stroke; the risk is highest in the first 48 hours following a transient ischemic attack

3. Clinical manifestation:

   • Acute focal neurologic deficit and/or speech disturbance

Risk factor [3m9]

• Hypertension

• Diabetes

• Age

• Smoking

• Obesity

• Alcoholism

• Unhealthy diet

• Psychosocial stress

• Lack of regular physical activity

Complication

• Stroke

Epidemiology

Incidence per 100.000 [csd][ted][dq8][sdd][6s5][ahz][fte]

Approach

• Blood test: hemoglobin, thrombocytes, glucose, troponins, partial thromboplastin time, PT-INR, toxicology, sedimentation rate, ANA, RF [fte]

• Blood gas

• ECG

• CT caput

• MR caput

• CT angiography

• Doppler ultrasonography

• Echocardiography

• Lumbar puncture

ABCD2 score for risk stratification: [fte]

• Age > 60 = 1p

• Blood pressure: Systolic >140 or diastolic >90 = 1p

• Clinic: Paresis > speech impairment = 2/1p

• Duration: > 60 min > 10-59 min = 2/1p

• Diabetes = 1 p

Treatment

Goal of treatment: reduce the risk of stroke with up to 80% [fte][u3f][3m9]

1. Vascular risk factor reduction:

   • Anticoagulation for atrial fibrillation

   • Antiplatelet therapy (aspirin/clopidogrel) if intracranial atherosclerosis

   • Statins if atherosclerosis

   • Management of hypertension

2. Carotid endarterectomy for symptomatic carotid artery stenosis (>50%)

3. Lifestyle interventions: smoking cessation or weight loss

Differential diagnoses

Brain tumor, Carotid artery dissection, Epilepsy, Hypoglycemia, Hyponatremia, Intracranial hemorrhage, Meningitis, Migraine, Multiple sclerosis, Myocardial infarction, Spinal disc herniation, Stroke, Subarachnoid hemorrhage, Syncope