TIA Is It Really A Big Deal?

1. TIAIs It Really A Big Deal? Jan Jahnel, RN, CNRN Stroke Nurse Coordinator

2. Continuing Education Provider OSF Saint Francis Medical Center Continuing Education Provider Program (CEPP) is an approved provider of continuing nursing education by the Illinois Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

3. Conflict of Interest There is no conflict of interest or bias on the part of the presenter.

4. Objectives • Define transient ischemic attack (TIA) • Review risks of stroke following TIA • Discuss TIA symptoms • Explain TIA management including nursing assessments

5. Definition(s) • Transient, neurologic deficit lasting <24 hours (classical) • Focal, neurologic dysfunction due to brain or retinal ischemia with symptoms lasting typically <1 hour & without evidence of infarction (revised)

7. Causes TIAs are usually caused by one of three things

8. Cause 1 • Low blood flow at a narrow part of a major artery carrying blood to the brain, such as the carotid artery

9. Pathology • Large artery plaque can begin early • In carotids, often at bifurcation or within 2 cm of ICA origin • cavernous segment next most common • Intracranial lesions less common • more often in Asians, African Americans • Often very pronounced deficit immediately, occasional fluctuations

10. Cause 2 Narrowing of the smaller blood vessel in the brain, blocking blood flow for a short period of time; usually caused by plaque (a fatty substance) build up

11. Pathology • Atherosclerosis can affect small vessels also (<400 micrometers) • Leads to “lacunar syndromes” typically • Can be devastating and dense like large artery disease • can be “stuttering” course

12. Cause 3 • A blood clot in another part of the body (such as the heart) breaks off, travels to the brain, and blocks a blood vessel in the brain

13. Same symptoms of Stroke Sudden numbness or weakness of the face, arm or leg on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble waking, dizziness, loss of balance or coordination

15. TIA • Carotid Territory TIA: transient monocular blindness, dysphasia and contralateral weakness or sensory disturbance. • Vertebrobasilar TIA: vertigo, visual disturbances ( reduced vision, double vision) bilateral simultaneous weakness or sensory disturbance • Lacunar TIA : pure motor symptom, pure sensory, sensorimotor, and ataxic hemiparesis • Low flow TIA: severe occlusion of neck vessel, caused by postural changes, monocular or binocular blurring, dimming, lower limb weakness,

16. The short duration of these symptoms and lack of permanent brain injury is the main difference between TIA and stroke. TIA vs STROKE

17. ABCD² Score • Risk assessment to improve the prediction of short-term stroke risk following a TIA. • Optimized to predict the risk of stroke within 2 days by also predicts the risk within 90 days • Higher scores are associated with greater risk of stroke after TIA National Stroke Association Johnston SC, Rothwell PM, Huynh-Huynh MN, Giles MF, Elkins JS, Sidney S, “Validation and refinement of scores to predict very early stroke risk after transient ischemic attack,” Lancet, 369:283-292, 2007

19. ABCD2 Stroke risk, % (2-day/7-day/90-day) • 0-1 point: 0/0/2% • 2-3 points: 1/1/3% • 4-5 points: 4/6/10% • 6-7 points: 8/12/18% Johnston SC, et al. Lancet 2007;369:283-292

20. TIA Risk of CVA post TIA • Several studies have shown that: • 11-20% risk of CVA post index TIA @ 90 days • 2-7% risk of recurrent CVA post index CVA @ 90 days

21. TIA • TIA = brain “angina”?!?

22. TIA Risk of CVA greatest in first 48 hours following a TIA

23. Assessment • Frequent neuro checks/vital signs • Imaging • Labs • Risk factors • Don’t underestimate patient complaints of symptoms • Treat as an emergency • education

24. Neurologic Exam: NIH Stroke Scale • 13 item scoring system, 7 minute exam • Integrates neurologic exam components • CN (visual), motor, sensory, cerebellar, inattention, language, LOC • Maximum score is 42, signifying severe stroke • Minimum score is 0, a normal exam • Scores greater than 15-20 are more severe

25. TIA workup • Imaging (MRI/MRA) • Carotid dopplers • Echocardiogram • Lab work up • Control/treat risk factors

26. Treatment • Prevention is best • TIA and CVA are preventable! • Treatment same for CVA & TIA • Risk factor modification most important • control what you can

27. Treatment • Antiplatelet agents • Anticoagulation • Risk factor modification- HTN, diabetes, high cholesterol, smoking, a-fib………

28. Is it TIA or a Stroke

29. REMEMBER! • If the person returns to baseline or return to normal the treatment clock resets

30. Case • 61 year old caucasion male admitted 3/12 to the ED with c/o expressive aphasia-pt states he knows what he wants to say but can’t express himself- also history of blurry vision X 6 months- MRI scheduled by PCP – PMH HTN, atherosclerosis, high cholesterol (zocor) and previous MI • symptoms resolved on arrival to ED at 1829 recurrence of sx at 1850 with NIHSS 2

31. CASE cont • FAST 333 called- neurology at bedside- CT scan done –negative • Labs essentially nl- glucose 152 • Neurology note states patient nearly back to normal upon assessment • Admitted to general floor with tele • Q 1 hour neuro checks Q2 hour vitals

32. Case • Vitals and neuro checks not appropriate for general unit so provider paged for change or transfer • After admission to floor patients family came out and stated that the patient was having recurrence of symptoms • Eventually moved to neuro ICU with NIHSS of 4 IV tpa started- continued to worsen taken to angio

33. Case cont • 95% LICA stenosis • Carotid endarterectomy 3/24 • Transferred to rehab 3/30 • Came in with TIA resolved symptoms • Discharged to rehab 18 days later • NIHSS 11

34. Documentation • Document neuro checks as ordered • Document concise neuro assessment • Document time of any change • Notify physician immediately • Document any interventions or encounters

35. TIA Is it a big deal?

36. YES it can be……… • Summary • Risk greater for stroke within first 48 hours • Monitor your patient frequently………NIHSS……vitals……. • Document any changes….interactions with providers • Don’t trivialize or disregard subtle changes • Clock resets- stroke or TIA

38. THANK YOU

39. To Obtain CE Credit • Print and complete post test • Print and complete evaluation form • Free for Central Illinois AANN Chapter members who were unable to attend the May 21st conference • $5.00 for non-members • 1 contact hour will be provided • This offer expires June 1, 2013

40. Where to send forms Send completed post test and evaluation form to Central Illinois AANN Chapter 2821 W. Wilder St. Peoria, Il 61615 AANN Central Illinois Chapter