TIA
March, 2011
Mohammad Anas Hajjar, M.D
1. The classical definition of TIA is
A. an episode of focal cerebral ischemia lasting less than 24 hours
B. an episode of focal cerebral or spinal cord ischemia lasting less than 24 hours
C. an episode of focal cerebral, retinal or spinal cord ischemia lasting less than
24 hours
D. an episode of focal cerebral, retinal or spinal cord ischemia lasting more than
24 hours
Correct answer is C
2. In patients with TIA, despite complete symptom resolution MRI shows evidence
of acute tissue infarction in
A. less than 10%
B. 20-50%
C. 75%
D. MRI shows no acute findings in patients with TIA.
Correct answer is B
3. Which of the following causes TIA?
a. large artery atherosclerosis with distal embolism or vessel occlusion
b. Small deep cerebral vessel occlusion or stenosis
c. vasospasm
d. a and b
e. All of the above
Correct answer is E
True or False:
a. MRI is more likely to be abnormal in patients with symptoms of TIA lasting for
more than one hour Correct answer: T
b. CT scan is very useful in distinguishing new from old strokes
Correct answer: F
c. CT scan has good sensitivity in identifying cerebral hemorrhage and large
masses Correct answer: T
d. Carotid ultrasonography has high sensitivity and specificity for carotid
bifurcation stenosis >70% and TIA in the vertebrobasilar system
Correct answer: F. carotid US is not helpful in the vertebrobasilar system
e. MRA and CTA both have high sensitivity and specificity for any stenosis >50%;
Correct answer: T
f. Catheter angiography has 60, SBP>140, Clinical feature of unilateral weakness, duration of
symptoms
b. Age > 65, SBP>140 and/or DBP > 90, Clinical feature of unilateral weakness,
duration of symptoms
c. Age > 60, SBP>140 and/or DBP > 90, Clinical feature of unilateral weakness,
duration of symptoms
d. Age > 60, SBP>140 and/or DBP > 90, Clinical feature of unilateral weakness,
duration of symptoms, Diabetes
Correct answer is D (please show table)
5. Which of the following TIA patients needs to be hospitalized?
a. All patients with TIA should be considered for at least 24 hour observation
b. Symptomatic patients
c. Patients with symptoms lasting for more than one hour
d. Patients with ABCD score of 4 or more
Correct answer is: A. This is based on expert opinion. The 2009 AHA guidelines
recommend hospitalization of patients who present within 72 hours of TIA if they
have ABCD score of 3 or more, or if diagnostic evaluation cannot be done in 48
hours
6. (Real case): 62 year-old male with hypertension was brought to ED with
syncope. His blood pressure was 239/126. CT head showed extensive white
matter chronic ischemic changes with no acute findings. His MRA brain
showed narrowing in the right internal carotid artery. He was admitted with a
diagnosis of malignant hypertension and started on Nicardipine drip. Next day
patient’s blood pressure is controlled with oral antihypertensive medications
only and he has no signs of focal neurologic deficit. Later on patient becomes
aphasic and he does not follow any commands. His blood pressure is
126/73.Your next step is:
a. Do a stat CT scan; if there is no bleeding give TPA since patient has an acute
ischemic stroke
b. Give TPA immediately since patient had a CT scan within the past 24 hours
with no bleeding
c. Start patient on Normal Saline and, if necessary, IV vasopressors to increase
his blood pressure. Keep patient’s head of bed in flat position
d. Observe the patient for one hour and if not improved call a neurologist
Correct answer is: C. Patient’s symptoms completely resolved when his SBP was
above 140
7. A 68 year-old diabetic male was brought by his wife to the ED with left sided
weakness. His symptoms lasted for 2 hours and started to improve en-route to the
ED. His other health problems include systemic hypertension and dyslipidemia. He
is compliant with his medications. On physical exam he is alert and oriented, his
blood pressure is 136/72, and pulse is 85. His neurologic exam is completely
normal. What is the next step:
a. Give ASA 162-325 mg orally, ask the patients to see his PCP in 48 hours and
resume his home medicines.
b. Give ASA 162-325 mg orally, refer the patient to a neurologist and resume
his home medicines.
c. Give ASA 162-325 mg orally, admit the patient, for observation and
workup, resume home medications.
d. Give ASA 162-325 mg orally , admit the patient, for observation and
workup, hold his antinypertensives for the first 24 hours
Correct answer is: d. Permissive hypertension is recommended in the first 24
hours
8. Current guidelines for patients with atherosclerotic stroke or TIA recommend
LDL level below:
a. 70
b. 100
c. 110
d.130
Correct answer is: a
9. Comparing Carotid Endarterectomy (CEA) with Carotid angioplasty and
stenting in patients with TIA and carotid stenosis (more than 50%), which of
the following is true?
a. They are both equally effective
b. Carotid angioplasty and stenting is superior to CEA
c. CEA is superior to Carotid angioplasty and stenting unless surgery is
contraindicated
d. There are no randomized trials to compare both
Correct answer is: c. several large randomized trials have shown superiority of
CEA
10. Match the following therapeutic choices with indications or benefits.
a. Heparin 1. Small benefit over aspirin
b. Clopidogrel 2. Slightly less GI bleeding
c. ASA/Dyperodamol combination 3. Reduce recurrent TIA/Stroke
d. Dabigatran 4. Consider in recurrent TIAs
e. Aspirin 5. TIA due to atrial fibrillation
Correct answers: a: 4, b: 2, c: 1, d: 5, e: 3
Risk for Stroke at Various Time Points After TIA Based on ABCD2 Score
Age: 60 years = 1 point
Blood pressure: Systolic blood pressure 140 mm Hg and/or diastolic blood
pressure 90 mm Hg = 1 point
Clinical features: Unilateral weakness = 2 points
Speech disturbance without weakness = 1 point
Duration of symptoms: 60 minutes = 2 points
10–59 minutes = 1 point
Diabetes: Yes = 1 point
________________________________________________________________________
ABCD2 Score Risk Category Stroke Risk
2 Days 7 Days 90 Days
0–3 Low 1.0 1.2 3.1
4–5 Moderate 4.1 5.9 9.8
6–7 High 8.1 11.7 17.8