Brain Trauma Stroke
Figure 2: Flowchart of Acute Transient Ischemic Attack Management (24 hours)
Suspicion of TIA
and present with different manifestations (symptoms, duration, frequency) and diverse risk factor profiles.30
Most of these patients will Yes Symptoms persist? No
not suffer an early stroke after a TIA, but it is a great challenge for physicians seeing these patients in the acute phase to distinguish those with high from those with low stroke risk. Tools for risk assessment are useful in order to achieve a fast, adequate and cost-effective management of TIA patients. Table 1 summarizes the most important factors associated with high stroke risk after TIAs.
Clinical Features and Scores Consider thrombolysis (Even if full recovery) Brain imaging (MRI, if not possible then CT) + Risk assessment
(progression, fluctuations, ABCD2 known vascular risk factors)
Outpatient Inpatient (stroke center)
Initiation of antiplatelet therapy
+
Full stroke work-up (vascular imaging, ECG, laboratory tests, echocardiography)
+
Outpatient (TIA clinic)
Verification of TIA diagnosis (history, neurological examination) Probable/possible TIA
Many factors were found to independently predict high stroke risk after TIAs. Of these, age (>60 years), blood pressure, unilateral weakness, speech disturbance, duration of symptoms, and diabetes were found to be significantly associated with early stroke risk in many studies, so they were used to compile the ABCD and later the ABCD2
scores.25,26
Both scores have been validated in many studies. They also have a good and statistically significant predictive value to detect ‘true’ TIAs as opposed to mimics.5,31
individual estimate and a recent study showed that the ABCD2
However, results are less valid for a short-term score
was less prognostic, but rather predicted a worse severity of recurrent ischemic events.30
validity of the ABCD2
Furthermore, recent studies have cast doubts on the score at least in some settings.27,31
Nevertheless,
this score has been adopted by several guidelines to characterize a standardised profile of patients once admitted to a stroke center.32 An important and presumably the best individual clinical feature that helps predict early stroke after a TIA are symptom progression or fluctuation within a short time window (<12 hours). Patients with such ‘unstable’ TIAs have repeatedly been shown to be at highest risk for subsequent stroke.6,33,34
Neuroimaging
Stroke prevention depending on risk profile (antiplatelet/anticoagulants, statins…)
CT = computed tomography; ECG = electrocardiography; MRI = magnetic resonance imaging; TIA = transient ischemic attack.
for stroke following TIAs is higher than the risk for myocardial infarction (MI) in patients with acute chest pain 12 and can be even higher (up to 25%) in patients with an underlying carotid stenosis, atrial fibrillation, and high ABCD2
scores.24–27 Long-term Stroke Risk
The Life Long After Cerebral Ischemia (LiLAC) study followed 2,473 patients, who were recruited after the period of highest stroke risk.29
In community-based studies, the average annual risk for stroke after TIAs was between 2.4 and 6.7%, in a follow-up ranging from three to nine years. Four major hospital-based studies showed similar results, with an annual stroke rate of between 2.2 and 5% over four to five years.28
At 10 years the risk for a major vascular event was 44.1%.
Risk Assessment after Transient Ischemic Attacks Although an estimate of the general risks of stroke after TIAs is straightforward and well evidenced, affected patients are heterogeneous
50
Computed tomography (CT) was shown to be of prognostic value. Detection of probably previous, silent infarction in TIA patients is associated with increased stroke risk.35
MRI–DWI (in contrast to CT)
is able to detect even small areas of ischemia very early including vascular territories of the posterior circulation and to deliver much more additional information (microbleeds, white matter, ischemic lesions, cerebral vessels, cerebral perfusion deficits). It is of greater usefulness in compliant patients without contraindications and should be first choice in early TIA work-up.36–38
Etiology and Vascular Territory
The etiology of TIAs is also thought to play an important role in the early risk for stroke. This assumption originates from the fact that patients with an associated active large artery disease (e.g. symptomatic carotid stenosis) have almost double the risk for early recurrent stroke compared with patients with lacunar stroke.3,20,39
Strategy for Treatment and Prevention Since TIAs are not a benign entity, all efforts should be made to quickly and efficiently manage patients after onset and despite full recovery from signs or symptoms. Increased public awareness is mandatory to admit patients in an emergency department or stroke unit and to gain better support for an update of healthcare facilities all over Europe and beyond for full work-up and best stroke prevention. Figure 2 summarizes the recommended management in a flowchart.
US NEUROLOGY
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