Current Neurology and Neuroscience Reports

, Volume 5, Issue 1, pp 13–20

Transient ischemic attack: A neurologic emergency

  • Mai N. Nguyen-Huynh
  • S. Claiborne Johnston


Classically, a transient ischemic attack (TIA) has been defined as an acute episode of neurologic symptoms lasting less than 24 hours attributed to focal ischemia in a vascular distribution of the brain or retina. Stroke and TIA share similar risk factors, evaluation, and secondary prevention. However, evaluation of patients with TIA has traditionally lacked the same urgency that has been directed to acute stroke, probably because patients with TIA are at baseline neurologically when the diagnosis is made. Recently, several studies have found a high risk of stroke shortly after TIA. Furthermore, recent evidence suggests that early recovery from ischemia actually is associated with greater instability. Identifying patients with the highest risk of recurrent ischemic events for urgent evaluation and intervention is key in secondary stroke prevention. This article reviews the current literature on new concepts about TIA, subsequent risk of stroke, and guidelines on evaluation and treatment.


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References and Recommended Reading

  1. 1.
    Johnston SC: Transient ischemic attack. N Engl J Med 2002, 347:1687–1692.PubMedCrossRefGoogle Scholar
  2. 2.
    Brainin M, McShane LM, Steiner M, et al.: Silent brain infarcts and transient ischemic attacks. A three-year study of first-ever ischemic stroke patients: the Klosterneuburg Stroke Data Bank. Stroke 1995, 26:1348–1352.PubMedGoogle Scholar
  3. 3.
    Johnston SC, Fayad P, Gorelick PB, et al.: Prevalence and knowledge of transient ischemic attacks among US adults. Neurology 2003, 60:1429–1434.PubMedGoogle Scholar
  4. 4.
    Fisher CM: Intermittent cerebral ischemia. In Cerebral Vascular Disease. Edited by Wright IS, Millikan CH. New York: Grune and Stratton; 1958:81–97.Google Scholar
  5. 5.
    Siekert RG, Whisnant JP. In Cerebral Vascular Diseases: Fourth Conference. New York: Grune and Stratton; 1965.Google Scholar
  6. 6.
    Kidwell CS, Alger JR, Di Salle F, et al.: Diffusion MRI in patients with transient ischemic attacks. Stroke 1999, 30:1174–1180.PubMedGoogle Scholar
  7. 7.
    Albers GW, Caplan LR, Easton JD, et al.: Transient ischemic attack—proposal for a new definition. N Engl J Med 2002, 347:1713–1716.PubMedCrossRefGoogle Scholar
  8. 8.
    Johnston SC, Gress DR, Browner WS, Sidney S: Short-term prognosis after emergency-department diagnosis of transient ischemic attack. JAMA 2000, 284:2901–2906. This is the first large cohort to reveal the high early risk of stroke after a TIA.PubMedCrossRefGoogle Scholar
  9. 9.
    Lovett JK, Dennis MS, Sandercock PA, et al.: Very early risk of stroke after a first transient ischemic attack. Stroke 2003, 34:138–140. This is the first population-based cohort to confirm the high early risk of stroke after a TIA.CrossRefGoogle Scholar
  10. 10.
    Whisnant JP, Matsumoto N, Elveback LR: Transient cerebral ischemic attacks in a community. Rochester, Minnesota, 1955 through 1969. Mayo Clin Proc 1973, 48:194–198.PubMedGoogle Scholar
  11. 11.
    Whisnant JP, Wiebers DO: Clinical epidemiology of transient cerebral ischemic attacks (TIA) in the anterior and posterior circulation. In Occlusive Cerebrovascular Disease. Edited by Sundt TM. Philadelphia: WB Saunders; 1987:60–65.Google Scholar
  12. 12.
    Coull AJ, Lovett JK, Rothwell PM: Population based study of early risk of stroke after transient ischemic attack or minor stroke: implications for public education and organisation of services. BMJ 2004, 328:326–328.PubMedCrossRefGoogle Scholar
  13. 13.
    Streifler JY, Eliasziw M, Benavente OR, et al.: The risk of stroke in patients with first-ever retinal vs. hemispheric transient ischemic attacks and high-grade stenosis. North American Symptomatic Carotid Endarterectomy Trial. Arch Neurol 1995, 52:246–249.PubMedGoogle Scholar
  14. 14.
    Gladstone DJ, Kapral MK, Fang J, et al.: Management and outcomes of transient ischemic attacks in Ontario. Can Med Assoc J 2004, 170:1099–1104.CrossRefGoogle Scholar
  15. 15.
    Hill MD, Yiannakoulias N, Jeerakathil T, et al.: The high risk of stroke immediately after transient ischemic attack. Neurology 2004, 62:2015–2020.PubMedGoogle Scholar
  16. 16.
    Lisabeth LD, Ireland JK, Risser JM, et al.: Stroke risk after transient ischemic attack in a population-based setting. Stroke 2004, 35:1842–1846.PubMedCrossRefGoogle Scholar
  17. 17.
    Kennedy J, Hill MD, Eliasziw M, et al.: Short-term prognosis following acute cerebral ischaemia. Stroke 2002, 33:382. This important analysis demonstrates that the risk of stroke after a TIA is significantly higher than the risk of stroke after a stroke.Google Scholar
  18. 18.
    Wiebers DO, Whisnant JP, O’Fallon WM: Reversible ischemic neurologic deficit (RIND) in a community: Rochester, Minnesota, 1955–1974. Neurology 1982, 32:459–465.PubMedGoogle Scholar
  19. 19.
    Humphrey PR, Marshall J: Transient ischemic attacks and strokes with recovery prognosis and investigation. Stroke 1981, 12:765–769.PubMedGoogle Scholar
  20. 20.
    Johnston SC, Sidney S, Bernstein AL, Gress DR: A comparison of risk factors for recurrent TIA and stroke in patients diagnosed with TIA. Neurology 2003, 60:280–285.PubMedCrossRefGoogle Scholar
  21. 21.
    Hankey GJ, Jamrozik K, Broadhurst RJ, et al.: Long-term risk of first recurrent stroke in the Perth Community Stroke Study. Stroke 1998, 29:2491–2500.PubMedGoogle Scholar
  22. 22.
    Sacco RL, Shi T, Zamanillo MC, Kargman DE: Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: the Northern Manhattan Stroke Study. Neurology 1994, 44:626–634.PubMedGoogle Scholar
  23. 23.
    Petty GW, Brown RD, Whisnant JP, et al.: Survival and recurrence after first cerebral infarction: a population-based study in Rochester, Minnesota, 1975 through 1989. Neurology 1998, 50:208–216.PubMedGoogle Scholar
  24. 24.
    Burn J, Dennis MS, Bamford JM, et al.: Long-term risk of recurrent stroke after a first-ever stroke. The Oxfordshire Community Stroke Project. Stroke 1994, 25:333–337.PubMedGoogle Scholar
  25. 25.
    Johnston SC, Easton JD: Are patients with acutely recovered cerebral ischemia more unstable? Stroke 2003, 34:2446–2450. This article shows that early recovery, even if not complete, is likely a sign of instability and is associated with high risk of recurrence.PubMedCrossRefGoogle Scholar
  26. 26.
    Johnston SC, Leira EC, Hansen MD, Adams HP: Early recovery after cerebral ischemia risk of subsequent neurological deterioration. Ann Neurol 2003, 54:439–444. This study uses data from a randomized trial to show that patients with significant early recovery are actually at higher risk for subsequent ischemia.PubMedCrossRefGoogle Scholar
  27. 27.
    Aslanyan S, Weir CJ, Johnston SC, Lees KR: Poststroke neurological improvement within 7 days is associated with subsequent deterioration. Stroke 2004, 35:2165–2170.PubMedCrossRefGoogle Scholar
  28. 28.
    Alexandrov AV, Demchuk AM, Burgin WS, et al.: Ultrasoundenhanced thrombolysis for acute ischemic stroke: phase I. Findings of the CLOTBUST trial. J Neuroimaging 2004, 14:113–117.PubMedCrossRefGoogle Scholar
  29. 29.
    Alexandrov AV, Felberg RA, Demchuk AM, et al.: Deterioration following spontaneous improvement: sonographic findings in patients with acutely resolving symptoms of cerebral ischemia. Stroke 2000, 31:915–919.PubMedGoogle Scholar
  30. 30.
    Rordorf G, Cramer SC, Efird JT, et al.: Pharmacological elevation of blood pressure in acute stroke. Clinical effects and safety. Stroke 1997, 28:2133–2138.PubMedGoogle Scholar
  31. 31.
    Johnston CM, Sidney S, Gress DR, Johnston SC: The prognostic value of head computerized tomography in TIA evaluation. Neurology 2001, 56:A159-A160.CrossRefGoogle Scholar
  32. 32.
    Gass A, Ay H, Szabo K, Koroshetz WJ: Diffusion-weighted MRI for the “small stuff”: the details of acute cerebral ischaemia. Lancet Neurol 2004, 3:39–45.PubMedCrossRefGoogle Scholar
  33. 33.
    Elkins JS, Sidney S, Gress DR, et al.: Electrocardiographic findings predict short-term cardiac morbidity after transient ischemic attack. Arch Neurol 2002, 59:1437–1441.PubMedCrossRefGoogle Scholar
  34. 34.
    Antithrombotic Trialists’ Collaboration: Collaborative metaanalysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002, 324:71–86.CrossRefGoogle Scholar
  35. 35.
    Chen ZM, Sandercock PA, Pan HC, et al.: Indications for early aspirin use in acute ischemic stroke: a combined analysis of 40,000 randomized patients from the Chinese Acute Stroke Trial and the International Stroke Trial. Stroke 2000, 31:1240–1249.PubMedGoogle Scholar
  36. 36.
    Farrell B, Godwin J, Richards S, Warlow CP: The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry 1991, 54:1044–1054.PubMedGoogle Scholar
  37. 37.
    The Dutch TIA Trial Group: A comparison of two doses of aspirin (30mg vs. 283mg a day) in patients after a transient ischemic attack or minor ischemic stroke. N Engl J Med 1991, 325:1261–1266.CrossRefGoogle Scholar
  38. 38.
    Hankey GJ, Sudlow CL, Dunbabin DW: Thienopyridine dervatives (ticlopidine, clopidogrel) versus aspirin for preventing stroke and other serious vascular events in high vascular risk patients. Cochrane Database Syst Rev 2000, 2:CD001246.PubMedGoogle Scholar
  39. 39.
    CAPRIE Steering Committee: A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996, 348:1329–1339.CrossRefGoogle Scholar
  40. 40.
    Diener HC, Cunha L, Forbes C, et al.: European Stroke Prevention Study 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996, 143:1–13.PubMedCrossRefGoogle Scholar
  41. 41.
    Mohr JP, Thompson JL, Lazar RM, et al.: A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001, 345:1444–1451.PubMedCrossRefGoogle Scholar
  42. 42.
    Gubitz G, Counsell C, Sandercock PA, Signorini D: Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev 2000, 2:CD000024.PubMedGoogle Scholar
  43. 43.
    The North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991, 325:445–453.CrossRefGoogle Scholar
  44. 44.
    The European Carotid Surgery Trialists’ Collaborative Group: Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998, 351:1379–1387.CrossRefGoogle Scholar
  45. 45.
    Mayberg MR, Wilson SE, Yatsu F, et al.: Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA 1991, 266:3289–3294.PubMedCrossRefGoogle Scholar
  46. 46.
    Hebert PR, Gaziano JM, Chan KS, Hennekens CH: Cholesterol lowering with statin drugs, risk of stroke, and total mortality: an overview of randomized trials. JAMA 1997, 278:313–321.PubMedCrossRefGoogle Scholar
  47. 47.
    Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebocontrolled trial. Lancet 2002, 360:7–22.CrossRefGoogle Scholar
  48. 48.
    PROGRESS Collaborative Group: Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001, 358:1033–1041.CrossRefGoogle Scholar
  49. 49.
    The Heart Outcomes Prevention Evaluation Study Investigators: Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000, 342:145–153.CrossRefGoogle Scholar
  50. 50.
    Dahlof B, Devereux RB, Kjeldsen SE: Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002, 359:995–1003.PubMedCrossRefGoogle Scholar
  51. 51.
    Johnston SC, Smith W: Practice variability in management of transient ischemic attacks. Eur Neurol 1999, 42:105–108.PubMedCrossRefGoogle Scholar
  52. 52.
    Nguyen-Huynh MN, Fayad P, Gorelick PB, Johnston SC: Knowledge and management of transient ischemic attacks among U.S. primary care physicians. Neurology 2003, 61:1455–1466.PubMedGoogle Scholar
  53. 53.
    Benade MM, Warlow CP: Cost of identifying patients for carotid endarterectomy. Stroke 2002, 33:435–439.PubMedCrossRefGoogle Scholar
  54. 54.
    Berge E, Abdelnoor M, Nakstad PH, Sandset PM: Low molecularweight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. Lancet 2000, 355:1205–1210.PubMedCrossRefGoogle Scholar
  55. 55.
    Saxena R, Lewis S, Berge E, et al.: Risk of early death and recurrent stroke and effect of heparin in 3169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial. Stroke 2001, 32:2333–2337.PubMedGoogle Scholar
  56. 56.
    Feinberg WM, Albers GW, Barnett HJ, et al.: Guidelines for the management of transient ischemic attacks. From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks of the Stroke Council of the American Heart Association. Circulation 1994, 89:2905–2965.Google Scholar
  57. 57.
    Bruetman ME, Fields WS, Crawford ES, DeBakery ME: Cerebral hemorrhage in carotid artery surgery. Arch Neurol 1963, 9:458–467.PubMedGoogle Scholar
  58. 58.
    Wylie EJ, Hein MF, Adams JE: Intracranial hemorrhage following surgical revascularization for treatment of acute strokes. J Neurosurg 1964, 21:212–215.PubMedCrossRefGoogle Scholar
  59. 59.
    Rothwell PM, Eliasziw M, Gutnikov SA, et al.: Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004, 363:915–924. The results of this analysis showed that the greatest benefit of endarterectomy was seen with earlier randomization for surgery, and argued for the use of carotid endarterectomy early after TIA.PubMedCrossRefGoogle Scholar
  60. 60.
    Johnston SC, Nguyen-Huynh MN: Is hospitalization after TIA cost-effective simply on the basis of treatment with tPA? Paper presented at American Heart Association 29th International Stroke Meeting, San Diego, CA, 2004.Google Scholar
  61. 61.
    Putman SF, Adams HP: Usefulness of heparin in initial management of patients with recent transient ischemic attacks. Arch Neurol 1985, 42:960–962.PubMedGoogle Scholar
  62. 62.
    Biller J, Bruno A, Adams HP: A randomised trial of aspirin or heparin in hospitalized patients with recent transient ischemic attacks. A pilot study. Stroke 1989, 20:441–447.PubMedGoogle Scholar
  63. 63.
    Panagos PD, Pancioli AM, Khoury J, et al.: Short-term prognosis after emergency department diagnosis and evaluation of transient ischemic attack (TIA). Acad Emerg Med 2003, 10:432b-433b.CrossRefGoogle Scholar
  64. 64.
    Mielke O, Pullwitt A, Hennerici M, et al.: Transient ischemic attacks are more than “mini-strokes”. Stroke 2004, 35:245.Google Scholar
  65. 65.
    Albers GW, Hart RG, Lutsep HL, et al.: Supplement to the guidelines for the management of transient ischemic attacks. A statement from the ad hoc committee on guidelines for the management of transient ischemic attacks, stroke council, American Heart Association. Stroke 1999, 30:2502–2511.PubMedGoogle Scholar
  66. 66.
    National Stroke Association: Stroke Prevention Guidelines [online]. Available at: Accessed August 17, 2004.Google Scholar

Copyright information

© Current Science Inc. 2005

Authors and Affiliations

  • Mai N. Nguyen-Huynh
    • 1
  • S. Claiborne Johnston
    • 1
  1. 1.Department of NeurologyUniversity of California, San FranciscoSan FranciscoUSA

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