Brigham and Women's Hospitals

TIA

Transient ischemic attack (TIA) and minor stroke pathway

Goal

  1. The goal of this care guideline is to minimize stroke-related admissions and length of stay.

Initial evaluation

  1. For patients with new persistent deficits, with last known well within 24 h, proceed with an acute stroke pathway. Otherwise, may proceed with the pathway below.
  2. For any patient with suspected TIA or stroke, consult neurology.
  3. Screen for COVID-19 related risk factors:

High Risk Symptoms

  • Fever, subjective or documented
  • New sore throat
  • New cough
  • New runny nose or nasal congestion
  • New muscle aches
  • New shortness of breath
  • High risk exposure (>15 min without protection)
  • Seizure
  • Inability to answer screening questions (e.g. encephalopathy, aphasia)

  1. Perform and document NIHSS
  2. Diagnostic studies:
  1. Labs: CBC, BMP, PT/INR, fibrinogen, lipid panel, HgbA1C, ESR, CRP, troponin
  1. Consider: NT-proBNP, blood cultures, UA, urine/serum toxicology, COVID-19 testing if indicated above
  2. Hypercoagulation panel could be considered in select patients.
  1. EKG, keep on telemetry for duration of hospitalization (ok to travel off monitor)
  2. Imaging:
  1. CT/CTA head and neck preferred
  2. Consider Carotid US
  3. Consider MRI/MRA head and neck
  4. Consider CT or MR venography

Discharge criteria checklist

  1. Clinical and Laboratory

❑ Adult with low-risk TIA (ABCD2 ≤ 3)

OR

Non-disabling stroke (e.g. No dysphagia, encephalopathy, gait instability, severe limb weakness, severe neglect/visual deficit).

❑ No fluctuating neurological deficits or recurrent TIAs in the past month.

❑ No clinical concern for high recurrence risk stroke etiology (e.g. endocarditis, hypercoagulability of malignancy, giant cell arteritis).

❑ No concern for stroke mimics (e.g. meningoencephalitis, seizure, cerebral amyloid angiopathy-related spells).

❑ No medical instability (e.g. rapid AFib, severe hypertension, respiratory distress

❑ No psychosocial limitations compromising rapid virtual F/U (language barrier, internet access, psychiatric comorbidities)

  1. Diagnostics

❑ Head CT shows no evidence of hemorrhage or significant edema.

❑ No evidence for significant (>50%) stenosis or embolic occlusion of the ‘culprit’ artery

❑ No evidence for cerebral arteriopathy (e.g. vasculitis, RCVS, Moyamoya)

❑ No evidence of cervical arterial dissection

❑ TTE is reassuring or deemed not necessary by neurology consultant

TTE indicated during hospitalization

  • Clinical concern for major valvular disease: e.g. new murmur, hx of rheumatic heart dz
  • Clinical evidence of cardiomyopathy: e.g. heart failure, history of cardiomyopathy
  • Evidence of active myocardial ischemia
  • Clinical concern for infective endocarditis: e.g. history of IVDA, fever, AVR/MVR, other stigmata
  • Concern for hypercoagulability and marantic endocarditis: active cancer, history of APLS, unexplained thrombocytopenia, unexplained DVT

  1. Note
  1. Even if Discharge Criteria are met, the patient may be admitted per the discretion of neurology, OR if the recommended post-discharge tests or follow-up cannot be arranged within a suitable time frame.
  2. COVID-19 positive patients with TIA/minor stroke will be admitted to the COVID-19 unit with neurology consult team follow-up.

Management

  1. Neurology consultant will determine appropriate management, including antiplatelet / anticoagulation therapy, statin, and blood pressure recommendations.

Outpatient tests

  1. Cardiac Evaluation:
  1. Additional TTE or TEE with contrast
  2. Cardiac monitoring with 30 day MCT or implanted loop monitor
  1. Additional stroke mechanism evaluation, determined per neurology
  1. Lower extremity vascular ultrasound, pelvic MRV, CT venogram
  2. TCDs
  3. CT chest/abdomen/pelvis

Outpatient follow-up

  1. PCP followup
  2. Rapid neurology follow up (within 2 weeks):
    Please contact Stacy Greene at 617-525-9932 or sgreene4@partners.org
    Please cc Linda Bresette, N.P. lbresette@bwh.harvard.edu to ensure follow up