Brain Trauma Stroke
Is There an Optimal Management Regimen for Transient Ischemic Attack Patients to Best Prevent Stroke?
Anastasios Chatzikonstantinou, MD1 and Michael G Hennerici, MD, PhD2 1. Neurologist and Senior Physician; 2. Professor of Neurology, and Chair, Department of Neurology, University Hospital of Mannheim, University of Heidelberg
Abstract
Transient ischemic attacks (TIAs) are associated with a high risk of subsequent stroke and often pose a diagnostic and treatment challenge. It is important to separate TIAs from stroke as well as from TIA mimics to estimate individual stroke risk early and properly. New definitions and standards of clinical investigations are supportive: clinical parameters as symptom fluctuations, clinical scores (such as the ABCD2 score) and advanced magnetic resonance brain imaging in particular. Management should take place in a stroke-specialized center and consist of rapid assessment and identification of those patients at highest risk for subsequent strokes, including extensive brain and vascular imaging as well as cardiological assessement. Based on these work-up results, best suitable prevention should start immediately, usually consisting of antiplatelet agents, anticoagulation, statins, antihypertensive, and/or antidiabetic drugs and lifestyle modifications, including cessation of smoking. Studies have demonstrated that such an optimal management can reduce the risk of stroke following TIA by up to 80%.
Keywords Transient ischemic attack (TIA), stroke, risk prediction, stroke prevention
Disclosure: The authors have no conflicts of interest to declare. Received: July 29, 2010 Accepted: October 4, 2010 Citation: US Neurology, 2010;6(2):48–52 Correspondence: Michael G Hennerici, MD, PhD, Department of Neurology, Universitätsmedizin, Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany. E:
hennerici@neuro.ma.uni-heidelberg.de
The classic definition of transient ischemic attacks (TIAs) based on focal neurological deficits most likely due to cerebrovascular diseases with full recovery within 24 hours dates back to the 1960s.1
With the advent of
advanced neuroimaging techniques (computed tomography [CT] and magnetic resonance imaging [MRI]), new insights into pathobiology and prognosis of cerebrovascular events, as well as the approval of recombinant tissue plasminogen activator (rtPA) treatment and the increasing emergency management in stroke units, this definition has become outdated and suggestions for its change have been frequently made.2
these patients to a stroke unit for full work-up within 72 hours, others propose 24-hour open ‘TIA clinics’ or even a quick work-up in a specialized outpatient department.4 score5
or fluctuations of symptoms6
Predictors such as the ABCD2 characterizing the individual risk for
stroke are clinical or imaging-related (CT, MRI).7
Although many patients with acute ischemic stroke have repeatedly been demonstrated to benefit from this advanced concept of ‘time is brain’ and ‘stroke is an emergency’, those patients with rapid, spontaneous recovery after onset of symptoms (within less than three hours) have still been investigated less sufficiently: among the extremes are misdiagnosis of ‘TIA mimics’ resulting in no treatment at all or premature thrombolysis as well as underestimation of the high risk for suffering a full stroke within 10–14 days if adequate diagnosis and prevention is omitted or patients do not seek medical advice in due time.
With this in mind and considering the fact that TIAs are well recognized risk factors for stroke (mean annual stroke risk after TIAs has been found to be up to 15%),3
TIAs stopped to be considered harmless long
ago. Currently, different strategies have been inaugurated for the management immediately after onset. While many prefer admitting
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Good TIA management requires a practical definition and confident diagnosis, based on good and reliable diagnostic tools, separation from TIA mimics, a valid prognosis and stroke risk assessment to identify potential sources of stroke and risk factors and a strategy for treatment and prevention.
Definition and Diagnosis of Transient Ischemic Attack
The original TIA definition as “a cerebral dysfunction of ischemic nature lasting no longer than 24 hours with a tendency to recur” was based on pure clinical findings and was formulated in a time period in which neuroimaging was rudimental and acute stroke treatment missing. Despite neuropathological evidence already available at that time,8 people thought that TIAs did not cause permanent brain damage. A new definition of TIA and even the abandoning of this term have been proposed during the last decades. Many experts support the idea of changing the time limit to <1–2 hours with practical consequences in the acute situation, when the decision whether the patient should be
© TOUCH BRIEFINGS 2010
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