Differential diagnosis of transient ischemic attack and stroke
- Louis R Caplan, MD
Louis R Caplan, MD
- Professor of Neurology
- Harvard Medical School
The symptoms of brain ischemia may be transient, lasting seconds to minutes, or can persist for longer periods of time. Symptoms and signs remain indefinitely if the brain becomes irreversibly damaged and infarction occurs. Unfortunately, neurologic symptoms do not accurately reflect the presence or absence of infarction, and the tempo of the symptoms does not indicate the cause of the ischemia [1,2]. This is a critical issue because treatment depends upon accurately identifying the cause of symptoms, and the nature, location, and severity of causative cardiac, hematologic, and cerebrovascular abnormalities.
The differential diagnosis of transient ischemic attack and stroke will be reviewed here. The evaluation of stroke and transient cerebral ischemia are discussed separately. (See "Overview of the evaluation of stroke" and "Initial evaluation and management of transient ischemic attack and minor stroke".)
TRANSIENT ISCHEMIC ATTACK
Transient ischemic attack (TIA) is defined as a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. In keeping with this definition of TIA, ischemic stroke is defined as an infarction of central nervous system tissue. (See "Definition of transient ischemic attack".)
The term "transient ischemic attack" was first introduced in the early 1950s based upon the recognition that a transient focal loss of neurologic function often preceded strokes . In the years after this initial description in patients with carotid artery disease, various groups and committees arbitrarily defined TIAs as lasting less than 24 hours . However, this classic definition of TIA was inadequate for several reasons. Most notably, there is risk of permanent tissue injury (ie, infarction) even when focal transient neurologic symptoms last less than one hour.
Subsequent data demonstrated that ischemic attacks that last longer than one hour are most often associated with brain infarction [4,5]. Most TIAs last less than one hour . Thus, the benign connotation of TIA has been replaced by an understanding that even relatively brief ischemia can cause permanent brain injury.
- Caplan LR. TIAs: we need to return to the question, 'What is wrong with Mr. Jones?'. Neurology 1988; 38:791.
- Caplan LR. Transient ischemic attack: definition and natural history. Curr Atheroscler Rep 2006; 8:276.
- FISHER M. Occlusion of the internal carotid artery. AMA Arch Neurol Psychiatry 1951; 65:346.
- Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack--proposal for a new definition. N Engl J Med 2002; 347:1713.
- Caplan LR. Transient ischemic attack with abnormal diffusion-weighted imaging results: what's in a name? Arch Neurol 2007; 64:1080.
- Kumar, S, Caplan, LR. Clinical syndromes — brain. In: Transient ischemic attacks, 1st ed, Chaturvedi, S, Levine, SR (Eds), Blackwell Publishing, Malden 2004. p.73.
- MONTGOMERY BM, PINNER CA. TRANSIENT HYPOGLYCEMIC HEMIPLEGIA. Arch Intern Med 1964; 114:680.
- Bos MJ, van Rijn MJ, Witteman JC, et al. Incidence and prognosis of transient neurological attacks. JAMA 2007; 298:2877.
- van Rooij FG, Vermeer SE, Góraj BM, et al. Diffusion-weighted imaging in transient neurological attacks. Ann Neurol 2015; 78:1005.
- Cochrane T, Schmahmann JD. Compressive myelopathy presenting as cervical cord neurapraxia: a differential diagnosis of TIA. Neurology 2005; 65:1140.
- Muraszko KM, Oldfield EH. Vascular malformations of the spinal cord and dura. Neurosurg Clin N Am 1990; 1:631.
- Krings T, Geibprasert S. Spinal dural arteriovenous fistulas. AJNR Am J Neuroradiol 2009; 30:639.
- Villani F, D'Amico D, Pincherle A, et al. Prolonged focal negative motor seizures: a video-EEG study. Epilepsia 2006; 47:1949.
- Fisher CM. Transient paralytic attacks of obscure nature: the question of non-convulsive seizure paralysis. Can J Neurol Sci 1978; 5:267.
- Fisher CM. Migraine accompaniments versus arteriosclerotic ischemia. Trans Am Neurol Assoc 1968; 93:211.
- Caplan, LR. Nonatherosclerotic vasculopathies. In: Caplan's Stroke: A Clinical Approach, 4th ed, Saunders, Philadelphia 2009. p.389.
- Liberman A, Karussis D, Ben-Hur T, et al. Natural course and pathogenesis of transient focal neurologic symptoms during pregnancy. Arch Neurol 2008; 65:218.
- TRANSIENT ISCHEMIC ATTACK
- Symptoms of TIA
- TRANSIENT NEUROLOGIC EVENTS
- Migraine aura
- Transient global amnesia
- Other causes
- DISTINGUISHING TRANSIENT ATTACKS
- Nature of symptoms
- Progression and course
- Duration and tempo
- Precipitating factors
- Associated symptoms
- Patient age and gender
- PERSISTENT NEUROLOGIC DEFICITS WITH ABRUPT ONSET
- INFORMATION FOR PATIENTS