Transient Ischaemic Attacks

TIAs
Joan T. Moroney
Department of Neurology
Beaumont Hospital/RCSI
 Learning objectives:
Know the vascular anatomy and
neuroanatomy
Know the pathophysiology and clinical
features of stroke
Risk factors for stroke
Principles of rehabilitation including
multidisciplinary team
 Definition of TIA
Distinction between stroke and TIA less
important in recent years
Shared pathogenetic mechanisms and
preventive approaches
Most recent definition of stroke for clinical
trials includes symptoms >24hrs or
imaging of acute clinically relevant brain
lesion in those with rapidly vanishing
symptoms
 Conventional Definition of TIA
Abrupt onset of focal neurological deficit
lasting <24 hours
 New Definition of TIA
Brief episode of focal neurological deficit
(brain or retinal) with clinical symptoms
typically lasting <1 hour and without
evidence of infarction on brain imaging
 Prevalence of TIAs
Men 65-69y 2.7%
Men 75-79y 3.6%
Women 65-69y 1.6%
Women 75-79y 4.1%
 Incidence of TIAs
Population-based studies
Age and gender-adjusted rates
Range from 68-83 per 100,000
Higher rates in men and blacks
 TIA-Infarction Spectrum
One-third of TIAs considered infarction
based on dwi-MRI findings
15% of all strokes are heralded by a TIA
Recognition of TIA thus offers valuable
opportunity for stroke prevention
But 50% of patients fail to report their TIA
 Risk of Stroke & Death after TIA
90-day risk of stroke From 3-17%
Highest within first 30 days

1- year mortality Up to 25% die

10-year stroke risk High at 18.8%
Combined 10-yr risk 42.8% (4% per year)
of stroke, MI or
vascular death
 Differential Diagnosis
Partial seizure
Migraine
Glucose abnormality
Electrolyte abnormality
Non-neurological spell
 Stroke Mimics & Clinical Features
Similar events, preceding
aura, headache
History of seizures,
Complicated migraine witnessed seizure, post-ictal
Seizures period
Hypo/hyperglycaemia History of DM, glucose
abnormal, LOC
Hypertensive
encephalopathy Headache, delirium,
hypertension, cerebral
Subdural haematoma oedema
Brain tumour History of trauma,
Demyelinating disease headache, LOC
Conversion disorder Mode of onset, progressive,
headaches, raised ICP
Signs in a nonvascular
distribution, inconsistencies
 Awareness of Stroke Symptoms
2001 CDC Survey 17 US states and BVI MMWR 2004

Sudden numbness or weakness of the face, arm,

or leg94.1%;
Sudden confusion, trouble speaking, or trouble
understanding 87.9%.
Sudden trouble walking, dizziness, or loss of
balance or coordination85%.
Sudden trouble seeing in 1 or both eyes68.1%.
Sudden severe headache with no known cause
61.3%.
But 38% incorrectly reported chest pain as a sign
of stroke
 Awareness of Stroke Symptoms/Risks
A&E Survey n=163 admitted with possible stroke
Kothari et al Stroke 1997

Did not know a single sign or symptom39%

>65y (28%) less likely to know
Than<65y (47%)
Did not know a single risk factor43%
Overall almost 40% did not know the signs,
symptoms or risk factors for stroke
 Awareness of TIA
National Stroke Association Hill et al Neurology 2004

2.3% reported being told they had a TIA

Of those:
Only 64% seen <24hrs
Only 8.2% knew definition of TIA
Only 8.6% could identify a typical symptom
Men, nonwhites, lower income and education
less knowledgeable
 Key Points in the History

Time of onset of symptoms

Recent events: stroke
MI Trauma Surgery Bleeding
Comorbidities Hypertension Diabetes
Medications Anticoagulants Insulin
Antihypertensives
 Less likely to be a TIA, but..
Isolated vertigo-dizzy Hearing, tinnitus, ear
But beware if vascular fullness, preceding
risk factors infection, strong
positional element,
previous similar bouts
Dix-Hallpike & head-
thrust test
 Less likely to be a TIA, but..
Isolated confusion Level of alertness,
But beware if vascular fluctuation, agitation,
risk factors diurnal variation
Collateral history Dont miss an aphasia
Beware of thalamic especially fluent or
localisation pure word deafness
 When to admit?
Risks for large-artery disease
In NASCET with first ever hemispheric TIA:
90-day stroke risk was 20%
Risk of stroke after TIA exceeded the risk
after hemispheric stroke

Eliasziw et al CMAJ 2004

 When to admit?
Johnston et al JAMA 2000

1707 TIA patients assessed in ED

180 (10%) had a stroke within 90 days
91 (5%) had a stroke within 2 days
Predictors of stroke:
Age>60y, diabetes, focal weakness or
speech impairment
Duration >10 minutes
 Lifetime Risk of Stroke
Sesadri et al Framingham Study Stroke 2006
Kurth et al Arch Int Med 2006

>1 in 6 chance for adults >55yrs

Women at higher risk
Perhaps because of survival advantage
WHS 37,000 >45y: healthy lifestyle
no smoking, low BMI, moderate alcohol,
regular exercise and a healthy diet had
significantly reduced risk of IS
 Independent Stroke Risk Factors
BP is most powerful determinant of stroke risk

Hypertension BP<120/80 have 50%

Among top 3 stroke lower lifetime risk of
risk factors in terms of stroke vs.
population- hypertensives
Sesadri et al Framingham Study
attributable fraction: Stroke 2006
33.9% for lacunar and
35.3% for nonlacunar
Ohira et al ARIC Study Stroke
2006
 Independent Stroke Risk Factors
Kissela et al Diabetes Care 2005, Ohira et al Framingham Study Stroke 2006

Diabetes mellitus Increases stroke

Age-specific incidence incidence at all ages
rates Risk most prominent
Among top 3 stroke risk <55y blacks, <65y
factors in terms of whites
population-attributable
fraction: 26.3% for
lacunar and 11.3% for
nonlacunar
 Independent Stroke Risk Factors
Current smoking
Among top 3 stroke
risk factors in terms of
population-
attributable fraction:
22% for lacunar and
11.4% for nonlacunar
Ohira et al ARIC Study Stroke
2006
2-fold risk for
ischaemic stroke vs.
nonsmokers after
adjustment for other
risk factors (FHS,
CHS, NHLBI)
 Independent Stroke Risk Factors
Atrial Fibrillation 5-fold risk for stroke after
adjustment for other risk
factors (Sesadri et al Framingham
Study Stroke 2006)
In Japanese men low HDL
increased risk of IS
Physical activity in sport,
Low HDL (HHP/NHLBI) leisure time or work reduces
stroke risk
Physical Inactivity (PHS, Almost 40% reduction in stroke
NHS, NOMASS, ARIC) incidence in most active
category
 Independent Stroke Risk Factors
Baltimore-Washington Young Stroke Study. Kittner et al NEJM 1996

Oestrogen WHI found oestrogen alone

increased risk of IS by 55%
Pregnancy But had no significant effect on
haemorrhagic stroke
Risk of IS/ICH 2.4x higher
during pregnancy and first 6
weeks post
Risk of IS increased 8.7 fold in
6 weeks post-partum
Risk of ICH RR 2.5x higher
during pregnancy with
dramatic increased RR 28.3
post-partum
 Independent Stroke Risk Factors
Baltimore-Washington Young Stroke Study. Kittner et al NEJM 1996
Post-menopause
Oestrogen alone or +
progesterone increases
stroke risk in
postmenopausal
healthy women and
provides no protection
for women with CHD
WHI found oestrogen +
progesterone increased
risk of IS by 44%
But no effect on
haemorrhagic stroke
Excess risk apparent in
all age groups and in all
categories of baseline
stroke risk