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  • Review Article
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Evaluation and management of transient ischemic attack: an important component of stroke prevention

Nature Clinical Practice Cardiovascular Medicine volume 4, pages 310–318 (2007)Cite this article

Abstract

Stroke and transient ischemic attack (TIA) share similar risk factors and methods of evaluation and secondary prevention. As neurological symptoms resolve after TIA, however, there has been a widely held perception that urgent evaluation and treatment following TIA are unnecessary. In actual fact, it is becoming increasingly clear that the short-term stroke risk after TIA is very high. Recent studies have identified independent predictors that indicate which patients are at highest risk of recurrent ischemic events. These risk scores could enable physicians to target appropriate patients for urgent care. In this Review, we summarize the recent literature on stroke risk after TIA and risk stratification, and recently published guidelines on evaluation and treatment.

Key Points

  • The early stroke risk after a transient ischemic attack is very high

  • The ABCD2 score enables physicians to identify patients at high risk of stroke, allowing more urgent evaluations and interventions, and should be used routinely in practice

  • Consensus guidelines on management of patients with transient ischemic attack are available, and the latest guidelines advocate more urgency in the evaluations and treatment of transient ischemic attack

  • In-hospital observation should be considered for high-risk individuals and in cases when outpatient evaluations cannot be expedited

  • Physician compliance with current guidelines is poor, and more educational efforts to increase health-care providers' awareness of the danger of transient ischemic attack are needed

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References

  1. Brainin M et al. (1995) Silent brain infarcts and transient ischemic attacks— three-year study of first-ever ischemic stroke patients: the Klosterneuburg Stroke Data Bank. Stroke 26: 1348–1352

    Article  CAS  Google Scholar 

  2. Johnston SC (2002) Transient ischemic attack. N Engl J Med 347: 1687–1692

    Article  Google Scholar 

  3. Johnston SC et al. (2003) Prevalence and knowledge of transient ischemic attacks among US adults. Neurology 60: 1429–1434

    Article  CAS  Google Scholar 

  4. Siekert RG and Whisnant JP (Eds; 1965) Cerebral Vascular Diseases: Fourth Conference. New York: Grune and Stratton

    Google Scholar 

  5. Kidwell CS et al. (1999) Diffusion MRI in patients with transient ischemic attacks. Stroke 30: 1174–1180

    Article  CAS  Google Scholar 

  6. Albers GW et al.; TIA Working Group (2002) Transient ischemic attack—proposal for a new definition. N Engl J Med 347: 1713–1716

    Article  Google Scholar 

  7. Johnston SC et al. (2000) Short-term prognosis after emergency-department diagnosis of TIA. JAMA 284: 2901–2906

    Article  CAS  Google Scholar 

  8. Lovett JK et al. (2003) Very early risk of stroke after a first transient ischemic attack. Stroke 34: 138–140

    Article  Google Scholar 

  9. Coull AJ et al.; Oxford Vascular Study (2004) Population based study of early risk of stroke after transient ischemic attack or minor stroke: implications for public education and organisation of services. BMJ 328: 326–328

    Article  CAS  Google Scholar 

  10. Kleindorfer D et al. (2005) Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke 36: 720–723

    Article  Google Scholar 

  11. Streifler JY et al. (1995) The risk of stroke in patients with first-ever retinal vs. hemispheric transient ischemic attacks and high-grade stenosis. North American Symptomatic Carotid Endarterectomy Trial. Arch Neurol 52: 246–249

    Article  CAS  Google Scholar 

  12. Kennedy J et al. (2002) Short-term prognosis following acute cerebral ischaemia [abstract]. Stroke 33 (Suppl): 382

    Google Scholar 

  13. Wiebers DO et al. (1982) Reversible ischemic neurologic deficit (RIND) in a community: Rochester, Minnesota, 1955–1974. Neurology 32: 459–465

    Article  CAS  Google Scholar 

  14. Humphrey PRD and Marshall J (1981) Transient ischemic attacks and strokes with recovery prognosis and investigation. Stroke 12: 765–769

    Article  CAS  Google Scholar 

  15. Rothwell PM et al. (2005) A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 366: 29–36

    Article  CAS  Google Scholar 

  16. Johnston SC et al. (2007) Validation and refinement of scores to predict very early stroke risk after transient ischemic attack. Lancet 369: 283–292

    Article  Google Scholar 

  17. Douglas VC et al. (2003) Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke 34: 2894–2898

    Article  Google Scholar 

  18. Purroy F et al. (2004) Higher risk of further vascular events among transient ischemic attack patients with diffusion-weighted imaging acute ischemic lesions. Stroke 35: 2313–2319

    Article  Google Scholar 

  19. Coutts SB et al. (2005) Triaging transient ischemic attack and minor stroke patients using acute magnetic resonance imaging. Ann Neurol 57: 848–854

    Article  Google Scholar 

  20. Gass A et al. (2004) Diffusion-weighted MRI for the “small stuff”: the details of acute cerebral ischaemia. Lancet Neurol 3: 39–45

    Article  Google Scholar 

  21. Fazekas F et al. (1996) Magnetic resonance imaging correlates of transient cerebral ischemic attacks. Stroke 27: 607–611

    Article  CAS  Google Scholar 

  22. Kimura K et al. (2000) Lesions visualized by contrast-enhanced magnetic resonance imaging in transient ischemic attacks. J Neurol Sci 173: 103–108

    Article  CAS  Google Scholar 

  23. Engelter ST et al. (1999) Diffusion MR imaging and transient ischemic attacks. Stroke 30: 2762–2763

    Article  CAS  Google Scholar 

  24. Takayama H et al. (2000) Usefulness of diffusion-weighted MRI in the diagnosis of transient ischemic attacks [Japanese]. No To Shinkei 52: 919–923

    CAS  PubMed  Google Scholar 

  25. Ay H et al. (2002) 'Footprints' of transient ischemic attacks: a diffusion-weighted MRI study. Cerebrovasc Dis 14: 177–186

    Article  Google Scholar 

  26. Rovira A et al. (2002) Diffusion-weighted MR imaging in the acute phase of transient ischemic attacks. AJNR Am J Neuroradiol 23: 77–83

    PubMed  Google Scholar 

  27. Johnston SC et al. (2006) National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol 60: 301–313

    Article  Google Scholar 

  28. Antithrombotic Trialists' Collaboration (2002) Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324: 71–86

    Article  Google Scholar 

  29. Albers GW et al. (1999) AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. Stroke 30: 2502–2511

    Article  CAS  Google Scholar 

  30. Farrell B et al. (1991) The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry 54: 1044–1054

    Article  CAS  Google Scholar 

  31. The Dutch TIA Trial Study Group (1991) A comparison of two doses of aspirin (30 mg vs 283 mg a day) in patients after a transient ischemic attack or minor ischemic stroke. N Engl J Med 325: 1261–1266

  32. Diener HC et al. (1996) European Stroke Prevention Study 2—Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 143: 1–13

    Article  CAS  Google Scholar 

  33. ESPRIT Study Group; Halkes PH et al. (2006) Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet 367: 1665–1673

    Article  CAS  Google Scholar 

  34. Hankey GJ et al. Thienopyridine derivatives (ticlopidine, clopidogrel) versus aspirin for preventing stroke and other serious vascular events in high vascular risk patients. The Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD001246. DOI:10.1002/14651858.CD001246

  35. CAPRIE Steering Committee (1996) A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 348: 1329–1339

  36. Diener HC et al.; MATCH investigators (2004) 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 364: 331–337

    Article  CAS  Google Scholar 

  37. Gubitz G et al. Anticoagulants for acute ischaemic stroke. Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD000024. DOI:10.1002/14651858.CD000024.pub2

  38. North American Symptomatic Carotid Endarterectomy Trial Collaborators (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325: 445–453

  39. European Carotid Surgery Trialists' Collaborative Group (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351: 1379–1387

  40. Mayberg MR et al. (1991) Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group. JAMA 266: 3289–3294

    Article  CAS  Google Scholar 

  41. Sacco RL et al.; American Heart Association; American Stroke Association Council on Stroke; Council on Cardiovascular Radiology and Intervention; American Academy of Neurology (2006) Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 37: 577–617

    Article  Google Scholar 

  42. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators (2006) High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 355: 549–559

  43. PROGRESS Collaborative Group (2001) Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 358: 1033–1041

  44. Yusuf S et al. (2000) Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 342: 145–153

    Article  CAS  Google Scholar 

  45. Dahlof B et al.; LIFE Study Group (2002) Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 359: 995–1003

    Article  CAS  Google Scholar 

  46. Schrader J et al.; MOSES Study Group (2005) Morbidity and mortality after stroke, eprosartan compared with nitrendipine for secondary prevention: principal results of a prospective randomized controlled study (MOSES). Stroke 36: 1218–1226

    Article  CAS  Google Scholar 

  47. Johnston SC et al. (2006) National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol 60: 301–313

    Article  Google Scholar 

  48. Johnston SC and Smith W (1999) Practice variability in management of transient ischemic attacks. Eur Neurol 42: 105–108

    Article  CAS  Google Scholar 

  49. Nguyen-Huynh MN et al. (2003) Knowledge and management of transient ischemic attacks among US primary care physicians. Neurology 61: 1455–1456

    Article  Google Scholar 

  50. Benade MM and Warlow CP (2002) Cost of identifying patients for carotid endarterectomy. Stroke 33:435–439

    Article  Google Scholar 

  51. Edlow JA et al. (2006) National study on emergency department visits for transient ischemic attack, 1992–2001. Acad Emerg Med 13: 666–672

    PubMed  Google Scholar 

  52. Gladstone DJ et al. (2004) Management and outcomes of transient ischemic attacks in Ontario. CMAJ 170: 1099–1104

    Article  Google Scholar 

  53. Kennedy J et al. (2003) The Fast Assessment of Stroke and Transient Ischemic Attack to prevent Early Recurrence (FASTER) Trial. Sem Cerebrovasc Dis 3: 25–30

    Article  Google Scholar 

  54. Rothwell PM et al.; Carotid Endarterectomy Trialists' Collaboration (2004) Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 363: 915–924

    Article  CAS  Google Scholar 

  55. Johnston SC and Nguyen-Huynh MN (2005) Is hospitalization after TIA cost-effective on the basis of treatment with tPA? Neurology 65: 1799–1801

    Article  Google Scholar 

  56. Whisnant JP et al. (1973) Transient cerebral ischemic attacks in a community: Rochester, Minnesota, 1955 through 1969. Mayo Clin Proc 48: 194–198

    CAS  PubMed  Google Scholar 

  57. Putman SF and Adams HP Jr (1985) Usefulness of heparin in initial management of patients with recent transient ischemic attacks. Arch Neurol 42: 960–962

    Article  CAS  Google Scholar 

  58. Biller J et al. (1989) A randomised trial of aspirin or heparin in hospitalized patients with recent transient ischemic attacks: a pilot study. Stroke 20: 441–447

    Article  CAS  Google Scholar 

  59. Panagos PD et al. (2003) Short-term prognosis after emergency department diagnosis and evaluation of transient ischemic attack (TIA). Acad Emerg Med 10: 432b–433b

    Article  Google Scholar 

  60. Hill MD et al. (2004) The high risk of stroke immediately after transient ischemic attack. Neurology 62: 2015–2020

    Article  CAS  Google Scholar 

  61. Lisabeth LD et al. (2004) Stroke risk after transient ischemic attack in a population-based setting. Stroke 35: 1842–1846

    Article  Google Scholar 

  62. Correia M et al. (2006) Transient ischemic attacks in rural and urban northern Portugal: incidence and short-term prognosis. Stroke 37: 50–55

    Article  Google Scholar 

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Authors and Affiliations

  1. MN Nguyen-Huynh is Assistant Professor in the Department of Neurology, and SC Johnston is the Director of the Stroke Service and Associate Professor in Neurology and Epidemiology at the University of California, San Francisco, CA, USA.,

    Mai N Nguyen-Huynh & S Claiborne Johnston

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  1. Mai N Nguyen-Huynh
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  2. S Claiborne Johnston
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Corresponding author

Correspondence to S Claiborne Johnston.

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The authors declare no competing financial interests.

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Nguyen-Huynh, M., Johnston, S. Evaluation and management of transient ischemic attack: an important component of stroke prevention. Nat Rev Cardiol 4, 310–318 (2007). https://doi.org/10.1038/ncpcardio0889

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