We know that 10-15% of strokes are preceded by TIAs, with 50% of these strokes occurring within 48hrs of a TIA. We need to be better as emergency physicians at catching the sentinel event. Dr. David Carr highlights at EMU 2019 his pearls in TIA diagnosis, workup and management: respect the eyes, look for the Crochetage sign on ECG, urgent head and neck imaging and dual antiplatelet agents for high risk patients…
Pearls in TIA diagnosis, workup and management
- TIAs present with negative symptoms (lack of function): loss of sensory, motor, speech and/or vision. Common mimics like migraines will ‘march’ with positive symptoms of pain, scintillating scotomas etc.
- Respect the eyes, visual field deficits =/= retinal pathology, patients with retinal TIAs need the same stroke workup
- Get urgent (<24hrs) head and neck imaging for your high-risk TIA patients: CT or MRI and vascular imaging (CTA or MRA) from aortic arch to vertex
- Atrial fibrillation. **Remember to ask about TIA symptoms before you cardiovert a patient
- Crochetage sign (notch in apex of R wave) seen in II, III, aVF is highly specific sign of the presence of a PFO or ASD
Outpatient management for high-risk TIAs:
- Dual antiplatelets (FASTER, CHANCE, POINT trials)
- Load with ASA 160-325mg chewed followed by ASA 81mg po daily
- Load with Clopidogrel 300mg po followed by 75mg po daily for 3 weeks only
Dr. David Carr is an Associate Professor in the Division of Emergency Medicine at the University of Toronto. He serves as the Assistant Director of Risk Management and Faculty Development at the University Health Network in Toronto. He has been the recipients of both Undergraduate and Post Graduate Clinical Teaching awards. During the Baseball season, he works at the Roger’s Centre as the Medical director of stadium medicine for the Toronto Blue Jays.
Podcast Episode 117 – TIA Update – Risk Stratification, Workup and Dual Antiplatelet Therapy with Walter Himmel and David Dushenski
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