Dallas - Stroke symptoms that disappear in under an hour, known as a transient ischemic attack (TIA), need emergency assessment to help prevent a full-blown stroke, according to a new American Heart Association scientific statement published today in the Association’s journal Stroke. The statement offers a standardized approach to evaluating people with suspected TIA, with guidance specifically for hospitals in rural areas that may not have access to advanced imaging or an on-site neurologist.
TIA is a temporary blockage of blood flow to the brain. Each year, about 240,000 people in the U.S. experience a TIA, although this estimate may represent underreporting of TIA because symptoms tend to go away within an hour. While the TIA itself doesn’t cause permanent damage, nearly 1 in 5 of those who have a TIA will have a full-blown stroke within three months after the TIA, almost half of which will happen within two days. For this reason, a TIA is more accurately described as a warning stroke rather than a “mini-stroke,” as it’s often called.
TIA symptoms are the same as stroke symptoms, only temporary. They begin suddenly and may have any or all of these characteristics:
- Symptoms begin strong then fade;
- Symptoms typically last less than an hour;
- Facial droop;
- Weakness on one side of the body;
- Numbness on one side of the body;
- Trouble finding the right words/slurred speech; or
- Dizziness, vision loss or trouble walking.
The F.A.S.T. acronym for stroke symptoms can be used to identify a TIA: F ― Face drooping or numbness; A ― Arm weakness; S ― Speech difficulty; T ― Time to call 9-1-1, even if the symptoms go away.
“Confidently diagnosing a TIA is difficult since most patients are back to normal function by the time they arrive at the emergency room,” said Hardik P. Amin, M.D., chair of the scientific statement writing committee and associate professor of neurology and medical stroke director at Yale New Haven Hospital, St. Raphael Campus in New Haven, Connecticut. “There also is variability across the country in the workup that TIA patients may receive. This may be due to geographic factors, limited resources at health care centers or varying levels of comfort and experience among medical professionals.”
For example, Amin said, “Someone with a TIA who goes to an emergency room with limited resources may not get the same evaluation that they would at a certified stroke center. This statement was written with those emergency room physicians or internists in mind – professionals in resource-limited areas who may not have immediate access to a vascular neurologist and must make challenging evaluation and treatment decisions.”
The statement also includes guidance to help health care professionals tell the difference between a TIA and a “TIA mimic” – a condition that shares some signs with TIA but is due to other medical conditions such as low blood sugar, a seizure or a migraine. Symptoms of a TIA mimic tend to spread to other parts of the body and build in intensity over time.
Who is at risk for a TIA?
People with cardiovascular risk factors, such as high blood pressure, diabetes, obesity, high cholesterol and smoking, are at high risk for stroke and TIA. Other conditions that increase risk of a TIA include peripheral artery disease, atrial fibrillation, obstructive sleep apnea and coronary artery disease. In addition, a person who has had a prior stroke is at high risk for TIA.
Which tests come first once in the emergency room?
After assessing for symptoms and medical history, imaging of the blood vessels in the head and neck is an important first assessment. A non-contrast head CT should be done initially in the emergency department to rule out intracerebral hemorrhage and TIA mimics. CT angiography may be done as well to look for signs of narrowing in the arteries leading to the brain. Nearly half of people with TIA symptoms have narrowing of the large arteries that lead to the brain.
A magnetic resonance imaging (MRI) scan is the preferred way to rule out brain injury (i.e., a stroke), ideally done within 24 hours of when symptoms began. About 40% of patients presenting in the ER with TIA symptoms will actually be diagnosed with a stroke based on MRI results. Some emergency rooms may not have access to an MRI scanner, and they may admit the patient to the hospital for MRI or transfer them to a center with rapid access to one.
Blood work should be completed in the emergency department to rule out other conditions that may cause TIA-like symptoms, such as low blood sugar or infection, and to check for cardiovascular risk factors like diabetes and high cholesterol.
Once TIA is diagnosed, a cardiac work-up is advised due to the potential for heart-related factors to cause a TIA. Ideally, this assessment is done in the emergency department, however, it could be coordinated as a follow-up visit with the appropriate specialist, preferably within a week of having a TIA. An electrocardiogram to assess heart rhythm is suggested to screen for atrial fibrillation, which is detected in up to 7% of people with a stroke or TIA. The American Heart Association recommends that long-term heart monitoring within six months of a TIA is reasonable if the initial evaluation suggests a heart rhythm-related issue as the cause of a TIA or stroke.
Early neurology consultation, either in-person or via telemedicine, is associated with lower death rates after a TIA. If consultation isn’t possible during the emergency visit, the statement suggests following up with a neurologist ideally within 48 hours but not longer than one week after a TIA, given the high risk of stroke in the days after a TIA. The statement cites research that about 43% of people who had an ischemic stroke (caused by a blood clot) had a TIA within the week before their stroke.
Assessing stroke risk after TIA
A rapid way to assess a patient’s risk of future stroke after TIA is the 7-point ABCD2 score, which stratifies patients into low, medium and high risk based on Age, Blood pressure, Clinical features (symptoms), Duration of symptoms (less than or greater than 60 minutes) and Diabetes. A score of 0-3 indicates low risk, 4-5 is moderate risk and 6-7 is high risk. Patients with moderate to high ABCD2 scores may be considered for hospitalization.
Collaboration among emergency room professionals, neurologists and primary care professionals is critical to ensure the patient receives a comprehensive evaluation and a well-communicated outpatient plan for future stroke prevention at discharge.
“Incorporating these steps for people with suspected TIA may help identify which patients would benefit from hospital admission, versus those who might be safely discharged from the emergency room with close follow-up,” Amin said. “This guidance empowers physicians at both rural and urban academic settings with information to help reduce the risk of future stroke.”
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The most common heart- or stroke-related diagnoses for women seen in the emergency department were high blood pressure (16% of visits), high blood pressure-related heart or kidney disease (14.1%) and atrial fibrillation (10.2%). The most common diagnoses for men were high blood pressure-related heart or kidney disease (14.7%), high blood pressure (10.8%) and heart attack (10.7%).
"Previous studies have shown sex differences in patterns of CVD among hospitalized patients," Mamas said. "However, examining CVD encounters in the emergency department provides a more complete picture of the cardiovascular health care needs of men and women, as it captures encounters prior to hospitalization." He also points out that previous studies of CVD emergency visits are limited to suspected heart attack visits. "Therefore, this analysis of 15 CVD conditions helps to better understand the full spectrum of acute CVD needs, including sex disparities in hospitalization and risk of death."
The study found that outcomes from the emergency CVD visits were slightly different for men and women. Overall, women were less likely to die (3.3% of women vs 4.3% of men) or be hospitalized (49.1% of women vs 52.3% of men) after an emergency department visit for CVD. The difference may be due to women’s generally lower risk diagnoses, said Mamas, but there could be an underestimation of deaths in women.
"We did not track deaths outside of the hospital setting," said Mamas. "Given past evidence that women are more likely to be inappropriately discharged from the emergency department, and strong evidence for the systemic undertreatment of women, further study is warranted to track outcomes beyond the emergency department visit."
An additional limitation of the data includes potential misdiagnosis errors in cases where the final diagnosis did not match the emergency diagnosis, particularly after a hospitalization and additional bloodwork and other health information could be obtained. Furthermore, the data is limited in that it does not capture information related to severity of disease, which may make comparisons around mortality differences between different patient groups challenging.
"Our work with this large, nationally representative sample of cardiovascular emergency visits highlights differences in health care needs of men and women, which may be useful to inform planning and provision of health care services," said Mamas. "We also encourage further research into understanding the underlying factors driving the differences in CVD patterns and outcomes between men and women."
