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    Suspected Transient Ischemic Attack (beta)

    Official guideline from the American College of Emergency Physicians.

    Summary by Eric Steinberg, DO
    Strength
    Level A
    Level B
    Level C

    Diagnosis

    Clinical Decision Rules
    1. In adult patients with suspected transient ischemic attack (TIA), do not rely on current existing risk stratification instruments (eg, age, blood pressure, clinical features, duration of transient ischemic attack and presence of diabetes [ABCD²] score) to identify transient ischemic attack patients who can be safely discharged from the emergency department (ED).
    Imaging
    1. The safety of delaying neuroimaging from the initial emergency department (ED) workup is unknown. If noncontrast brain MRI is not readily available, it is reasonable for physicians to obtain a noncontrast head computerized tomography (CT) as part of the initial transient ischemic attack (TIA) workup to identify transient ischemic attack mimics (e.g. intracranial hemorrhage, mass lesion). However, noncontrast head computerized tomography should not be used to identify patients at high short-term risk for stroke.
    2. When feasible, physicians should obtain magnetic resonance imaging (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 (e.g. carotid ultrasonography, computed tomography angiography [CTA], or magnetic resonance angiography [MRA]) to identify patients at high short-term risk for stroke.
    4. In adult patients with suspected transient ischemic attack (TIA), carotid ultrasonography may be used to exclude severe carotid stenosis because it has accuracy similar to that of magnetic resonance angiography (MRA) or computed tomography angiography (CTA).
    Protocols
    1. In adult patients with suspected transient ischemic attack (TIA) without high-risk conditions, a rapid emergency department (ED)-based diagnostic protocol may be used to evaluate patients at short-term risk for stroke. High-risk conditions include abnormal initial head computerized tomography (CT) result (if obtained), suspected embolic source (presence of atrial fibrillation, cardiomyopathy, or valvulopathy), known carotid stenosis, previous large stroke, and crescendo transient ischemic attack.
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    Research PaperLo BM, Carpenter CR, Hatten BW, et al. American College of Emergency Physicians. Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department. Ann Emerg Med. 2016;68(3):354-370.e29.