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Strokes and Transient Neurological Attacks - TIAs
Jay S. Luxenberg, MD and Ernest H. Rosenbaum, MD

The difference between a transient ischemic attack (TIAs)2 and ischemic stroke attacks is that the symptoms resolve in less than 24 hours. The underlying cause can be identical for TIA and stroke; thus, early diagnosis and treatment is needed. Symptoms are usually easy to diagnosis but often difficult to distinguish a TIA from a stroke early. 3

Patients are not always helpful, as they can be affected with neurological deficits, and symptoms are often indistinguishable from each other.

Accurate diagnosis is vital, and a diagnosis is important, as the risk of a stroke in days or weeks following a TIA is high, with an average risk of about 11% at 90 days after a TIA when carefully monitored and followed following a TIA diagnosis.

TIA treatment is complex, as it requires an Emergency Department evaluation, hospitalization, and sometimes stroke prevention if the diagnosis is missed, as there are competing conditions, such as migraine and vasovagal syncope.

The differential may include Meniere's disease, hyperventilation, cardiac syncope, hypoglycemia, or orthostatic hypotension. Also, following a TIA, it may be a harbinger of an increased risk for dementia (especially vascular dementia), as well as a potential risk for stroke or myocardial infarction.

The implications of this are as follows:
A TNA - transient neurological attack - may be non-focal and treated in a benign way, and there's no consistent evaluation plan or guidelines for prognostic information.

No matter what the cause of the TNA/TIA events are, greater attention needs to be exerted in order to find who is at greater risk through a more complete evaluation, especially to rule out underlying contributing diseases.4 The goal is to assess the stroke risk by using a validated ABCD.

Only identifying the potential cause of a TNA/TIA can reduce the risk of subsequent stroke and vascular dementia. These investigations are justified. The following are to be considered:

1. Brain imaging
2. Carotid imaging
3. Electrocardiogram
4. Careful history and physical examination
5. Cholesterol panel, glucose, hemoglobin A1c
6. Assessment for vascular risk factors

Cardiac Monitoring and Echocardiogram
A vague diagnosis is unacceptable.

Treatment and preventive practices are recommended for all patients with TIA, including anti-platelet drugs, such as aspirin, Dipyridamole, clopidogrel, a statin and an antihypertensive program, using agents as necessary.

Hospitalization may be indicated, especially when there is a non-focal TNA because of a shorter stroke risk versus patients with high risk for a stroke.

Those with a TIA/TNA with sudden onset symptoms without an underlying etiology need a diagnosis, if possible to help plan future follow-up care, especially adding preventive lifestyle measures.

There is an association between an elevated non-fasting triglyceride blood level associated with increased risk of myocardial infarction, ischemic heart disease and death, and arteriosclerotic events.5 In this study of 13,956 participants, it was shown that non-fasting triglyceride levels were associated with an increased risk of ischemic strokes.

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