AHA/ASA Guidelines for the Definition and Evaluation of Transient Ischemic Attack
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]
AHA/ASA Guidelines for the Definition and Evaluation of Transient Ischemic Attack[1]
Definition[1]
Arguments in favour of definition
| Class III |
| "1." A 24-hour duration of symptoms does not accurately demarcate patients with and without tissue infarction. (Level of Evidence:A ) " |
| "2." The frequency distribution of durations of transiently symptomatic cerebral ischemic events shows no special relationship to the 24-hour time point.(Level of Evidence:A ) " |
| Class I |
| "1." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:C ) " |
| Class IIa |
| "1."A tissue-based definition of TIA will harmonize cerebrovascular nosology with other ischemic conditions and appropriately direct diagnostic attention to identifying the cause of ischemia and whether brain injury occurred.(Level of Evidence:C ) " |
Arguments against the new definition
| Class I |
| "1." Imaging studies currently play a central role in both determining the origin of and classifying acute cerebrovascular syndromes.(Level of Evidence:A ) " |
| Class IIa |
| "1.The new definition will modestly alter stroke and TIA prevalence and incidence rates, but these changes are to be encouraged, not discouraged, because they reflect increasing accuracy of diagnosis."(Level of Evidence:C) " |
| "2.The new definition will modestly alter stroke and TIA prevalence and incidence rates, but these changes are to be encouraged, not discouraged, because they reflect increasing accuracy of diagnosis."(Level of Evidence:C) " |
| "3.To facilitate comparison with prior studies, symptom duration is an important data element to collect in epidemiological studies."(Level of Evidence:C) " |
| "4.It would be reasonable to adopt a term such as acute neurovascular syndrome (see below) that can be used until
the diagnostic evaluation is completed or if a diagnostic evaluation is not performed."(Level of Evidence:C) " |
| "5.It is reasonable to use terms like cerebral infarction with transient signs without a fixed time criterion."(Level of Evidence:A) " |
| Class III |
| "1.We do not support linking any of these terms to a 24-hour time criterion because all cerebral infarction definitions with specific time limitations are capricious."(Level of Evidence:A) " |
| "2.It is impossible to define a specific time cutoff that can distinguish whether a symptomatic ischemic event will result in brain injury with high sensitivity and specificity."(Level of Evidence:A) " |
AHA-Endorsed Revised Definition of TIA
| Class IIa |
| "1.For patients with relatively brief symptom duration (eg, symptoms that persist several hours but less than a day) who do not receive a detailed diagnostic evaluation, it may be difficult to determine whether stroke or TIA is the most appropriate diagnosis. For these patients, it would be reasonable that a term such as acute neurovascular syndrome should be chosen, analogous to the terminology used in cardiology."(Level of Evidence:C) " |
Diagnostic Evaluation[1]
| Class I |
| "1.Patients with TIA should preferably undergo neuroimaging evaluation within 24 hours of symptom onset. MRI, including DWI, is the preferred brain diagnostic imaging modality. If MRI is not available, head CT should be performed.(" .(Level of Evidence:B ) " |
| "2.Noninvasive imaging of the cervicocephalic vessels should be performed routinely as part of the evaluation of patients with suspected TIAs".(Level of Evidence:A ) " |
| "3.Noninvasive testing of the intracranial vasculature reliably excludes the presence of intracranial stenosis and is reasonable to obtain when knowledge of intracranial steno-occlusive disease will alter management. Reliable diagnosis of the presence and degree of intracranial stenosis requires the performance of catheter angiography to confirm abnormalities detected with noninvasive testing." .(Level of Evidence:A ) " |
| "4.Patients with suspected TIA should be evaluated as soon as possible after an event" .(Level of Evidence:B ) " |
| Class IIa |
| "1.Initial assessment of the extracranial vasculature may involve any of the following: CUS/TCD, MRA, or CTA, depending on local availability and expertise, and characteristics of the patient."(Level of Evidence:B) " |
| "2.If only noninvasive testing is performed before endarterectomy, it is reasonable to pursue 2 concordant noninvasive findings; otherwise, catheter angiography should be considered."(Level of Evidence:B) " |
| "3.The role of plaque characteristics and detection of MESs is not yet defined."(Level of Evidence:B) " |
| "4.ECG should occur as soon as possible after TIA. Prolonged cardiac monitoring inpatient telemetry or Holter monitor) is useful in patients with an unclear origin after initial brain imaging and electrocardiography."(Level of Evidence:B) " |
| "5.Echocardiography (at least TTE) is reasonable in the evaluation of patients with suspected TIAs, especially in patients in whom no cause has been identified by other elements of the workup. TEE is useful in identifying PFO, aortic arch atherosclerosis, and valvular disease and is reasonable when identification of these conditions will alter management."(Level of Evidence:B) " |
| "6.Routine blood tests (complete blood count, chemistry panel, prothrombin time and partial thromboplastin time, and fasting lipid panel) are reasonable in the evaluation of patients with suspected TIAs"(Level of Evidence:B) " |
| "7.It is reasonable to hospitalize patients with TIA if they present within 72 hours of the event and any of the following criteria are present:
a. ABCD2 score of more than or equal to 3 (Level of Evidence:C) b. ABCD2 score of 0 to 2 and uncertainty that diagnostic workup can be completed within 2 days as an outpatient(Level of Evidence:C) c. ABCD2 score of 0 to 2 and other evidence that indicates the patient’s event was caused by focal ischemia(Level of Evidence:C) . |
References
- ↑ 1.0 1.1 1.2 Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E; et al. (2009). "Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists". Stroke. 40 (6): 2276–93. doi:10.1161/STROKEAHA.108.192218. PMID 19423857.