Transient Ischemic Attack Disease

DESCRIPTION

The sudden onset of a focal and transient (< 24 hours) neurological deficit due to brain ischemia

System(s) affected: Nervous
Genetics: Inheritance is polygenic with a tendency to clustering of risk factors within families
Incidence/Prevalence in USA: Incidence 160/100,000; prevalence 135 per 100,000
Predominant age: Risk increases over age 45 and is highest in the seventh and eighth decades
Predominant sex: Male > Female (3:1)

SIGNS AND SYMPTOMS

Carotid circulation (hemispheric) - monocular visual loss, hemiplegia, hemianesthesia, neglect, aphasia, visual field defects; less often headaches, seizures, amnesia, confusion
Vertebrobasilar (brainstem or cerebellar) - bilateral visual obscuration, diplopia, vertigo, ataxia, facial paresis, Horner's syndrome, dysphagia, dysarthria
Cerebellar or brainstem lesion in patients with headache, nausea, vomiting, and ataxia

CAUSES

Carotid atherosclerotic disease with artery-to-artery thromboembolism
Small, deep vessel disease associated with hypertension
Cardiac - cardioembolism secondary to valvular (mitral valve) pathology; mural hypo- or akinesias with thrombosis (acute anterior myocardial infarctions or congestive cardiomyopathies); cardiac arrhythmia (atrial fibrillation)
Hypercoagulable states - antiphospholipid antibodies, deficiency of protein S, protein C. Presence of antithrombin 3, oral contraceptives.
Other causes - spontaneous and post-traumatic (i.e., chiropractic manipulation) arterial dissection, fibromuscular dysplasia

RISK FACTORS

Age
Hypertension
Cardiac disease
Smoking
Diabetes
Antiphospholipid antibodies
Family History
Hypercholesterolemia
Atrial fibrillation

LABORATORY

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

Duplex carotid ultrasonography
Cerebral angiography
ECG
Transthoracic echocardiogram (TTE); if normal and a cardiac source is suspected, follow with transesophageal echocardiogram
Holter monitoring
EEG for suspected seizure
INR and partial thromboplastin time (PTT) (Coumadin prolongs INR)
Antiphospholipid antibodies

IMAGING

Acute phase - CT of head to rule out hemorrhage
Angiography - carotid arterial stenosis
Digital subtraction - stenosis

DIAGNOSTIC PROCEDURES

N/A

APPROPRIATE HEALTH CARE

Acute phase: Outpatient for investigations; inpatient for surgery

GENERAL MEASURES

Strict control of medical risk factors, e.g., diabetes, hypertension, hyperlipidemia, cardiac disease
Counseling towards cessation of smoking

SURGICAL MEASURES

In medically fit patients with non-disabling stroke, carotid endarterectomy (CEA) is indicated for stenosis of 70-99% on side ipsilateral to stroke; CEA is of modest benefit for carotid stenosis 0f 50-69% and depends on risk factors. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) showed no benefit of CEA above medical therapy alone in stenosis of <50%.

ACTIVITY

No restrictions

DIET

As appropriate to underlying medical problems (diabetic diet, low fat diet, low salt diet etc.)

PATIENT EDUCATION

National Stroke Association, 9707 E. Easter Ln, Englewood, CO 80112 (800-STROKES)

PREVENTION/AVOIDANCE

Stop smoking
Control blood pressure, diabetes, hyperlipidemia
Antiplatelet therapy
Angiotensin converting enzyme (ACE) inhibitors
Statins

POSSIBLE COMPLICATIONS

Stroke
Seizure
Trauma if patient experiences sudden fall due to weakness

EXPECTED COURSE AND PROGNOSIS

5-20% risk of stroke on ipsilateral side within one year and cumulative thereafter. Frequency increases with addition of multiple risk factors and severity of carotid stenosis.

ASSOCIATED CONDITIONS

Atrial fibrillation
Major cause of death in first five years after a TIA is cardiac disease

AGE-RELATED FACTORS

Pediatric:

Cardiac (especially developmental abnormalities)
Metabolic - homocystinuria, Fabry's disease

Geriatric: Atrial fibrillation is a frequent cause of TIA among the elderly
Others: Adults < 45 years old most likely to have a cardiac source of embolism

PREGNANCY

A hypercoagulable state is associated with pregnancy and parturition

OTHER NOTES

N/A

ABBREVIATIONS

EC ASA = enteric coated aspirin
INR = international normalized ratio

Clinical Investigations

ROLE OF HOMOEOPATHY

Holistic healing that treats the person, not just the disease. Experience gentle, lasting wellness with expert constitutional care.