transient ischemic attack (TIA)
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Introduction
A transient ischemic attack (TIA) is a focal neurologic deficit that resolves fully within 24 hours.
The risk of subsequent stroke is 5-10%/year & is highest in the 1st month following a TIA.
Liken to unstable angina of the brain.[17]
Etiology
- large vessel, low flow
- embolic
- cardiac
- aortic arch atheroma
- intravenous drug abuse (IVDA)
- paroxysmal atrial fibrillation identified in 24% of patients with idiopathic TIA[34]
- lacunar or small penetrating vessel
- hematologic disorders
- vasculopathies
Epidemiology
- incidence 1.19/1000 person-years (1948-2017)[47]
- risk of stroke after TIA was lower from 2000-2017 vs 1948-1985[47]
Pathology
- due to ischemia rather than infarction
- any obstructive process in extra- or intracranial arteries can cause a low-flow TIA if collateral circulation to the ischemic area is also impaired
- lacunar TIA's are due to transient cerebral ischemia from stenosis of intracerebral penetrating vessels, usually from lipohyalinosis secondary to hypertension or atheromatous disease at their origin
History
- onset, improvement or progression of symptoms, anatomic location of deficit, activity prior to onset, headache, nausea/vomiting, loss of consciousness, brisk neck movement, visual aura, scotoma, vertigo, seizure, trauma, confusion, dysarthria, incontinence, dysphagia, palpitations, prior TIAs or strokes, amaurosis fugax, HTN, diabetes, CAD, hyper- lipidemia, IVDA, cocaine, valvular heart disease, migraine, anticoagulants, oral contraceptives, tobacco, alcohol
Clinical manifestations
- general
- duration minutes to hours
- most TIAs last 10-20 minutes
- no aura or warning
- no incontinence[4]
- most patients with TIAs are neurologically intact
- low flow TIA's are brief (minutes to hours), recurrent, & stereotyped.
- duration minutes to hours
- embolic TIA's are characterized by focal neurologic symptoms lasting hours
- patients are alert after episode[4]
- carotid artery territory TIAs
- paresthesias of hand, arm & face (contralateral)
- weakness of hand, arm & face (contralateral)
- aphasia (dominant hemisphere)
- dysarthria
- unilateral neglect
- loss of vision (ipsilateral eye)
- carotid bruit
- lacunar TIAs
- hemibody sensory loss or paresthesias
- pure motor hemiparesis
- vertebrobasilar artery territory TIAs
- classic symptoms[49]
- motor weakness
- dysphasia
- hemianopia or quadrantanopia or monocular visual loss
- vertigo + diplopia + dysarthria
- ataxia + other TIA symptoms
- non-classic or non-consensus symptoms[49] -isolated symptoms of vertigo, ataxia, diplopia, dysarthria, bilateral decreased vision, or numbness in one body segment: face, arm, or leg
Laboratory
- complete blood count (CBC)
- coagulation studies
- PT/PTT, INR
- studies for hypercoagulable state
- serum chemistries:
- erythrocyte sedimentation rate (ESR) or serum C-reactive protein (serum CRP)
- antinuclear antibodies (ANA)
- syphilis serology
- toxicology screen
- lumbar puncture
Diagnostic procedures
- electrocardiogram to evaluate for atrial fibrillation
- Holter monitoring vs telemetry
- at least 24 hours[36]
- paroxysmal atrial fibrillation in 24% of patients with idiopathic TIA[34]
- transthoracic echocardiography
- rule oout left ventricular thrombus or atrial thrombus
- transesophageal echocardiography not routinely indicated (see ischemic stroke)
- angiography
- candidates for carotid endarterectomy
- long-term anticoagulation considered for patient with probable large vessel disease
- recurrent TIAs & inconclusive noninvasive evaluation
- suspected carotid or cerebral dissection
Radiology
- computed tomography (CT) to rule out intracranial hemorrhage
- CT angiography or magnetic resonance (MR) angiography of the head & neck
- initial imaging for TIA
- candidates for carotid endarterectomy
- long-term anticoagulation considered for patient with probable large vessel disease
- recurrent TIAs & inconclusive noninvasive evaluation
- suspected carotid or cerebral dissection
- magnetic resonance imaging (MRI)
- diffusion-weighted imaging may be more sensitive
- identification of vascular occlusions predicts further ischemic events[14]
- positive MRI findings in 14% of patients considered to be at low risk for ischemic stroke[44]
- carotid ultrasound (Doppler) all
- patients with TIA[4]
- most important to exclude significant atherosclerosis[4]
- > 70% stenosis of extracranial internal carotid artery associated with high risk of ischemic stroke within 2 weeks[4]
- transcranial Doppler of intracranial vertebrobasilar system[42]
- suspected posterior circulation involvement
- combination of neuroimaging + ABCD2 score (ABCD3-I) refines prediction of stroke[19]
Complications
- risk of stroke substantial
- 2-33% within 24 hours depending upon ABCD2 score[18]
- 17-18% at 3 months[7]; 1/2 occur within 2 days[51]
- 90-day risk for stroke wsimilar after classic TIA (10.6%) vs nonconsensus TIA (11.6%)[49]
- see risk factors for stroke after TIA[6]
- death, recurrent stroke, MI, or admission to a care facility in ~1/3 of patients within 5 years of TIA[38]
- depression common (14% at 1 year)[22]
- anxiety may occur
- increased incidence of PTSD 3 months after TIA (30% vs 3% in general population)[31]
Differential diagnosis
- migraine headache
- seizures
- focal seizures may produce localized or migratory symptoms
- postictal weakness (Todd's paralysis)
- brain lesions
- metabolic disorder
- peripheral nerve disorder
- syncope
- myasthenia gravis
- vertigo
- thoracic outlet syndrome
- transient global amnesia
- stroke is due to infarction, TIA is due to ischemia[4]
Management
- treat acute TIA as suspected ischemic stroke; (see ACLS algorithm for suspected stroke)
- hospitalize all patients with ABCD2 score >= 3[4]
- it may be safe to send selected patients home on dual antiplatelet therapy if:
- recovery from symptoms
- normal physical examination
- normal blood tests
- head CT negative for blood
- electrocardiogram negative for atrial fibrillation
- follow up with neurology in 1-2 weeks[24]
- follow up with primary physician within 24 hours also recommended[24]
- next day follow-up with vascular neurologist[42]
- dual antiplatelet therapy for 3 weeks, then aspirin low dose daily[53]
- risk of subsequent stroke among patients evaluated in a TIA clinic similar to those hospitalized[50]
- patients treated in the emergency department without further follow-up have higher risk of subsequent stroke[50]
- urgent assessment & treatment of patients with TIA or minor stroke diminishes subsequent hospital bed-days, acute costs, & 6-month disability[17]
- do not attempt to acutely lower blood pressure unless
- systolic blood pressure > 220 mm Hg
- mean arterial blood pressure > 140 mm Hg
- patient has acute coronary syndrome
- aortic dissection suspected
- thrombolytic therapy planned[4]
- lower blood glucose to < 150 mg/dL
- treatment depends upon underlying pathology
- carotid disease
- anti-platelet therapy
- aspirin* 325 mg QD or Plavix (clopidogrel) 75 mg PO QD
- aspirin reduces risk of subsequent stroke 93% at 2 weeks & 74% at 12 weeks relative to placebo[35]
- dual antiplatelet therapy decreases risk of stroke at the cost of increased risk for major hemorrhage[39][40][45]
- short-term (up to 3 weeks) dual antiplatelet therapy with aspirin plus clopidogrel or ticagrelor, then aspirin alone[41][45][48]
- American Heart Association endorses dual antiplatelet therapy for 21 days[4]
- dual antiplatelet therapy within 24 hours[48]
- high-intensity statin therapy indicated for secondary prevention[4]
- atorvastatin may reduce risk of stroke in high-risk patients[20]
- no indication for adjunctive fibrate unless serum triglycerides in excess of 500 mg/dL
- carotid endarterectomy
- may be performed within 48 hours of TIA[32]
- symptomatic patients with > 70% stenosis (GRS11)[21]
- priority of carotid endarterectomy over dual dual antiplatelet therapy based upon lack of comparison[21]
- 50-99% stenosis[33]
- patients with > 70% stenosis at no greater risk of stroke than patients with lesser stenosis[8]
- carotid endarterectomy (CEA) appears safer than carotid stenting in elderly (see CEA)
- hydration
- prevention of orthostatic hypotension
- anti-platelet therapy
- vertebrobasilar disease
- aspirin, Plavix or Aggrenox
- dual antiplatelet therapy within 24 hours continued for 3 weeks[48]
- single antiplatelet therapy after 3 weeks
- heparin followed by warfarin
- aspirin, Plavix or Aggrenox
- lacunar TIA (10%)
- aspirin* 325 mg QD, Plavix or Aggrenox
- dual antiplatelet therapy within 24 hours continued for 3 weeks[48]
- single antiplatelet therapy after 3 weeks
- highest early stroke risk among TIAs[23]
- aspirin* 325 mg QD, Plavix or Aggrenox
- cardiac emboli
- patients with atrial fibrillation
- heparin followed by warfarin
- patient with prosthetic valves:
- add dipyridamole or aspirin
- arterial dissection
- recurrent symptoms on aspirin
- combination therapies
- Plavix 75 mg + aspirin 81 mg QD
- NOT superior to clopidogrel alone[11] (see MATCH study)
- may reduce risk of recurrent stroke in Chinese patients[25]
- also see secondary prevention of cardiovascular disease
- increases risk of major bleed (0.9% vs 0.2%)[40]
- Aggrenox (dipyridamole + aspirin), see ESPIRIT study
- Plavix 75 mg + aspirin 81 mg QD
- ACE inhibitor + diuretic may be of some value[5]
- treat dyslipidemia with statin[16] or niacin
- aggressive statin therapy (i.e. high-intensity statin)
- atorvastatin 40-80 g QD or rosuvastatin 20-40 mg QD[46] recommended for secondary stroke prevention[21]
- following ischemic stroke or TIA, LDL target of <70 mg/dL[43]
- aggressive statin therapy (i.e. high-intensity statin)
* may be no benefit to doses > 162 mg/day
Follow-up:
- workup for coronary artery disease
- lipid panel
- rule out hyperhomocysteinemia
- ECG stress testing
- also see prevention of ischemic stroke
- young patients with negative initial evaluation have better prognosis
- 10 year mortality 34%[13]
More general terms
Additional terms
- ABCD2 score
- ACLS algorithm for suspected stroke
- atherosclerotic intracranial arterial stenosis
- ischemic stroke
- prevention of ischemic stroke
- reversible ischemic neurologic deficit (RIND)
- risk factors for ischemic stroke after TIA
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 703
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 537-540
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1021-22
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 5.0 5.1 Prescriber's Letter 8(7):38 2001
- ↑ 6.0 6.1 Journal Watch 24(7):54, 2004 Inatomi Y et al DWI abnormalities and clinical characteristics in TIA patients. Neurology 62:376, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14872016
Warach S & Kidwell CS The redefinition of TIA: the uses and limitations of DWI in acute ischemic cerebrovascular syndromes. Neurology 62:359, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14872012 - ↑ 7.0 7.1 Journal Watch 24(7):54-55, 2004 Coull AJ et al Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ 328:326,2004 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/14744823 <Internet> http://bmj.bmjjournals.com/cgi/content/full/328/7435/326
- ↑ 8.0 8.1 Journal Watch 24(10):79, 2004 Eliasziw M, Kennedy J, Hill MD, Buchan AM, Barnett HJ; North American Symptomatic Carotid Endarterectomy Trial Group. Early risk of stroke after a transient ischemic attack in patients with internal carotid artery disease. CMAJ. 2004 Mar 30;170(7):1105-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15051694
- ↑ Gladstone DJ, Kapral MK, Fang J, Laupacis A, Tu JV. Management and outcomes of transient ischemic attacks in Ontario. CMAJ. 2004 Mar 30;170(7):1099-104. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15051693
Johnston DC, Hill MD. The patient with transient cerebral ischemia: a golden opportunity for stroke prevention. CMAJ. 2004 Mar 30;170(7):1134-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15051699 - ↑ O'Rourke F, Dean N, Akhtar N, Shuaib A. Current and future concepts in stroke prevention. CMAJ. 2004 Mar 30;170(7):1123-33. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15051698
- ↑ 11.0 11.1 Journal Watch 24(17):133, 2004 Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, Leys D, Matias-Guiu J, Rupprecht HJ; MATCH investigators. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo- controlled trial. Lancet. 2004 Jul 24;364(9431):331-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15276392
- ↑ Prescriber's Letter 11(10): 2004 Concomitant use of Aspirin and Clopidogrel (Plavix) in Cerebrovascular Disease Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=201002&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 13.0 13.1 Journal Watch 25(15):118, 2005 van Wijk I, Kappelle LJ, van Gijn J, Koudstaal PJ, Franke CL, Vermeulen M, Gorter JW, Algra A; LiLAC study group. Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study. Lancet. 2005 Jul 7;365(9477):2098-104. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15964446
Hankey GJ. Redefining risks after TIA and minor ischaemic stroke. Lancet. 2005 Jul 7;365(9477):2065-6. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15964427 - ↑ 14.0 14.1 Coutts SB, Simon JE, Eliasziw M, Sohn CH, Hill MD, Barber PA, Palumbo V, Kennedy J, Roy J, Gagnon A, Scott JN, Buchan AM, Demchuk AM. Triaging transient ischemic attack and minor stroke patients using acute magnetic resonance imaging. Ann Neurol. 2005 Jun;57(6):848-54. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15929051
- ↑ Ay H et al, Transient ischemic attack with infarction: A unique syndrome? Ann Neurol 2005; 57:679 PMID: https://www.ncbi.nlm.nih.gov/pubmed/15852402
- ↑ 16.0 16.1 16.2 Rothwell PM et al, Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): A prospective population-based sequential comparison Lancet 2007, 370:1432 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17928046
- ↑ 17.0 17.1 17.2 Luengo-Fernandez R et al Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): A prospective population-based sequential comparison. Lancet Neurol 2009 Mar; 8:235. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19200786
- ↑ 18.0 18.1 Chandratheva A et al. Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009 Jun 2; 72:1941 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19487652
- ↑ 19.0 19.1 Merwick A et al. Addition of brain and carotid imaging to the ABCD2 score to identify patients at early risk of stroke after transient ischaemic attack: A multicentre observational study. Lancet Neurol 2010 Nov; 9:1060. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20934388
- ↑ 20.0 20.1 Callahan A et al. Risk of stroke and cardiovascular events after ischemic stroke or transient ischemic attack in patients with type 2 diabetes or metabolic syndrome: Secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Arch Neurol 2011 Oct; 68:1245. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21670382
- ↑ 21.0 21.1 21.2 21.3 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ 22.0 22.1 El Husseini N et al Depression and Antidepressant Use After Stroke and Transient Ischemic Attack Stroke March 29, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22461330 <Internet> http://stroke.ahajournals.org/content/early/2012/03/29/STROKEAHA.111.643130.abstract
- ↑ 23.0 23.1 Paul NLM et al. Population-based study of capsular warning syndrome and prognosis after early recurrent TIA. Neurology 2012 Sep 25; 79:1356. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22972645
- ↑ 24.0 24.1 24.2 Bohan SJ Is It Safe to Send TIA Patients Home? Journal Watch. June 4, 2013 Massachusetts Medical Society http://www.jwatch.org
Montassier E et al. Results of an outpatient transient ischemic attack evaluation: A 90-day follow-up study. J Emerg Med 2013 May; 44:970. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23478183 - ↑ 25.0 25.1 Wang Y et al Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. N Engl J Med. June 26, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23803136 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1215340
Hankey GJ Dual Antiplatelet Therapy in Acute Transient Ischemic Attack and Minor Stroke N Engl J Med. June 26, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23803138 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1305127 - ↑ Giles MF, Rothwell PM. Transient ischaemic attack: clinical relevance, risk prediction and urgency of secondary prevention. Curr Opin Neurol. 2009 Feb;22(1):46-53 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19155761
- ↑ Easton JD, Saver JL, Albers GW et al Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. 2009 Jun;40(6):2276-93 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19423857
- ↑ Swain S, Turner C, Tyrrell P et al Diagnosis and initial management of acute stroke and transient ischaemic attack: summary of NICE guidance. BMJ. 2008 Jul 24;337:a786. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18653633
- ↑ Easton JD, Saver JL, Albers GW et al Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. 2009 Jun;40(6):2276-93. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19423857
- ↑ Johnston SC1, Rothwell PM, Nguyen-Huynh MN et al Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007 Jan 27;369(9558):283-92. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17258668
- ↑ 31.0 31.1 Kiphuth IC et al Increased Prevalence of Posttraumatic Stress Disorder in Patients After Transient Ischemic Attack. Stroke. Oct 2, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25278556 <Internet> http://stroke.ahajournals.org/content/early/2014/10/01/STROKEAHA.113.004459.abstract
- ↑ 32.0 32.1 Ferrero E et al A retrospective study on early carotid endarterectomy within 48 hours after transient ischemic attack and stroke in evolution. Ann Vasc Surg. 2014 Jan;28(1):227-38 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24011816
- ↑ 33.0 33.1 Johansson E, Wester P Recurrent stroke risk is high after a single cerebrovascular event in patients with symptomatic 50-99% carotid stenosis: a cohort study. BMC Neurol. 2014 Feb 4;14:23 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24495323
- ↑ 34.0 34.1 34.2 Sposato LA et al. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: A systematic review and meta-analysis. Lancet Neurol 2015 Apr; 14:377 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25748102
- ↑ 35.0 35.1 Rothwell PM et al Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials. Lancet. May 18, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27209146 Free Article <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2930468-8/abstract
- ↑ 36.0 36.1 Edwards JD et al. Underutilization of ambulatory ECG monitoring after stroke and transient ischemic attack: Missed opportunities for atrial fibrillation detection. Stroke 2016 Aug; 47:1982 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27406109
- ↑ 37.0 37.1 Lee J, Inoue M, Mlynash M et al. MR perfusion lesions after TIA or minor stroke are associated with new infarction at 7 days. Neurology 2017 May 12; PMID: https://www.ncbi.nlm.nih.gov/pubmed/28500226
- ↑ 38.0 38.1 Edwards JD, Kapral MK, Fang J et al Long-term morbidity and mortality in patients without early complications after stroke or transient ischemic attack. CMAJ July 24, 2017 vol. 189 no. 29 E954-E961 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28739847 <Internet> http://www.cmaj.ca/content/189/29/E954
Hill MD Long-term stroke prevention: We can do better . CMAJ July 24, 2017 vol. 189 no. 29 E952-E953 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28739846 <Internet> http://www.cmaj.ca/content/189/29/E952 - ↑ 39.0 39.1 Hilkens NA, Algra A, Kappelle LJ, et al. Early time course of major bleeding on antiplatelet therapy after TIA or ischemic stroke. Neurology 2018 Feb 20; 90:e683 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29374102 Free PMC Article <Internet> http://n.neurology.org/content/90/8/e683
- ↑ 40.0 40.1 40.2 Johnston SC, Easton JD, Farrant M et al Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med 2018; 379:215-225. Online May 16, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29766750 Free PMC Article https://www.nejm.org/doi/full/10.1056/NEJMoa1800410
Grotta JC Antiplatelet Therapy after Ischemic Stroke or TIA. N Engl J Med. May 16, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29766754 https://www.nejm.org/doi/full/10.1056/NEJMe1806043
Tillman H, Johnston SC, Farrant M et al Risk for Major Hemorrhages in Patients Receiving Clopidogrel and Aspirin Compared With Aspirin Alone After Transient Ischemic Attack or Minor Ischemic Stroke. A Secondary Analysis of the POINT Randomized Clinical Trial JAMA Neurol. Published online April 29, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31034032 https://jamanetwork.com/journals/jamaneurology/fullarticle/2731585 - ↑ 41.0 41.1 Prasad K, Siemieniuk R, Hao Q et al Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline BMJ 2018;363:k5130 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30563885 https://www.bmj.com/content/363/bmj.k5130
Hao Q, Tampi M, O'Donnell M et al Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis. BMJ 2018;363:k5108 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30563866 Free full text https://www.bmj.com/content/363/bmj.k5108 - ↑ 42.0 42.1 42.2 Chang BP, Rostanski S, Willey J et al. Safety and feasibility of a rapid outpatient management strategy for transient ischemic attack and minor stroke: The Rapid Access Vascular Evaluation-Neurology (RAVEN) approach. Ann Emerg Med 2019 Jul 17; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31326206 https://www.annemergmed.com/article/S0196-0644(19)30437-8/fulltext
- ↑ 43.0 43.1 Amarenco P, Kim JS, Labreuche J et al. A comparison of two LDL cholesterol targets after ischemic stroke. N Engl J Med 2019 Nov 18; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31738483 https://www.nejm.org/doi/10.1056/NEJMoa1910355
- ↑ 44.0 44.1 Coutts SB, Moreau F, Asdaghi N, et al. Rate and prognosis of brain ischemia in patients with lower-risk transient or persistent minor neurologic events. JAMA Neurol 2019 Dec; 76:1439. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31545347 https://jamanetwork.com/journals/jamaneurology/article-abstract/2751257
- ↑ 45.0 45.1 45.2 Johnston SC, Amarenco P, Denison H, et al. Ticagrelor and aspirin or aspirin alone in acute ischemic stroke or TIA. N Engl J Med 2020 Jul 16; 383:207-217 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32668111 https://www.nejm.org/doi/10.1056/NEJMoa1916870
- ↑ 46.0 46.1 NEJM Knowledge+ Question of the Week. Aug 4, 2020 https://knowledgeplus.nejm.org/question-of-week/843/
- ↑ 47.0 47.1 47.2 Lioutas VA, Ivan CS, Himali JJ et al Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke. JAMA. 2021;325(4):373-381 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33496774 https://jamanetwork.com/journals/jama/article-abstract/2775447
- ↑ 48.0 48.1 48.2 48.3 48.4 Mendelson SJ, Prabhakaran S Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke. A Review. JAMA. 2021;325(11):1088-1098 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33724327 https://jamanetwork.com/journals/jama/fullarticle/2777474
- ↑ 49.0 49.1 49.2 49.3 Tuna MA, Rothwell PM. Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: Population-based validation by investigation and prognosis. Lancet 2021 Mar 6; 397:902. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33676629 PMCID: PMC7938377 Free PMC article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31961-9/fulltext
- ↑ 50.0 50.1 50.2 Shahjouei S, Li J, Koza E et al Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack. A Systematic Review and Meta-analysis. JAMA Netw Open. 2022;5(1):e2136644 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34985520 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787633
- ↑ 51.0 51.1 Amin HP, Madsen TE, Bravata DM et al Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association. Stroke. 2023. Jan 19 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36655570 Review. https://www.ahajournals.org/doi/10.1161/STR.0000000000000418
- ↑ Amarenco P. Transient ischemic attack. N Engl J Med. 2020;382:1933-1941. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32402163
- ↑ 53.0 53.1 Guan L, Han S, Johnston SC et al Duration of Benefit and Risk of Dual Antiplatelet Therapy up to 72 Hours After Mild Ischemic Stroke and Transient Ischemic Attack. Neurology. 2024 Oct 8;103(7):e209845. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39270151 Clinical Trial.
- ↑ NINDS Transient Ischemic Attack (TIA) Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Transient-Ischemic-Attack-Information-Page