Transient Ischemic Attack (TIA)
Basics
Description
- A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction
- Major predictor of stroke: 7.5–17.4% of patients with transient ischemic attack (TIA) experience a stroke within 3 months (1). 15% of patients with stroke report recent TIA.
- Synonym(s): ministroke
Epidemiology
Incidence
200,000 to 500,000 new TIA cases reported each year. Nearly 800,000 patients experience stroke per year in the United States, of which nearly 700,000 are acute ischemic stroke (1).
Prevalence
- Prevalence of TIA in general population: ~2.0%
- Predominant age: Risk increases >60 years; highest in 7th and 8th decades
- Predominant sex: male > female
- Predominant race/ethnicity: African Americans > Hispanics > Caucasians
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) and diabetes
- Lacunar infarcts
- 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
- Arteritis
- Noninfectious necrotizing vasculitis
- Drugs, irradiation, local trauma
- Sympathomimetic drugs (e.g., cocaine)
- Other causes: spontaneous and posttraumatic (e.g., chiropractic manipulation) arterial dissection
- Fibromuscular dysplasia
Genetics
Inheritance is polygenic, with tendency to clustering of risk factors within families.
Risk Factors
- Older age (i.e., >60 years old)
- HTN, cardiac diseases (atrial fibrillation, MI, valvular disease)
- Atherosclerotic disease (carotid/vertebral stenosis)
- Diabetes
- Hyperlipidemia
- Obesity
- Cigarette smoking
- Thrombophilias
General Prevention
- 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)
- Improved blood pressure control has been very useful, with antiplatelet therapy being key for preventing recurrence if previous TIA (2)
ALERT
- 1.5–3.5% risk of stroke in first 48 hours after TIA
- Up to 40% of patients with stroke have history of TIA
Geriatric Considerations
- Older patients have a higher mortality rate—highest in 7th and 8th decades.
- Atrial fibrillation is a frequent cause among the elderly.
Pediatric Considerations
- Congenital heart disease is a common cause among pediatric patients.
- Genetic: Marfan syndrome, moyamoya, or sickle cell disease
Pregnancy Considerations
- 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
- Some disease processes mimic TIA presentation (seizures, migraines, metabolic disturbances, syncope, multiple sclerosis)
- Difference: gradual onset with nonspecific symptoms (headache, memory loss) vs acute onset with specific neurologic deficits (TIA)
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Citation
Domino, Frank J., et al., editors. "Transient Ischemic Attack (TIA)." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2020. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688263/all/Transient_Ischemic_Attack__TIA_.
Transient Ischemic Attack (TIA). In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2020. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688263/all/Transient_Ischemic_Attack__TIA_. Accessed May 29, 2023.
Transient Ischemic Attack (TIA). (2020). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (27th ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688263/all/Transient_Ischemic_Attack__TIA_
Transient Ischemic Attack (TIA) [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2020. [cited 2023 May 29]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688263/all/Transient_Ischemic_Attack__TIA_.
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