تقریبا تصاویر و الگوریتمها تا حد خیلی زیادی مطالب رو پوشش میدن، یه چندتا نکته رو هم بگم که شاید اونجا کمتر بهشون اشاره شده باشه.
▪︎Typical TIAs are characterized by transient, focal neurologic symptoms, generally with sudden onset, without evidence of acute infarction.which can be localized to a single vascular territory within the brain, including one or more of the following:
• Transient monocular blindness (amaurosis fugax)
• Aphasia or dysarthria
• Hemianopia
• Hemiparesis and/or hemisensory loss
▪︎Antiplatelet therapy:
▫️For most patients* with TIA and minor ischemic stroke who do not have a known cardioembolic source at presentation and in the absence of contraindications, we start antiplatelet therapy immediately following an MRI or noncontrast head CT to rule out hemorrhagic etiology.
*Exceptions are patients who are on oral anticoagulation or have a clear new indication for anticoagulation.
▫️Aspirin alone(162 to 325 mg daily):
• Low-risk TIA: ABCD2 score < 4
• Ischemic stroke of moderate or greater severity: (NIHSS) score > 5.
For patients already on antiplatelet therapy with either aspirin or clopidogrel at the time of stroke onset, we continue their existing antiplatelet regimen.
▫️Short-term dual antiplatelet therapy (DAPT):aspirin (160 to 325 mg loading dose, followed by 50 to 100 mg daily) plus clopidogrel (300
to 600 mg loading dose, followed by 75 mg daily).
•High-risk TIA, defined as an ABCD2 score of ≥ 4.
•Minor ischemic stroke: NIHSS score ≤ 5
•Stroke due to intracranial large artery atherosclerosis.
▫️The duration of DAPT is typically limited to 21 days for patients with high-risk TIA or minor ischemic. Thereafter, antiplatelet treatment with one of them alone should be continued indefinitely.
▪︎Early brain imaging with MRI or CT(without contrast) indicated for all patients with suspected TIA.(DWI is preferred).
▪︎TTE is the preferred initial test for
the majority of patients with a suspected cardiac or aortic source of emboli.
▫️ کی باید TEE کنیم؟
• Patients < 45 years without known cardiovascular disease (ie, absence of myocardial infarction or valvular
disease history).
• Patients with a high pretest probability of a cardiac embolic source in whom a negative TTE would
be likely to be falsely negative.
• Patients with atrial fibrillation and suspected left atrial or left atrial appendage thrombus, especially in the
absence of therapeutic anticoagulation, but only if the TEE would impact management
• Patients with a mechanical heart valve
• Patients with suspected aortic pathology
.
▪︎ A diligent search
for a potential embolic source is necessary in all cases of TIA.
▪︎Anticoagulation:
▫️we recommend not using full-dose parenteral anticoagulation (eg, intravenous heparin) for treatment of unselected patients.
▫️Patients already on anticoagulation
anticoagulation can be started or resumed immediately for patients with a TIA and started or resumed at ≥ 3 days after onset for patients with
minor ischemic stroke and persisting mild neurologic deficits.
▫️Indications to start or continue anticoagulation in TIA:
For patient with clear indication for anticoagulation (eg, atrial fibrillation, venous thromboembolism, mechanical heart valve) at onset of TIA.
▫️Contraindications —
Early anticoagulation should be avoided when potential contraindications to anticoagulation are present, such as a large infarction (based upon clinical syndrome or brain imaging findings); severe uncontrolled, persistent hypertension (eg, systolicblood pressure ≥185 or diastolic blood pressure ≥110 mmHg); symptomatic hemorrhagic infarction; or other bleeding conditions.
▪︎Infective endocarditis is an important cause of embolic stroke and TIA for which anticoagulation is hazardous. Endocarditis must be excluded in any patient with a TIA or stroke and other suggestive findings such as fever and a heart murmur.
▪︎DDXs(Table)
☆راهنما:
▪︎تاپیک جدید
▫️توضیحاتی دربارهی همان تاپیک
▪︎Rapid overview of emergency management.
▪︎Evaluation of patient possible TIA.
▪︎Immediate antithrombotic treatment of TIA.