Transient Ischemic Attack (TIA)

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Basics

Description

  • A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction
  • Major predictor of stroke: 15% of patients with stroke report recent TIA.
  • Synonym(s): ministroke

Epidemiology

Incidence

200,000 to 500,000 new TIA cases reported each year

  • 83 cases per 100,000 people/year in the United States

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)
  • Diabetes
  • Hyperlipidemia
  • Obesity
  • Atherosclerotic disease (carotid/vertebral stenosis)
  • 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)
  • Causation is key to preventing recurrence (1).
ALERT
  • 1.5–3.5% risk of stroke in first 48 hours after TIA
  • Up to 40% of patients with stroke have history suggestive of TIA symptoms.

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.
  • Other causes include the following:
    • Metabolic: homocystinuria, Fabry disease
    • Central nervous system infection
    • Clotting disorders
    • Genetic: Marfan syndrome, moyamoya, or sickle cell disease

Pregnancy Considerations

  • Preeclampsia, eclampsia, and HELLP syndrome
  • Thrombotic thrombocytopenic purpura (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, multiple sclerosis
    • Difference: gradual onset with nonspecific symptoms (headache, memory loss) versus acute onset with specific neurologic deficits (TIA)

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Basics

Description

  • A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction
  • Major predictor of stroke: 15% of patients with stroke report recent TIA.
  • Synonym(s): ministroke

Epidemiology

Incidence

200,000 to 500,000 new TIA cases reported each year

  • 83 cases per 100,000 people/year in the United States

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)
  • Diabetes
  • Hyperlipidemia
  • Obesity
  • Atherosclerotic disease (carotid/vertebral stenosis)
  • 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)
  • Causation is key to preventing recurrence (1).
ALERT
  • 1.5–3.5% risk of stroke in first 48 hours after TIA
  • Up to 40% of patients with stroke have history suggestive of TIA symptoms.

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.
  • Other causes include the following:
    • Metabolic: homocystinuria, Fabry disease
    • Central nervous system infection
    • Clotting disorders
    • Genetic: Marfan syndrome, moyamoya, or sickle cell disease

Pregnancy Considerations

  • Preeclampsia, eclampsia, and HELLP syndrome
  • Thrombotic thrombocytopenic purpura (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, multiple sclerosis
    • Difference: gradual onset with nonspecific symptoms (headache, memory loss) versus acute onset with specific neurologic deficits (TIA)

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