Transient Ischemic Attack (TIA)
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- A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction
- Most important predictor of stroke: 15% of patients with stroke report previous TIA.
- Synonym(s): ministroke
- 200,000 to 500,000 new TIA cases reported each year
- 83 cases per 100,000 people/year in the United States
- 400 to 800 cases per 100,000 persons aged 50 to 59 years
- Prevalence of TIA in general population: ~2.3%
- Predominant age: Risk increases >60 years; highest in 7th and 8th decades
- Predominant sex: male > female (3:1)
- Predominant race/ethnicity: African Americans > Hispanics > Caucasians. The difference in African Americans is exaggerated at younger ages.
Etiology and Pathophysiology
Temporary reduction/cessation of cerebral blood flow adversely affecting neuronal function
- Carotid/vertebral atherosclerotic disease
- Artery-to-artery thromboembolism
- Low-flow ischemia
- Small, deep vessel disease associated with hypertension (HTN)
- Lacunar infarcts
- Cardiac diseases
- 1–6% of patients with MI develop stroke.
- Embolism secondary to the following:
- Valvular (mitral valve) pathology
- Mural hypokinesias/akinesias with thrombosis (acute anterior MI/congestive cardiomyopathies)
- Cardiac arrhythmia (atrial fibrillation accounts for 5–20% incidence)
- Hypercoagulable states
- Antiphospholipid antibodies
- Increased estrogen (e.g., oral contraceptives)
- Pregnancy and parturition
- Noninfectious necrotizing vasculitis
- Local trauma
- Sympathomimetic drugs (e.g., cocaine)
- Other causes: spontaneous and posttraumatic (e.g., chiropractic manipulation) arterial dissection
- Fibromuscular dysplasia
Inheritance is polygenic, with tendency to clustering of risk factors within families.
- Cardiac diseases (atrial fibrillation, MI, valvular disease)
- Atherosclerotic disease (carotid/vertebral stenosis)
- Cigarette smoking
- Lifestyle changes: smoking cessation, diet modification, weight loss, regular aerobic exercise, and limited alcohol intake
- Strict control of medical risk factors: diabetes (glycemic control), HTN (thiazide and/or ACE/ARB), hyperlipidemia (statins), anticoagulation when high risk of cardioembolism (e.g., atrial fibrillation, mechanical valves)
- Causation is key to preventing recurrence (1).
- 10–20% of patients with TIA have CVA within 90 days; up to 80% of this risk is preventable (2).
- 25–50% of those occur within the first 48 hours.
- Older patients have a higher mortality rate than younger patients—highest in 7th and 8th decades.
- Atrial fibrillation is a frequent cause among the elderly.
- Congenital heart disease is a common cause among pediatric patients.
- Other causes include the following:
- Metabolic: homocystinuria, Fabry disease
- Central nervous system infection
- Clotting disorders
- Genetic: Marfan syndrome, moyamoya, or sickle cell disease
- Preeclampsia, eclampsia, and HELLP syndrome
- TTP and hemolytic uremic syndrome
- Postpartum angiopathy
- Cerebral venous thrombosis
- Hypercoagulable states related to pregnancy
Commonly Associated Conditions
- Atrial fibrillation
- Uncontrolled HTN
- Carotid stenosis
- TIA mimics
- Some disease processes mimic TIA presentation.
- Seizures, migraines, metabolic disturbances, syncope
- Gradual onset with nonspecific symptoms (headache, memory loss)