Suspected Transient Ischemic Attack (beta)
Official guideline from American College of Emergency Physicians
Summary by Eric Steinberg, DO
Strength of Recommendation
A
B
C
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Patent Pending
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Attention COACH STUDY participants:
The principal investigators of the study request that you use the official version of the modified score here.
Diagnosis
- 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.
- 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 (e.g. intracranial hemorrhage, mass lesion). However, noncontrast head CT should not be used to identify patients at high short-term risk for stroke.
- When feasible, physicians should obtain MRI with diffusion-weighted imaging (DWI) to identify patients at high short-term risk for stroke.
- When feasible, physicians should obtain cervical vascular imaging (e.g. carotid ultrasonography, CTA, or MRA) to identify patients at high short-term risk for stroke.
- 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 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.
How strong is ACEP's recommendation?
