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Transient Ischemic Attack (TIA)

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General Information

Description

  • Transient ischemic attack (TIA) is a transient episode of neurologic dysfunction caused by focal ischemia of the brain, spinal cord, or retina, and without detection of acute infarction on neuroimaging. 1

Also called

  • acute neurovascular syndrome

Definitions

  • TIA
    • American Heart Association/American Stroke Association 2009 tissue-based definition of TIA - transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction (Stroke 2009 Jun;40(6):2276)OpenInNew
    • previous time-based definition was reversible focal ischemic neurologic dysfunction lasting < 24 hours 1
      • generally accepted for use in absence of computed tomography or magnetic resonance imaging availability
      • 30% of patients diagnosed with TIA using this definition may in fact have infarcted brain
  • ischemic stroke - episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction Stroke 2013 Jul;44(7):2064OpenInNewfull-textOpenInNew
  • nondisabling stroke - transient neurologic symptoms with presence of brain infarction but mild (National Institutes of Health Score ≤ 3 points) or no persistent clinical deficits 1

References

General references used

  1. Duca A, Jagoda A. Transient Ischemic Attacks: Advances in Diagnosis and Management in the Emergency Department. Emerg Med Clin North Am. 2016 Nov;34(4):811-835OpenInNew
  2. Coutts SB. Diagnosis and Management of Transient Ischemic Attack. Continuum (Minneap Minn). 2017 Feb;23(1, Cerebrovascular Disease):82-92OpenInNew
  3. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. 2009 Jun;40(6):2276-93OpenInNew
  4. Casaubon LK, Boulanger JM, Blacquiere D, et al; Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations (CSBPR): Hyperacute stroke care guidelines, update 2015. Int J Stroke 2015 Aug;10(6):924-40OpenInNew

Recommendation grading systems used

  • American Heart Association/American Stroke Association (AHA/ASA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • American College of Cardiology/American Heart Association (ACC/AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-quality randomized controlled trials
      • Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of moderate-quality randomized controlled trials
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-analyses of such studies
      • Level C-EO - consensus of expert opinion based on clinical experience
  • American College of Chest Physicians (ACCP) uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to recommendations
    • recommendations
      • Strong - benefits outweigh risk and burdens, or vice versa; recommend
      • Weak - conditional, benefits closely balanced with risks and burden; suggest
      • Ungraded - consensus based, uncertainty due to lack of evidence, expert opinion that benefits outweigh risk and burdens, or vice versa; insufficient evidence for a graded recommendation
    • quality of evidence
      • High - confidence that true effect lies close to estimate of effect from the estimate of effect
      • Moderate - moderate confidence in effect estimate, true effect likely to be close to the estimate of the effect, but possibility it is substantially different
      • Low - confidence in the effect estimate is limited, true effect may be substantially different from estimate of effect
      • Very low - little confidence in the effect estimate. true effect is likely to be substantially different
    • Reference - ACCP Evidence-Based Clinical Practice Guidelines for Antithrombotic Therapy and Prevention of Thrombosis (Ninth Edition) guideline and expert panel report on antithrombotic therapy for atrial fibrillation (Chest 2018 Nov;154(5):1121OpenInNew)
  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew
  • Canadian Cardiovascular Society (CCS) grading system for recommendations
    • strength of recommendation
      • Strong
      • Conditional (weak)
    • quality of evidence
      • High - future research unlikely to change confidence in estimate of effect; multiple well-designed, well-conducted clinical trials
      • Moderate - further research likely to have important impact on confidence in estimate of effect and may change estimate; limited clinical trials, inconsistency of results, or study limitations
      • Low - further research very likely to have significant impact on estimate of effect and is likely to change estimate; small number of clinical studies or cohort observations
      • Very Low - estimate of effect is very uncertain; case studies or consensus opinion
    • References
  • Canadian Stroke Best Practice Recommendations (CSBPR) levels of evidence
    • Evidence Level A
      • meta-analysis of randomized controlled trials or consistent findings from ≥ 2 randomized trials
      • desirable effects clearly outweigh undesirable effects or vice versa
    • Evidence Level B
      • single randomized controlled trial or consistent findings from ≥ 2 well-designed nonrandomized and/or uncontrolled trials, and large observational studies
      • desirable effects outweigh or are closely balanced with undesirable effects or vice versa
    • Evidence Level C
      • writing group consensus and/or supported by limited research evidence
      • desirable effects outweigh or are closely balanced with undesirable effects or vice versa
    • Reference - CSBPR Overview and Methodology (CSBPR 2014 PDFPictureAsPdf)
  • European Society of Cardiology (ESC) grading system for recommendations
    • classes of recommendations
      • Class I - evidence and/or general agreement that given treatment or procedure is beneficial, useful, and effective
      • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment or procedure
        • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
        • Class IIb - usefulness/efficacy less well-established by evidence/opinion
      • Class III - evidence or general agreement that given treatment or procedure is not useful/effective, and in some cases may be harmful
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or large nonrandomized studies
      • Level C - consensus of opinion of experts and/or small studies, retrospective studies, registries
    • References

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116640, Transient Ischemic Attack (TIA); [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116640. Registration and login required.
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    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Definitions

  • KeyboardArrowRight

    Epidemiology

    • Incidence/Prevalence

    • Risk factors

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

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      Physical

      • General physical

      • Neck

      • Cardiac

      • Neuro

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Clinical prediction rules

    • Blood tests

    • KeyboardArrowRight

      Imaging studies

      • Neuroimaging

      • Noninvasive vascular imaging

      • Cardiac imaging

    • Electrocardiography (ECG)

  • KeyboardArrowRight

    Management

    • Management overview

    • Acute management

    • Prevention of stroke after TIA

    • Follow-up

  • Complications

  • KeyboardArrowRight

    Prognosis

    • KeyboardArrowRight

      Risk of stroke after TIA

      • Risk scores for predicting stroke after TIA

      • KeyboardArrowRight

        Other prognostic factors for stroke

        • Nondisabling stroke with resolving symptoms

        • Carotid artery stenosis

        • Transient monocular blindness

    • Survival

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

    • Quality and Outcomes Framework Indicators

    • Efficacy

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • United States Guidelines

      • United Kingdom Guidelines

      • Canadian Guidelines

      • European Guidelines

      • Asian Guidelines

      • Mexican Guidelines

      • Central and South American Guidelines

      • Australian and New Zealand Guidelines

      • African Guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Gabor Toth MD, FAHA
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Affiliations

Associate Professor, Department of Medicine Neurology, Cleveland Clinic Lerner College of Medicine; Ohio, United States; Associate Director, Endovascular Surgical Neuroradiology Fellowship Program, and Lead, Endovascular Operations, Cleveland Clinic Foundation; Ohio, United States; Staff Physician, Vascular Neurology and Endovascular Neuroradiology, Cleveland Clinic Foundation; Ohio, United States

Conflicts of Interest

Dr. Toth declares no relevant financial conflicts of interest.

Recommendations Editor
Esther Jolanda van Zuuren MD
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Affiliations

Head of Allergy, Dermatology, and Venereology, Leiden University Medical Centre; Netherlands

Conflicts of Interest

Dr. van Zuuren declares no relevant financial conflicts of interest.

Deputy Editor
Alexander Rae-Grant MD, FRCPC, FAAN
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Affiliations

Deputy Editor Neurology, DynaMed Plus; Massachusetts, United States; Neurologist, Cleveland Clinic; Ohio, United States

Conflicts of Interest

Dr. Rae-Grant declares no relevant financial conflicts of interest.

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