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Transient Ischemic Attack


Be sure to arrange neurology consultation and/or follow up



Inclusion Criteria

  • Transient ischemic attack – resolved deficit, not crescendo
  • Negative head CT
  • Workup can be completed within ~18hrs

Exclusion Criteria

  • Head CT imaging positive for bleed, mass, or acute infarction.
  • Known extra-cranial embolic source – history of atrial fibrillation, cardiomyopathy, artificial heart valve, endocarditis, known mural thrombus, patent foramen ovale, or recent MI.
  • Known carotid stenosis (>50%)
  • Any persistent acute neurological deficit or crescendo TIAs
  • Non-focal symptoms – ie confusion, weakness, seizure, transient global amnesia
  • Hypertensive encephalopathy
  • Severe headache or evidence of cranial arteritis
  • Acute medical or social (poor home support) issues requiring inpatient admission
  • Prior large stroke - making serial neurological examinations problematic
  • Pregnancy

Potential Interventions

  • Neuro checks Q-2hr for 12 hrs, then Q4hr – to detect stroke, crescendo TIA, etc.
  • Neurology consult – to detect occult stroke. Consider hypercoagulable blood testing if <55 or as directed by *neurology.
  • Carotid imaging with MRI/MRA - to detect surgical carotid stenosis (>50%) and microinfarct
  • If contraindications to MRI/MRA and good renal function, then CTA of head and neck vessels
  • If contraindications to MRI/MRA and poor renal function, then carotid doppler
  • 2-D Echocardiography - to detect a cardioembolic source.
  • Cardiac monitoring – for at least 12 hours for paroxysmal atrial fibrillation
  • Appropriate antiplatelet therapy (Aspirin ⇒ If on ASA then Plavix OR Aggrenox)
  • TIA stroke preventive educational materials (lipids, smoking, DM, HT, obesity, alcohol, stroke)

Discharge Criteria

Home

    • No recurrent deficits, negative workup
    • Clinically stable for discharge home (on Asa – 81mg/day)

Admit

    • Recurrent symptoms / deficit
    • Evidence of treatable vascular disease - ie >50% stenosis of neck vessels
    • Evidence of embolic source requiring treatment (ie heparin / coumadin) - ie mural thrombus, Paroxysmal atrial fibrillation
    • Unable to complete workup or safely discharge patient within timeframe
    • Physician judgment


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