Significance of Atypical Transient Ischemic Attacks

Significance of Atypical Transient Ischemic Attacks Posted By:
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It is comprehensively recognized that the diagnosis of transient ischemic attacks (TIAs) can be difficult. While classic symptoms (motor weakness, dysphasia, hemianopia, monocular visual loss) are widely recognized, there has been no consensus on the significance of atypical TIA symptoms. In the past, atypical TIA symptoms have been deemed to be associated with a lower risk of an ischemic cause compared with typical TIAs. Yet, in a new prospective study of patients with minor ischemic stroke, classic TIA, or atypical TIA, the 90-day stroke risk was similar for atypical and classic TIA (10.6% vs 11.6%, respectively), as was the 10-year risk of major vascular events (27.1% vs 30.9%, respectively).

In the Oxford Vascular Study definition panel of atypical TIA, symptoms are transient and include:

  • Vertigo, with or without nausea/vomiting, not brought on by head movement or trauma
  • Sudden onset of ataxia with no other cause
  • Sudden onset of binocular double vision with no other ocular/neuromuscular cause
  • Sudden onset of isolated slurred speech
  • Sudden onset of isolated visual impairment without associated positive symptoms (does not include hemianopia/quadrantanopia)
  • Sudden onset of unilateral numbness, isolated to 1 body part (eg, finger, chin, leg) without march

In the cohort study, all patients were treated according to secondary prevention guidelines and the median follow-up was 5.2 years. Isolated atypical TIA symptoms were frequently associated with an underlying cause of stroke at high risk of recurrence, and at 1-year re-evaluation, brain infarction was as frequent in these patients as in patients with typical cardiovascular accident symptoms. Considering these findings demonstrating the prevalence of atypical TIA symptoms before vertebrobasilar ischemic stroke, the authors called for a revision to the list of symptoms consistent with TIA to better educate patients and non-stroke providers. TIA is a neurologic emergency: Thus, if you are a primary care provider, send these patients to the emergency department for evaluation of suspected TIA and/or ischemic stroke rule out. The benefits far outweigh the risks if symptoms are not seen as an emergency.

References
  • Lavallée PC, et al. Clinical significance of isolated atypical transient symptoms in a cohort with transient ischemic attack. Stroke. 2017;48:1495.
  • Tuna MA, et al. Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis. Lancet. 2021;397:902.

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Filed under: Cardiometabolic

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