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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Ratajczak-Tretel B, Lambert AT, Al-Ani R, Arntzen K, Bakkejord GK, Bekkeseth HMO, Bjerkeli V, Eldøen G, Gulsvik AK, Halvorsen B, Høie GA, Ihle-Hansen H, Ingebrigtsen S, Kremer C, Krogseth SB, Kruuse C, Kurz M, Nakstad I, Novotny V, Naess H, Qazi R, Rezaj MK, Rørholt DM, Steffensen LH, Sømark J, Tobro H, Truelsen TC, Wassvik L, Ægidius KL, Atar D, Aamodt AH. Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study - the importance of comprehensive clinical evaluation. BMC Neurol 2023; 23:115. [PMID: 36944929 PMCID: PMC10028765 DOI: 10.1186/s12883-023-03155-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management. METHODS Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis. RESULTS After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA2DS2-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091). CONCLUSION Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.
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Affiliation(s)
- B Ratajczak-Tretel
- Department of Neurology, Østfold Hospital Trust, Postboks 300, Grålum, 1714, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - A Tancin Lambert
- Department of Neurology, Østfold Hospital Trust, Postboks 300, Grålum, 1714, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - R Al-Ani
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - K Arntzen
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - G K Bakkejord
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - H M O Bekkeseth
- Lillehammer Hospital, Department of Neurology, Innlandet Hospital Trust, Lillehammer, Norway
| | - V Bjerkeli
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - G Eldøen
- Department of Neurology, Molde Hospital, Molde, Norway
| | - A K Gulsvik
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - B Halvorsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - G A Høie
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - H Ihle-Hansen
- Stroke Unit, Oslo University Hospital, Ullevål, Oslo, Norway
- Department of Internal Medicine, Vestre Viken Hospital Trust, Baerum Hospital, Gjettum, Norway
| | - S Ingebrigtsen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - C Kremer
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - S B Krogseth
- Department of Neurology, Vestfold Hospital, Tønsberg, Norway
| | - C Kruuse
- Department of Neurology, Herlev Gentofte Hospital, Herlev, Denmark
| | - M Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - I Nakstad
- Drammen Hospital, Department of Neurology, Vestre Viken Hospital Trust, Drammen, Norway
| | - V Novotny
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - H Naess
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - R Qazi
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - M K Rezaj
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - D M Rørholt
- Department of Neurology, Molde Hospital, Molde, Norway
| | - L H Steffensen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - J Sømark
- Lillehammer Hospital, Department of Neurology, Innlandet Hospital Trust, Lillehammer, Norway
| | - H Tobro
- Department of Neurology, Telemark Hospital, Skien, Norway
| | - T C Truelsen
- Department of Neurology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - L Wassvik
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - K L Ægidius
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - D Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - A H Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Neuromedicine and Movement science, The Norwegian University of Science and Technology, Trondheim, Norway
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Ratajczak-Tretel B, Tancin Lambert A, Al-Ani R, Arntzen K, Bakkejord GK, Bekkeseth HMO, Bjerkeli V, Eldøen G, Gulsvik A, Halvorsen B, Høie GA, Ihle-Hansen H, Ihle-Hansen H, Ingebrigtsen S, Johansen H, Kremer C, Krogseth SB, Kruuse C, Kurz M, Nakstad I, Novotny V, Næss H, Qazi R, Rezaj MK, Rørholt DM, Steffensen LH, Sømark J, Tobro H, Truelsen TC, Wassvik L, Ægidius KL, Atar D, Aamodt AH. Atrial fibrillation in cryptogenic stroke and TIA patients in the nordic atrial fibrillation and stroke The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Main results. Eur Stroke J 2022; 8:148-156. [PMID: 37021182 PMCID: PMC10069172 DOI: 10.1177/23969873221123122] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians. Patients and methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection. Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension ( p = 0.045) and dyslipidaemia ( p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%. Discussion and conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.
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Affiliation(s)
- B Ratajczak-Tretel
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Tancin Lambert
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - R Al-Ani
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - K Arntzen
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - GK Bakkejord
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - HMO Bekkeseth
- Department of Neurology, Lillehammer Hospital, Innlandet Hospital Trust, Lillehammer, Norway
| | - V Bjerkeli
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - G Eldøen
- Department of Neurology, Molde Hospital, Molde, Norway
| | - A Gulsvik
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - B Halvorsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - GA Høie
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - H Ihle-Hansen
- Ullevål, Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - H Ihle-Hansen
- Department of Internal Medicine, Vestre Viken Hospital Trust, Bærum Hospital, Gjettum, Norway
| | - S Ingebrigtsen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - H Johansen
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - C Kremer
- Department of Neurology, Department of Clinical Sciences Lund University, Skåne University Hospital, Malmö, Sweden
| | - SB Krogseth
- Department of Neurology, Vestfold Hospital, Tønsberg, Norway
| | - C Kruuse
- Department of Neurology, Herlev Gentofte Hospital, Herlev, Denmark
| | - M Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - I Nakstad
- Department of Neurology, Vestre Viken Hospital Trust, Drammen Hospital, Drammen, Norway
| | - V Novotny
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - H Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - R Qazi
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - MK Rezaj
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - DM Rørholt
- Department of Neurology, Molde Hospital, Molde, Norway
| | - LH Steffensen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - J Sømark
- Department of Neurology, Lillehammer Hospital, Innlandet Hospital Trust, Lillehammer, Norway
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - H Tobro
- Department of Neurology, Telemark Hospital, Skien, Norway
| | - TC Truelsen
- Department of Neurology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - L Wassvik
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - KL Ægidius
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - D Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - AH Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of neuromedicine and movement science, the Norwegian University of Science and Technology, Trondheim, Norway
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Ortiz-Garcia J, Gomez CR, Schneck MJ, Biller J. Recent advances in the management of transient ischemic attacks. Fac Rev 2022; 11:19. [PMID: 35949262 PMCID: PMC9340656 DOI: 10.12703/r/11-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Transient ischemic attack (TIA) constitutes an important clinical condition, indicating the presence of considerable risk for a subsequent ischemic stroke. Its prompt diagnosis and management have the potential for reducing the risk of neurologic disability, highlighting the critical need to prioritize the care of patients with TIA. The risk of ischemic stroke following a TIA is directly related to its etiopathogenesis, and recognizable causes are commonly categorized within one of three domains: cerebrovascular pathology, cardiac dysfunction, and hematologic disorders. Therefore, the clinical approach to patients suspected of having suffered a TIA demands a comprehensive evaluation, including testing of possible etiologic conditions in all three of these domains, best carried out in an expedited fashion since the stroke risk is greatest in the hours and days that follow the index event. The present is a review of the existing literature addressing the diagnosis, evaluation, prioritization, and management strategies available to clinicians who provide care to patients with TIA.
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Affiliation(s)
- Jorge Ortiz-Garcia
- Department of Neurology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri Columbia, Columbia, MO, USA
| | - Michael J Schneck
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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