Optimal Management for Transient Ischaemic Attack Patients to Best Prevent Stroke
only reveals acute ischaemic lesions (which would change the diagnosis from TIA to stroke according to the new definition), but also demonstrates the burden of previous cerebral ischaemia and allows more insight into the vascular state (including possible perfusion deficits).
scores >3, symptom fluctuations on presentation, ipsilateral carotid stenosis or potentially active known embolic sources (e.g. atrial fibrillation) after recent changes or withdrawal of antithrombotic medication, after surgery or interventional treatment, etc. They should be admitted into a specialised stroke centre to allow for a quick and comprehensive work-up. In case of repeat or permanent symptom fluctuations, immediate thrombolysis is recommended.6,34 An initiation of antiplatelet therapy (if not contraindicated) is generally recommended because of its rapid action and its known efficacy in secondary prevention.19
Patients at highest risk are those with TIA within the past 48 hours, ABCD2
Patients who had TIAs days before
presentation should also receive a full work-up in a specialised stroke setting to conduct the necessary examinations quickly.4
Most
guidelines agree that initial examinations (within 24 hours) should include extracranial and transcranial Doppler/duplex imaging, electrocardiography (ECG), laboratory tests and continuous 24-hour monitoring of clinical, ECG, blood pressure, respiration, fever and other parameters (oxygen, blood sugar, electrolytes, inflammation parameters).19,41
The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) could show that a blood-pressure-lowering regimen with perindopril and indapamide lead to a risk reduction over a follow-up period of four years.50
In the case of high-grade carotid
stenosis identified as the cause of TIA, early carotid endarterectomy is of benefit if performed shortly after the TIA and there is a favourable benefit–risk ratio.51,52
It is very important to stress that early identification, work-up and treatment of TIAs play an essential role in the effective stroke risk reduction. This well-known insight was evidence-based by studies that examined the impact of urgent TIA management and start of secondary prevention. In the EXPRESS study, it was demonstrated that the fast assessment of TIA patients and the commencement of suitable preventive treatment in UK reduced the risk of early stroke by about 80% after TIA or minor stroke compared with current standards.53
Conclusion
If a cardioembolic mechanism is suspected or no distinct aetiology has been found, transthoracic and/or transesophageal echocardiography for endocarditis, atrial thrombus or for right-left-shunting is recommended. This is particularly recommended in (but not limited to) patients below 55 years of age.42
Stroke Prevention
Several different treatments have been shown to independently improve long-term outcome and stroke prevention. Antiplatelet therapy should be immediately used in patients found to have non-cardioembolic TIAs. In most cases, aspirin is sufficient alone or sometimes in combination with dipyridamole.43,44
In cardioembolic TIAs due to atrial fibrillation, oral anticoagulation should be initiated,45
heparin administration or (in the near future) with new fast-acting anticoagulants (oral direct Xa-inhibitors).46,47
Statins are also effective in reducing recurrent stroke risk, as shown by the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial, and should be administered immediately after TIAs.48,49
1. 2. 3. 4. 5. 6.
Marshall J, The natural history of transient ischaemic cerebro-vascular attacks, Q J Med, 1964;33:309–24.
Easton JD, Albers GW, Caplan LR, et al., Discussion: Reconsideration of TIA terminology and definitions, Neurology, 2004;62:S29–34.
Daffertshofer M, Mielke O, Pullwitt A, et al., Transient ischaemic attacks are more than ‘ministrokes’, Stroke, 2004;35:2453–8.
Lavallee PC, Meseguer E, Abboud H, et al., A transient ischaemic attack clinic with round-the-clock access (SOS- TIA): feasibility and effects, Lancet Neurol, 2007;6:953–60.
Tsivgoulis G, Stamboulis E, Sharma VK, et al., Multicentre external validation of the ABCD2 score in triaging TIA patients, Neurology, 2010;74:1351–7.
Chatzikonstantinou A, Willmann O, Jager T, et al., Transient ischaemic attack patients with fluctuations are
7.
at highest risk for early stroke, Cerebrovasc Dis, 2009;27: 594–8.
Crisostomo RA, Garcia MM, Tong DC, Detection of diffusion-weighted MRI abnormalities in patients with transient ischaemic attack: correlation with clinical characteristics, Stroke, 2003;34:932–7.
8. 9.
Yates PO, Hutchinson EC, Cerebral infarction: the role of stenosis of the extracranial cerebral arteries, Memo Med Res Counc, 1961;300:1–95.
Albers GW, Caplan LR, Easton JD, et al., Transient ischaemic attack: proposal for a new definition, N Engl J Med, 2002;347:1713–6.
10. Sherman DG, Reconsideration of TIA diagnostic criteria, Neurology, 2004;62:S20–1.
11. Adams HPJ, del Zoppo G, Alberts MJ, et al., Guidelines for the early management of adults with ischaemic stroke: a
either after early low-molecular-weight
Anastasios Chatzikonstantinou is a Neurologist and Senior Physician at the University Hospital of Mannheim of the University of Heidelberg.
TIAs carry a high risk of early stroke and also influence long-term prognosis. While it can be challenging to recognise a TIA correctly and assess the individual risk of each patient, clinical features, risk scores, brain imaging and other investigations or parameters can help not only to make the correct diagnosis, but also estimate the stroke risk properly. Urgent assessment in a specialised stroke unit or dedicated emergency unit with special expertise and initiation if suitable preventive treatment such as antiplatelet agents, anticoagulation, statins, antihypertensive drugs or even early carotid endarterectomy, can greatly affect outcome and reduce the risk of a permanent stroke. n
Michael G Hennerici is a Professor of Neurology at the University of Heidelberg and Chair of the Department of Neurology at the University Hospital of Mannheim. He is founder of the European Stroke Conference and Chair of its Programme Committee and Editor-in-Chief of Cerebrovascular Diseases. In 2006 he was awarded the Karolinska Stroke Award for Excellence in Stroke Research.
guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists, Circulation, 2007;115:e478–534.
12. Hankey GJ, Redefining risks after TIA and minor ischaemic stroke, Lancet, 2005;365:2065–6.
13. Inatomi Y, Kimura K, Yonehara T, et al., DWI abnormalities and clinical characteristics in TIA patients, Neurology, 2004;62:376–80.
14. Lamy C, Oppenheim C, Calvet D, et al., Diffusion-weighted MR imaging in transient ischaemic attacks, Eur Radiol,
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