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Suspected Transient Ischemic Attack

Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department (2016)

Scope of Application

This guideline is intended for physicians working in EDs.

Inclusion Criteria

This guideline applies to adult patients aged 18 years and older presenting to the ED with a suspected TIA who have had resolution of symptoms.

Exclusion Criteria

This guideline is not intended to be used for pediatric patients. 

Critical Questions

  • In adult patients with suspected TIA, are there clinical decision rules that can identify patients at very low short-term risk for stroke who can be safely discharged from the ED?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    In adult patients with suspected TIA, do not rely on current existing risk stratification instruments (eg, age, blood pressure, clinical features, duration of TIA and presence of diabetes [ABCD2] score) to identify TIA patients who can be safely discharged from the ED.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    In adult patients with suspected TIA, do not rely on current existing risk stratification instruments (eg, age, blood pressure, clinical features, duration of TIA and presence of diabetes [ABCD2] score) to identify TIA patients who can be safely discharged from the ED.

    Level C Recommendations

    None specified.

  • In adult patients with suspected TIA, what imaging can be safely delayed from the initial ED workup?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    (1) The safety of delaying neuroimaging from the initial ED workup is unknown. If noncontrast brain MRI is not readily available, it is reasonable for physicians to obtain a noncontrast head CT as part of the initial TIA workup to identify TIA mimics (eg, intracranial hemorrhage, mass lesion). However, noncontrast head CT should not be used to identify patients at high short-term risk for stroke. (2) When feasible, physicians should obtain MRI with diffusion-weighted imaging (DWI) to identify patients at high short-term risk for stroke. (3) When feasible, physicians should obtain cervical vascular imaging (eg, carotid ultrasonography, CTA, or MRA) to identify patients at high short-term risk for stroke.

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    (1) The safety of delaying neuroimaging from the initial ED workup is unknown. If noncontrast brain MRI is not readily available, it is reasonable for physicians to obtain a noncontrast head CT as part of the initial TIA workup to identify TIA mimics (eg, intracranial hemorrhage, mass lesion). However, noncontrast head CT should not be used to identify patients at high short-term risk for stroke. (2) When feasible, physicians should obtain MRI with diffusion-weighted imaging (DWI) to identify patients at high short-term risk for stroke. (3) When feasible, physicians should obtain cervical vascular imaging (eg, carotid ultrasonography, CTA, or MRA) to identify patients at high short-term risk for stroke.

  • In adult patients with suspected TIA, is carotid ultrasonography as accurate as neck CTA or MRA in identifying severe carotid stenosis?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    In adult patients with suspected TIA, carotid ultrasonography may be used to exclude severe carotid stenosis because it has accuracy similar to that of MRA or CTA.
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    In adult patients with suspected TIA, carotid ultrasonography may be used to exclude severe carotid stenosis because it has accuracy similar to that of MRA or CTA.
  • In adult patients with suspected TIA, can a rapid ED-based diagnostic protocol safely identify patients at short-term risk for stroke?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    In adult patients with suspected TIA without high-risk conditions, a rapid ED-based diagnostic protocol may be used to evaluate patients at short-term risk for stroke. High-risk conditions include abnormal initial head CT result (if obtained), suspected embolic source (presence of atrial fibrillation, cardiomyopathy, or valvulopathy), known carotid stenosis, previous large stroke, and crescendo TIA.
    Level C Recommendations
    None specified.
    Level A Recommendations
    None specified.
    Level B Recommendations
    In adult patients with suspected TIA without high-risk conditions, a rapid ED-based diagnostic protocol may be used to evaluate patients at short-term risk for stroke. High-risk conditions include abnormal initial head CT result (if obtained), suspected embolic source (presence of atrial fibrillation, cardiomyopathy, or valvulopathy), known carotid stenosis, previous large stroke, and crescendo TIA.
    Level C Recommendations
    None specified.

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Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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