Transient ischemic attacks

Reduction of the risk of transient ischemic attacks or strokes in men who have had transient ischemia of the brain due to fibrin platelet emboli (aspirin only). This use has been found to be effective only in men (not women). 

The modern period in the history of stroke began in the 1960s when C. Miller Fisher described detailed clinical and pathological observations on the features of lacunar strokes, carotid artery disease, transient ischemic attacks, and intracerebral hemorrhage. His student Louis Caplan established one of the first stroke registry... 

Hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) have been shown to improve vascular outcomes due to their cholesterol-lowering effects as well as multiple pleiotropic effects. In high-risk populations, statin therapy is known to reduce the risk of vascular events such as myocardial infarction and stroke. A meta-analysis of 10 trials involving 79,494 subjects showed that statin therapy reduced the incidence of stroke by 18%, major coronary events by 27%, and all-cause mortality by 15%. The SPARCL trial recently showed that high-dose HMG-CoA reductase inhibitors prevent recurrent stroke and transient ischemic attacks. ... 

Amarenco P, Bogousslavsky J, Callahan 3rd A, Goldstein LB, Hennerici M, Rudolph AE, SiUesen H, Simunovic L, Szarek M, Welch KM, Zivin JA. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006 355 549-559. 

Blaser T, Hofmann K, Buerger T, Effenberger O, Wallesch CW, Goertler M. Risk of stroke, transient ischemic attack, and vessel occlusion before endarterectomy in patients with symptomatic severe carotid stenosis. Stroke 2002 33 1057-1062. 

Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, Leys D, Matias-Guiu J, Rupprecht HJ MATCH investigators. Aspirin and clopidogrel compared with clopidogrel alone after recent ischemic stroke or transient ischemic attack in high-risk patients (MATCH) randomised, double-blind, placebo-controlled trial. Lancet 2004 364(9431) 331-337. 

Cardioembolism Cardioembolism accounts for approximately 30% of all stroke and 25-30% of strokes in the young (age <45 years)." AF accounts for a large proportion of these strokes (15-25%). Symptoms may be suggestive, but they are not diagnostic. Repetitive, stereotyped, transient ischemic attacks (TIAs) are unusual in embolic stroke. The classic presentation for cardioembolism is the sudden onset of maximal symptoms. The size of the embolic material determines, in part, the course of the embolic material. Small emboli can cause retinal ischemic or lacunar symptoms. Posterior cerebral artery territory infarcts, in particular, are often due to cardiac embolism. This predilection is not completely consistent across the various cardiac structural abnormalities that predispose to stroke, and may be due to patterns of blood flow associated with specific cardiac pathologies. 

Jabaudon D, Sztajzel J, Sievert K, Landis T, Sztajzel R. Usefulness of amulatory 7 day ECG monitoring for the detection of atrial finrillation and flutter after acute stroke and transient ischemic attack. Stroke 2004 35 1647-1651. 

Risk factors for embolic cerebrovascular accidents include previous ischemic stroke, transient ischemic attacks (TIA), systemic embolism, age >75 yr, moderately or severely impaired left ventricular systolic function, hypertension, diabetes mellitus... 

FIGURE 6-9. Decision algorithm for stroke prevention in atrial fibrillation.27 Risk factors for stroke prior transient ischemic attack or stroke hypertension heart failure rheumatic heart valve disease prosthetic heart valve. Target International Normalized Ratio = 2.5 (range 2 to 3). 

Understand the types of cerebrovascular disease including transient ischemic attack, cerebral infarction, and cerebral hemorrhage. 

There are two main classifications of cerebral ischemic events transient ischemic attacks and cerebral infarction. 

Aspirin is typically considered to be the first-line secondary prevention agent for ischemic stroke and decreases the risk of subsequent stroke by approximately 25% in both men and women with previous transient ischemic attacks or stroke. 

Transient ischemic attacks or prior stroke (major independent risk factor)... 

Symptomatic carotid artery disease (stroke or transient ischemic attack)... 

Signs and symptoms Headache, vomiting, stupor, hemiparesis, aphasia, visual disturbances, and seizure transient ischemic attack is a strong predictor for stroke. Behavioral and performance changes may be present in patients with asymptomatic infarction. 

Transient ischemic attack A focal neurologic deficit lasting less than 24 hours in which symptoms resolve completely. 

A 74-year-old female has had several episodes of transient ischemic attacks (TIAs). She cannot tolerate aspirin. Which of the following should be considered as an alternative therapy ... 

A complete history and physical examination should assess (1) presence or absence of cardiovascular risk factors or definite cardiovascular disease in the individual (2) family history of premature cardiovascular disease or lipid disorders (3) presence or absence of secondary causes of hyperlipidemia, including concurrent medications and (4) presence or absence of xanthomas, abdominal pain, or history of pancreatitis, renal or liver disease, peripheral vascular disease, abdominal aortic aneurysm, or cerebral vascular disease (carotid bruits, stroke, or transient ischemic attack). 

Goal BP values are <140/90 for most patients, but <130/80 for patients with diabetes mellitus, significant chronic kidney disease, known coronary artery disease (myocardial infarction [MI], angina), noncoronary atherosclerotic vascular disease (ischemic stroke, transient ischemic attack, peripheral arterial disease [PAD], abdominal aortic aneurysm), or a 10% or greater Framingham 10-year risk of fatal coronary heart disease or nonfatal MI. Patients with LV dysfunction have a BP goal of <120/80 mm Hg. 

One clinical trial showed that the combination of an ACE inhibitor and thiazide diuretic reduces the incidence of recurrent stroke in patients with a history of ischemic stroke or transient ischemic attacks. 

Stroke is a term used to describe an abrupt onset of focal neurologic deficit that lasts at least 24 hours and is presumed to be of vascular origin. Stroke can be either ischemic or hemorrhagic in origin. Transient ischemic attacks (TIAs) are focal ischemic neurologic deficits lasting less than 24 hours and usually less than 30 minutes. 

In the elderly other reasons for episodic vertigo can be transient ischemic attacks, heart arrhythmias or viral infections causing vestibular neuritis. 

In addition to coronary sclerosis, evidence is accumulating that high Lp(a) levels may be important in the development of cerebrovascular and peripheral arterial disease, as well (J6, T8, U2). Lp(a) levels not only correlated well with clinical endpoints such as transient ischemic attack and cerebral infarction, but also were associated with the extent and severity of carotid atherosclerosis, as assessed by bidirectional Doppler ultrasound (K23, M33, Z2). 

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