Transient Ischemic Attack (TIA):

The Calm Before the Storm

Raymond Reichwein, M.D.
Associate Professor of Neurology
Penn State University College of Medicine
Milton S. Hershey Medical Center
January 8, 2009

Disclosures
Boehringer Ingelheim
Genentech
AGA Medical Corp

OBJECTIVES
Discuss the importance of TIA and future
stroke risk.
Discuss optimal TIA evaluation and
management.
Briefly discuss future stroke prevention, from
both an antiplatelet/anticoagulant therapy and
risk factor management standpoint.

Stroke in the US
730,000 new or recurrent strokes each year1
167,366 deaths in 1999 (1 of every 14.3 deaths)2
4,600,000 stroke survivors alive today2
Origin of strokes3
80% ischemic
20% hemorrhagic

1. Broderick J et al. Stroke. 1998;29:415-421.

2. American Heart Association. 2002 Heart and Stroke Statistical Update. 2001.
3. Pulsinelli WA. Cerebrovascular diseases. Cecil Textbook of Medicine. 1996.
07/30/15

TIA
Underrecognized
Underreported
Undertreated

TIA Knowledge
Among 10,112 participants
8.2% correctly related the definition of TIA
8.6% could identify a typical symptom
Men, non-whites, and those with lower income
and fewer years of education were less likely to
be knowledgeable about TIA.
Johnston, et al, Neurology 2003

TIA Definition
Resolution of acute neurological/stroke
deficits within 24 hours.
No imagable acute ischemic stroke changes.

TIAs
The majority of TIAs resolve within 60 minutes,
and most resolve within 30 minutes.
Less than 15% chance of complete resolution of
symptoms if last >1 hour (Levy).
NINDS IV t-PA trial data revealed only 2% chance
of complete symptom resolution @ 24 hours, for
neurological symptoms/deficits that didnt
completely resolve within 1 hour or rapidly
improve within 3 hours.

TIA Epidemiology
>200,000 events per year (compared to >730,000
strokes per year).
Approximately 10-20% of patients will experience a
stroke after a TIA within the first 90 days, and in
approx. 50% of these patients, the stroke occurs in the
first 24-48 hours.
Factors associated with increased stroke risk: advanced
age, diabetes mellitus, symptoms more than 10 minutes,
weakness, and impaired speech. Large artery
atherothrombotic disease more likely to present with a
TIA before a stroke, versus other etiologies.

TIA Epidemiology
Several recent studies reveal a >10% stroke
risk in the 90 days after a TIA.
The risk of stroke within the first 48 hours
after TIA is approximately 5% (greater than
MI risk after presenting with acute chest
pain syndrome).
Blacks and men had higher stroke risk.

Event Risk Within 3 Months

After TIA
12.7%
Independent risk factors for stroke within 90 days
10.5%

after TIA:

Event Rate

age > 60 years

diabetes mellitus
duration of episode greater than 10 min
weakness and speech impairment with the episode
5%
in
48 h

Stroke

2.6%

Recurrent Cardiac
Event
TIA

Johnston SC, et al. JAMA. 2000;284:29012906.

2.6%

Death

TIA before Stroke by Subtype

Large-artery atherothrombotic disease: 2550%.
Cardioembolic sources: 10-30%.
Small vessel/lacunar disease: 10-15%.

Symptomatic Internal Carotid Artery

Disease

NASCET Medical Arm Data (600 patients)

Two-day risk was 5.5%.
90-day ipsilateral stroke risk was 20%.
Degree of stenosis (>70% stenosis) didnt confer
increased stroke risk.
Infarct on brain imaging and presence of
intracranial major-artery disease doubled the early
stroke risk.
Benefit from CEA declines rapidly over several
weeks, particularly in women (Oxford data).

Cumulative Risk of Stroke

Post-TIA (%)

Post-Stroke (%)

48

3 10

1 year

12 13

5 14

5 years

24 29

25 40

30 days

Sacco. Neurology. 1997;49(suppl 4):S39.

Feinberg et al. Stroke. 1994;25:1320.

TIA and ischemic stroke

pathophysiology are the same.
The only difference is transient
versus persistent neurological
deficits. Certainly, a TIA state is
a much better clinical state to
intervene and prevent a future
disabling stroke.

Risk Factors for First Ischemic

Stroke
Modifiable
(value established)

Nonmodifiable

Age
Gender
Race/Ethnic
Heredity

Adapted from Sacco RL. Neurology 1998;51(suppl

3):S27-S30.

Hypertension
Atrial fibrillation
Cigarette smoking
Hypercholesterolemia
Heavy alcohol use
Asymptomatic carotid
stenosis
Transient ischemic
attack

Stroke in Young Individuals

Clotting disorders
Migraine
Birth control pills
Illicit drug use
Arterial dissection
Patent foramen ovale
Autoimmune disorders (lupus)

TIA Evaluation
Prompt evaluation and intervention is the
key.
Most TIA patients should be admitted for
diagnostic evaluation and management
(Observation unit or equivalent); often
significant delay if done as outpatient.
TIA and ischemic stroke diagnostic
evaluations should be the same.

Who should be admitted??

Anyone with no prior/recent TIA/stroke diagnostic
workup; new suspected etiology despite prior
workup.
Suspected large vessel (anterior or posterior
circulation) events.
Most suspected lacunar/small vessel events,
particularly if no prior workup (? calm before the
storm).
Recurrent/crescendo TIAs.

ABCD2 Score
Age 60 or older
Blood pressure >140/90
Clinical
- Unilateral weakness
- Speech impairment
Duration
- 60 minutes or more
- Less than 60 minutes
Diabetes

1 point
1 point
2 points
1 point
2 points
1 point
1 point

ABCD2 Score
Score 4 or greater admit to hospital
(moderate-high stroke risk).
Score predicted risk similarly among all
ethnic backgrounds.
Best predictor of 2, 7, and 90 day stroke
risk among validated scales.

Inpatient TIA Management

Neurochecks; follow blood pressures.
? Cardiac telemetry (paroxysmal a. fib).
? Intravenous Heparin for suspected high risk TIA
sources, pending completion of diagnostic evaluation.
Diagnostic evaluation should be completed within 24
hours; make decision regarding admission or
discharge at that point.
Potential IV t-PA use for recurrent event (acute
ischemic stroke) while hospitalized.

Presumptive TIA/stroke etiology

determines optimal treatment, as
well as risk for recurrent events.

Stroke Subtypes and Incidence

Other
5%

Cryptogenic
30%

Ischaemic stroke
85%

Cardiogenic
embolism
20%

Hemorrhagic
stroke
15%

Atherosclerotic
cerebrovascular
disease
20%
Small vessel
disease
lacunes
25%

Albers et al. Chest 2004; 126 (3 Suppl): 438S512S.

TIA BRAIN IMAGING

Prior CT(brain) studies revealed a 15-20%
incidence of cerebral infarction in a vascular
territory related to the patients symptoms/deficits.
Newer MRI(brain) studies, using diffusionweighted imaging (DWI), reveal approx. 30-50%
acute ischemic stroke findings, and about half of
these persisted on follow-up imaging. Best
correlated with prolonged TIA symptoms.

MRI Diffusion Imaging

Distinguish new versus old ischemic areas.
Distinguish new ischemic areas even with
clinical TIA.
Differentiate stroke etiology (small vessel
vs. large vessel; embolic sources).

Acute Embolic Strokes

Acute Ischemic Stroke