Two retrospective chart reviews of TIA found considerable practice variability in the evaluation of TIA patient. In 1 study of TIA patients presenting to an emergency department, 81% had a computed tomography scan, 75% had electrocardiogram, and 74% had a complete blood count.5 Carotid Doppler imaging was performed in the emergency department in 16%, and 26% were referred for outpatient Doppler studies. One percent had an ECG in the emergency department, and 16% were given ECGs as outpatients. Seventy-five percent of patients were discharged home. Those hospitalized had a median length of stay of 1 day. In the second study, 31% of the TIA patients had no diagnostic studies performed during the first month after presenting to their primary care physician.6
FIGURE
Expeditious evaluation of TIA is imperative
Recommendations from others
The American Heart Association (AHA) recommends that physicians use a stepwise approach to TIA evaluation as outlined in the Table. The AHA also recommends that the diagnostic evaluation of patients seen within 7 days of a TIA should be completed within 1 week or less. The AHA leaves the decision whether to hospitalize a patient up to the physician based on a patient’s circumstances. The goals of diagnostic testing are to identify or exclude causes of TIA requiring specific therapy, to assess modifiable risk factors, and to determine prognosis.7
The National Stroke Association recommends that patients with known high-grade stenosis in a vascular territory appropriate to the symptoms, and patients with recurrent symptoms, undergo urgent evaluation. Evaluation includes imaging and ruling out other causes of TIA. Patients should be admitted to the hospital if imaging is not immediately available. If indicated, carotid endarterectomy should be performed without delay.8
TABLE
Stepwise diagnostic evaluation for patients with transient ischemic attack
Initial Evaluation
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Second step (to resolve persistent diagnostic uncertainty as appropriate)
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| Adapted from Feinberg et al 1994.7 |
CLINICAL COMMENTARY:
Make the patient aware of the risks of TIA and quickly complete the work-up
Jon O. Neher, MD
Valley Medical Center, Renton, Wash
It is important to remember that a diagnosis of TIA can only be made retrospectively. All patients with ongoing focal neurologic signs must be evaluated immediately and (if the symptom duration is less than 3 hours) considered potential candidates for emergent thrombolytic therapy.
The vast majority of TIA patients are asymptomatic during their evaluation. Because they feel well and may have a considerable element of denial, it can be hard to get them to rapidly complete their evaluation in either the inpatient or outpatient setting. It is therefore critical that the patient be made aware that the highest risk period is soon after the TIA and that failure to quickly complete the work-up could have serious negative consequences.