Transient ischemic attack: Are there different types or classes? Risk of stroke and treatment options

  • Hakan Ay
  • Walter J. Koroshetz
Article

Opinion statement

Recent advances in neuroimaging have revolutionized the evaluation of the clinical syndrome of transient ischemic attack (TIA). Diffusion-weighted imaging demonstrates microinfarctions (< 1 cm3) in approximately 50% of patients with TIA, establishing that not all clinically transient spells are transient at the tissue level. The clinical syndrome of TIA that is associated with ischemic brain injury is called “transient symptoms with infarction” (TSI). TSI appears to be a different subset because it harbors higher risk of imminent stroke than “TIA with no infarction.“ Armed with the evidence of ischemia as the cause of transient spell, clinicians can pursue the most appropriate therapy for stroke prevention by targeting the underlying etiology of brain ischemia.

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References and Recommended Reading

  1. 1.
    Toole JF, Lefkowitz DS, Chambless LE, et al.: Selfreported transient ischemic attack and stroke symptoms: methods and baseline prevalence. The ARIC Study, 1987–1989. Am J Epidemiol 1996, 144:849–856.PubMedGoogle Scholar
  2. 2.
    Ovbiagele B, Kidwell CS, Saver JL: Epidemiological impact in the United States of a tissue-based definition of transient ischemic attack. Stroke 2003, 34:919–924.PubMedCrossRefGoogle Scholar
  3. 3.
    Johnston SC, Fayad PB, Gorelick PB, et al.: Prevalence and knowledge of transient ischemic attack among US adults. Neurology 2003, 60:1429–1434.PubMedGoogle Scholar
  4. 4.
    The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA Project Principal Investigators [no authors listed]. J Clin Epidemiol 1988, 41:105–114.CrossRefGoogle Scholar
  5. 5.
    Special report from the National Institute of Neurological Disorders and Stroke. Classification of cerebrovascular diseases III [no authors listed]. Stroke 1990, 21:637–676.Google Scholar
  6. 6.
    Transient focal cerebral ischemia: epidemiological and clinical aspects. The Study Group on TIA Criteria and Detection. XI [no authors listed]. Stroke 1974, 5:277–284.Google Scholar
  7. 7.
    Marshall J: The natural history of transient ischaemic cerebrovascular attacks. QJM 1964, 33:309–324.PubMedGoogle Scholar
  8. 8.
    Levy DE: How transient are transient ischemic attacks? Neurology 1988, 38:674–677.PubMedGoogle Scholar
  9. 9.
    Albers GW, Caplan LR, Easton JD, et al.: Transient ischemic attack—proposal for a new definition. TIA Working Group. N Engl J Med 2002, 347:1713–1716. This article proposes a new definition for TIA based on the absence or presence of imaging evidence of brain infarction.PubMedCrossRefGoogle Scholar
  10. 10.
    Ay H, Oliveira-Filho J, Buonanno FS, et al.: “Footprints” of transient ischemic attacks: a diffusion-weighted MRI study. Cerebrovasc Dis 2002, 14:177–186.PubMedCrossRefGoogle Scholar
  11. 11.
    Kidwell CS, Alger JR, Di Salle F, et al.: Diffusion MRI in patients with transient ischemic attacks. Stroke 1999, 30:1174–1180.PubMedGoogle Scholar
  12. 12.
    Engelter ST, Provenzale JM, Petrella JR, Alberts MJ: Diffusion MR imaging and transient ischemic attacks. Stroke 1999, 30:2762–2763.PubMedGoogle Scholar
  13. 13.
    Crisostomo RA, Garcia MM, Tong DC: Detection of diffusion-weighted MRI abnormalities in patients with transient ischemic attack: correlation with clinical characteristics. Stroke 2003, 34:932–937.PubMedCrossRefGoogle Scholar
  14. 14.
    Ferro JM, Falcao I, Rodrigues G, et al.: Diagnosis of transient ischemic attack by the nonneurologist. A validation study. Stroke 1996, 27:2225–2229.PubMedGoogle Scholar
  15. 15.
    Otten A, Nino YB, Limburg M, DeHaan R: Management of transient ischemic attacks by general practitioner. Cerebrovasc Dis 1995, 5:358–361.Google Scholar
  16. 16.
    Tomasello F, Mariani F, Fieschi C, et al.: Assessment of interobserver differences in the Italian multicenter study on reversible cerebral ischemia. Stroke 1982, 13:32–35.PubMedGoogle Scholar
  17. 17.
    Kraaijeveld CL, Van Gijn J, Schouten HJA, Staal A: Interobserver agreement for the diagnosis of transient ischemic attacks. Stroke 1984, 15:723–725.PubMedGoogle Scholar
  18. 18.
    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
  19. 19.
    Marks MP, de Crespigny A, Lentz D, et al.: Acute and chronic stroke: navigated spin-echo diffusionweighted MR imaging. Radiology 1996, 199:403–408.PubMedGoogle Scholar
  20. 20.
    Minematsu K, Li L, Sotak C, et al.: Reversible focal ischemic injury demonstrated by diffusion-weighted magnetic resonance imaging in rats. Stroke 1992, 23:1304–1311.PubMedGoogle Scholar
  21. 21.
    Ay H, Buonanno FS, Rordorf G, et al.: Normal diffusion-weighted MRI during stroke-like deficits. Neurology 1999, 52:1784–1792.PubMedGoogle Scholar
  22. 22.
    Krol AL, Coutts SB, Simon JE, et al.: Perfusion MRI abnormalities in speech or motor transient ischemic attack patients. Stroke 2005, 36:2487–2489.PubMedCrossRefGoogle Scholar
  23. 23.
    Ay H, Koroshetz WJ, Benner T, et al.: Transient ischemic attack with infarction: a unique syndrome? Ann Neurol 2005, 57:679–686. This study introduces the concept of TSI as a distinct clinical entity.PubMedCrossRefGoogle Scholar
  24. 24.
    Inatomi Y, Kimura K, Yonehara T, et al.: DWI abnormalities and clinical characteristics in TIA patients. Neurology 2004, 62:376–380.PubMedGoogle Scholar
  25. 25.
    Douglas VC, Johnston CM, Elkins J, et al.: Head computed tomography findings predict short term stroke risk after transient ischemic attack. Stroke 2003, 34:2894–2899.PubMedCrossRefGoogle Scholar
  26. 26.
    Coutts SB, Simon JE, Eliasziw M, et al.: Triaging transient ischemic attack and minor stroke patients using acute magnetic resonance imaging. Ann Neurol 2005, 57:848–854.PubMedCrossRefGoogle Scholar
  27. 27.
    Purroy F, Montaner J, Rovira A, et al.: Higher risk of further vascular events among transient ischemic attack patients with diffusion-weighted imaging acute ischemic lesions. Stroke 2004, 35:2313–2319.PubMedCrossRefGoogle Scholar
  28. 28.
    Coutts SB, Simon JE, Sohn CH: Silent ischemia in minor stroke and TIA patients identified on MR imaging. Neurology 2005, 65:513–517.PubMedCrossRefGoogle Scholar
  29. 29.
    Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators [no authors listed]. JAMA 1998, 279:1265–1272.CrossRefGoogle Scholar
  30. 30.
    The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group [no authors listed]. Lancet 1997, 349:1569–1581.CrossRefGoogle Scholar
  31. 31.
    Alpert JS, Thygesen K, Antman E, Bassand JP: Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000, 36:959–969.PubMedCrossRefGoogle Scholar
  32. 32.
    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. The paper identifies a benign subset of TIA that is associated with low risk of subsequent stroke and high risk of recurrent TIA.PubMedCrossRefGoogle Scholar
  33. 33.
    Fisher CM: Late-life migraine accompaniments as a cause of unexplained transient ischemic attacks. Can J Neurol Sci 1980, 7:9–17.PubMedGoogle Scholar
  34. 34.
    Rothwell PM, Giles MF, Flossmann E, et al.: A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 2005, 366:29–36. This study defines a 6-point score called the ABCD score to predict 7-day risk of stroke following a TIA.PubMedCrossRefGoogle Scholar
  35. 35.
    Donnan GA, O’Malley HM, Quang L, et al.: The capsular warning syndrome: pathogenesis and clinical features. Neurology 1993, 43:957–962.PubMedGoogle Scholar
  36. 36.
    Farrar J, Donnan GA: Capsular warning syndrome preceding pontine infarction. Stroke 1993, 24:762.PubMedGoogle Scholar
  37. 37.
    Yadav JS, Wholey MH, Kuntz RE, et al.: Protected carotid-artery stenting versus endarterectomy in highrisk patients. N Engl J Med 2004, 351:1493–1501.PubMedCrossRefGoogle Scholar
  38. 38.
    Benavente O, Eliasziw M, Streifler JY, et al.: Prognosis after transient monocular blindness associated with carotidartery stenosis. N Engl J Med 2001, 345:1084–1090.PubMedCrossRefGoogle Scholar
  39. 39.
    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.PubMedCrossRefGoogle Scholar
  40. 40.
    Chimowitz MI, Lynn MJ, Howlett-Smith H: Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 2005, 352:1305–1316.PubMedCrossRefGoogle Scholar
  41. 41.
    Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. SSYLVIA Study Investigators [no authors listed]. Stroke 2004, 35:1388–1392.CrossRefGoogle Scholar
  42. 42.
    Klijn CJ, Kappelle LJ, Tulleken CA, van Gijn J: Symptomatic carotid artery occlusion. A reappraisal of hemodynamic factors. Stroke 1997, 28:2084–2093.PubMedGoogle Scholar
  43. 43.
    Grubb RL, Derdeyn CP, Fritsch SM, et al.: Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA 1998, 280:1055–1060.PubMedCrossRefGoogle Scholar
  44. 44.
    Adams RJ, Chimovitz MI, Alpert JS, et al.: Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: a scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Circulation 2003, 108:1278–1290.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc. 2006

Authors and Affiliations

  • Hakan Ay
    • 1
  • Walter J. Koroshetz
  1. 1.Stroke Service and A.A. Martinos Center for Biomedical ImagingMassachusetts General Hospital, Harvard Medical SchoolBostonUSA

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