1. Early recognition and treatment of Transient Ischaemic Attack (TIA)
Prof. Pierre Amarenco, Paris, France

2. What is a TIA….
“Brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one-hour
and without evidence of acute infarction”.
Albers GW, Caplan LR, Easton JD et al. N Engl J Med 2002;347:

3. TIA : Symptom of stroke or ministroke ?

4. Four Different Perspectives to define « TIAs »
In the community: Recognition of transient symptoms to detect patients at risk for imminent stroke:
Transient Neurologic Symptoms or
Acute CerebroVascular Syndrome
Epidemiology study: differentiiation between transient and permanent symptoms without necessary brain imaging available (duration might be useful)
Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion (qualifying for brain infarction)
In the setting of a stroke unit: differentiation between transient symptoms from persisting symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion) and those without (e.g, different prognosis, risk stratification perspective)

5. Four Different Perspectives to define « TIAs »
In the community: Recognition of transient symptoms to detect patients at risk for imminent stroke:
Transient Neurologic Symptoms or
Acute CerebroVascular Syndrome
Epidemiologic study: differentiiation between transient and permanent symptoms without necessary brain imaging available (duration might be useful)
Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion (qualifying for brain infarction)
In the setting of a stroke unit: differentiation between transient symptoms from persisting symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion) and those without (e.g, different prognosis, risk stratification perspective)

6. Four Different Perspectives to define « TIAs »
In the community: Recognition of transient symptoms to detect patients at risk for imminent stroke:
Transient Neurologic Symptoms or
Acute CerebroVascular Syndrome
Epidemiology study: differentiiation between transient and permanent symptoms without necessary brain imaging available (duration might be useful)
Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion (qualifying the neurologic event as a brain infarction)
In the setting of a stroke unit: differentiation between transient symptoms from persisting symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion) and those without (e.g, different prognosis, risk stratification perspective)

7. Four Different Perspectives to define « TIAs »
In the community: Recognition of transient symptoms to detect patients at risk for imminent stroke:
Transient Neurologic Symptoms or
Acute CerebroVascular Syndrome
Epidemiology study: differentiiation between transient and permanent symptoms without necessary brain imaging available (duration might be useful)
Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion (qualifying for brain infarction)
In the setting of a stroke unit: differentiation between transient symptoms from persisting symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion) and those without (e.g, different prognosis, risk stratification perspective)

8. Current view Use the term Keep the term
“Cerebrovascular syndrome” to qualify any suspiscion of ischemic stroke (whether transient or permanent, ischemic or hemorrhagic)
Keep the term
“TIA” for symptoms without brain lesion on neuro-imaging

9. Cumulative risk of stroke after TIA
Cumulative risk of stroke TIA vs minor stroke
Cumulative risk of stroke after TIA 5 10 15 20 25 30 60 90
Days
TIA
Minor stroke
OXVASC 2 4 6 8 10 12 14 7 21 28
Days
Risk of stroke (%)
OCSP
The risks of early stroke are therefore very high
these risks contrast +++ with those in cohorts where all patients are treated as an emergency
1-2% - PA / JLM – Paris
Such large differences are unlikely to be due to selection-bias – higher risk!
Indeed -
BMJ 2004; 328: 326-8
Lancet 2005; 366: 29-36

10. TIA: diagnosis needed 2,416 pts [OXVASC, OCSP, ECST, UK-TIA]
23% of strokes preceded by a TIA
17% same day
9% day before
43% within 7 days before index stroke
Rothwell P et al. Neurology 2005;64:

11. Very Early Management in a TIA Clinic : 80% stroke risk reduction at 3 months
EXPRESS
Next day visit
SOS-TIA
Same day visit (24/24hr)
Lavallée et al. Lancet Neurol. 2007
Rothwell et al. Lancet. 2007

12. SOS-TIA TIA clinic, 24/24 h, 7/7 d Objectives :
To make an urgent diagnosis of TIA
To find out the cause
in less than 4 hours
To prevent a stroke within the next hours/days/weeks

13. Educational leaflet on TIA
Mailed to:
PCP, cardiologists, ophthalmologists, emergency physicians, neurologists in Ile-de-France (administrative region of Paris)

14. Yesterday, I was watching TV, and suddendly the
Remote control fell down from my right hand. I could
not move my fingers during 3 minutes. And then, suddendly
I have totally recovered. Is it some fatigue, Doctor?
Do you know?
This is a TIA
This patient is at risk for a massive stroke within the
next hours?
Give 300 mg of ASA
Pre-hospital
What to do?
Don’t down grade the symptoms
Tell the patient he is at risk for imminent stroke but
that we can avoid it
Tell him we have to do immediate diagnostic testing
and treatment

15. TIA symptoms:
Carotid (anterior circulation)
• transient monocular blindness
• hemiplegie
• hemi sensory loss
• speech difficulties (aphasia)
Vertebrobasilar (posterior circulation):
• hemiplegie (may involved both sides, not at the same moment)
• unilateral paresthesia (same)
• total or partial visual field defect (one or both sides)
• ataxia with gait unstability

17. ADMISSION at the Day Clinic
SUSPICION of TIA
SOS TIA
N°Vert
24/24 - 7/7
Nurse practitioner : Monday - Friday 9h to 17 h
Senior Vascular Neurologist on duty 17h to 9h and w.e.
TIA POSSIBLE
ADMISSION at the Day Clinic

18. SOS-TIA 2003-2005 Lavallée et al. Lancet Neurol. 2007
100% of patients had their work-up done in < 4 hrs
75% of patients were discharged home 3 or 4 hrs after admission to the SOS-TIA clinic

19. SOS-TIA Model vs. Usual Care LOS 6.5 days Recognition of TIAs - PCPs
GPs - Cardiologists - Ophthalmologists
1st Step
2nd Step
Admission
To Stroke Unit
100%
ABCD2 score
Vs.
Admission
to TIA Clinic
100%
TRIAGE
Stratifying the risk
According to a quick work-up
And underlying cause
3rd Step
Discharge
100%
75%
Admission
to Stroke Unit
25%
< 1 day
vs.

20. European Stroke Organisation
2008 Recommendations
Cerebrovasc Dis. 2008;25(5): Epub 2008 May 6

21. NICE recommendations
July 2008

22. ABCD2 Score
Johnston C, Rothwell PM etal. Lancet 2006

23. Short-Term Risk of Stroke by ABCD2 Score
Johnston C, Rothwell PM etal. Lancet 2006

24. 1622 -> 1176 Definite or possible TIAs

25. 1622 -> 1176 Definite or possible TIAs
Does ABCD2 score less than 4 allow more time to evaluate patients with TIA ?
Amarenco P, Labreuche J, Lavallée PC, et al. Stroke. 2009

27. SOS-TIA update

28. MODIFIABLE RISK FACTORS
Predicting Short/Long-Term High-Risk of Stroke/MI
CLINICAL EVENTS
TIA
MARKERS OF RISK
Stroke/MI
DWI/MRI
Stenosis
Plaque
MODIFIABLE RISK FACTORS
A-Fib
Other CSE
Intima-Media Thickness
HTN/Diabetes/Cholesterol/Smoking…
Genes / Age / Gender / Hs-CRP / ACE / TM …

29. Triaging TIAs: MRI
Calvet D et al. Stroke. 2009;40:

30. ABDC2 + I Giles M, Rothwell PM, Amarenco P, et al. Stroke 2010 10 9 81 2 3 4 5 6 7 8 9 10 ≤1
ABCD2 score
OR for infarction on brain imaging
DWI- imaged cohorts
CT- imaged cohorts
Giles M, Rothwell PM, Amarenco P, et al. Stroke 2010

31. ABDC2 + I
Giles M, Rothwell PM, Amarenco P, et al. Stroke 2010

32. Causes of Brain Infarctions
Intracranial
Atherosclerosis
Penetrating
Artery
Disease
Carotid Plaque with
Arteriogenic
Emboli
Flow
Reducing
Carotid
Stenosis
Aortic Arch
Plaque
Atrial Fibrillation
Cardiogenic
Emboli
Valve Disease
Left Ventricle Thrombi

33. SOS-TIA Ultra-early Neurosonographic evaluation in definite TIA
13% ECG abnormalities (10% AF)
Carotid US
97.3% of 1881pts
Carotid athero
Carotid stenosis ≥70%
65%
8.6%
13.9%
14% 2%
19%
DTC
97.3% of 1881 pts
Intracranial stenosis
Or occlusion
TTE/TEE
96%/77% of pts
Aortic arch pl≥4 mm
Major CSE
PFO/ASA
Lavallée PC, Labreuche J, Meseguer E et al. & Meseguer E, Lavallée PC, Mazighi M, et al. & Slaoui T, Lavallée PC, Labreuche J et al.

34. SOS-TIA: stratifying the risk with TCD
Meseguer E, Lavallée PC, Mazighi M, et al. Ann Neurol. 2010

35. SOS-TIA Stratifying the risk on the presence of carotid plaque on carotid ultrasound examination
Age and sex adjusted
RR=1.83 (95%CI, )
log-rank, p=0.001
No carotid plaque
Risk of combined stroke, myocardial infarction and vascular death from time of presenting with
suspected TIA according to presence or absence of ICA atherosclerosis
1-yr rate of Stroke, MI, Vasc Death 3.7% vs. 1.3%

36. SOS-TIA: Immediate Preventive Strategy for Mr B.
Antiplatelet agent, pre-hospital
Blood pressure lowering
Statin therapy (after lipid profile determination in fasting condition)
Smoking cessation
Anti diabetic treatment
Oral anticoagulant (e.g., Atrial fibrillation)
Carotid endarterectomy (stenosis ≥70%)

37. CONCLUSIONS
• TIA is an emergency: work-up has to be done < 24 hours, in a dedicated organized structure (TIA clinic)
With fast evaluation = same day discharged for up to 75% of pts (Pt satisfaction/Cost-effectiveness)
Risk becomes extremely low compared to that expected with a RRR= 80% at 3 months
TIA clinic should be developed in all comprehensive stroke centres for same day evaluation
It is no longer possible to wait more than 12 hours to do the evaluation of a TIA

38. What should be the early management of TIA patients
Admission to a dedicated structure (no matter the setting)
Immediate evaluation and treatment
A priori defined immediate process of care
Brain imaging
Arterial and cardiac evaluation
Blood testing
Full clinical evaluation
Decision on orientation by a senior stroke specialist: discharged home or admission to SU