Elsevier

The Lancet Neurology

Volume 5, Issue 4, April 2006, Pages 323-331
The Lancet Neurology

Review
Recent advances in management of transient ischaemic attacks and minor ischaemic strokes

https://doi.org/10.1016/S1474-4422(06)70408-2Get rights and content

Summary

The risk of recurrent stroke during the first few days after a transient ischaemic attack or minor stroke is much higher than previously estimated. However, there is substantial variation worldwide in how patients with suspected transient ischaemic attack or minor stroke are investigated and treated in the acute phase: some health-care systems provide immediate emergency inpatient care and others provide non-emergency outpatient clinical assessment. This review considers what is known about the early prognosis after transient ischaemic attack and minor ischaemic stroke, what factors identify individuals at particularly high early risk of stroke, and what evidence there is that urgent preventive treatment is likely to be effective in reducing the early risk of stroke.

Introduction

Stroke is a leading cause of death and the most common cause of neurological disability in adults in developed countries and is also a major cause of falls, epilepsy, depression, and dementia. In some Western populations the incidence of stroke is higher than that of acute coronary syndromes.1 Without more effective prevention, the risk of stroke will increase because of ageing populations in developed and developing countries.1, 2 There is evidence that primary prevention strategies are reducing the age-adjusted incidence of first stroke,3 but improvements in secondary prevention after transient ischaemic attack and stroke are also needed.4

About 15–20% of patients with stroke have a preceding transient ischaemic attack.5 A similar proportion of major strokes are also preceded by minor strokes. These “warning” events provide an opportunity for prevention, and some clinical guidelines highlight the need for urgent assessment of patients with transient ischaemic attack and minor stroke. However, until recently there was little information on the early prognosis after transient ischaemic attack or minor stroke, risk factors for early recurrence, optimum investigation, or the effectiveness of early intervention.4 Therefore there is uncertainty about how quickly patients with minor stroke or transient ischaemic attack should be seen for secondary prevention to be most effective. North American and UK guidelines suggest that assessment should be completed within one week of a transient ischaemic attack or minor stroke.6, 7 However, there is substantial variation worldwide regarding how patients with suspected transient ischaemic attack are managed in the acute phase: some health-care systems provide immediate emergency inpatient care and others provide non-emergency outpatient clinic assessment8, 9 with little consensus about which strategy is most cost-effective.10, 11 In this review we will discuss early prognosis after transient ischaemic attack and minor ischaemic stroke and what might be gained by early investigation and treatment.

Section snippets

What is the early risk of major stroke after a minor stroke or transient ischaemic attack?

The urgency of treatment of minor stroke or transient ischaemic attack should depend on the early risk of major stroke. Although one early retrospective study did suggest that the risk of stroke was high after a transient ischaemic attack,12 the risk has generally been considered to be relatively low (approximately 1–2% at one week and 2–4% at one month)10, 13, 14, 15 and many clinical services have been organised accordingly. However, these risks are underestimates because they were determined

Identification of high-risk patients

Patients with transient ischaemic attack and minor ischaemic stroke are a very heterogeneous group in terms of symptoms, risk factors, underlying pathology, and early prognosis. The key question might therefore not be whether emergency inpatient care or non-emergency outpatient care is most appropriate, but for which patients is emergency assessment needed and which patients can be appropriately managed in a non-emergency outpatient setting? Only about 50% of patients referred for specialist

Early treatment after transient ischaemic attack and minor stroke

To justify treating transient ischaemic attack and minor stroke as an emergency, it needs to be shown that urgent treatment could prevent some of the early recurrent strokes, or at least that there is a reasonable potential that future research will identify effective preventive treatments. There are several treatments that are likely to be effective in preventing stroke in the acute phase after a transient ischaemic attack or minor ischaemic stroke including aspirin,47 possibly in combination

Ongoing studies of treatment in the acute and subacute phases

The FASTER trial (Fast Assessment of Stroke and Transient Ischaemic Attack to prevent Early Recurrence) is the only ongoing randomised trial of treatment of patients in the hyperacute phase after transient ischaemic attack.60 FASTER is a two by two factorial-design trial comparing aspirin and clopidogrel versus aspirin alone, and simvastatin (40 mg) versus placebo in patients who have had a transient ischaemic attack or minor ischaemic stroke within the previous 24 h. Treatment is for 1 month

Optimum service provision

Optimum service provision for transient ischaemic attack and minor ischaemic stroke has yet to be determined, but will certainly be influenced by the recent development of reliable risk assessment and the results of future therapeutic studies. Health-care systems that provide emergency inpatient care for nearly all patients61 might consider rapid-access outpatient clinics for those with low risk scores. In countries, such as the UK, where patients with transient ischaemic attack are usually

Public education

The emergency treatment of minor stroke and transient ischaemic attack depends on the swift presentation of patients to specialist services and the capacity of specialist services to assess, investigate, and treat patients appropriately. However, public awareness of the symptoms of transient ischaemic attack and the need to seek medical attention urgently is poor.62, 63, 64 A nationwide telephone survey of adults in the USA revealed widespread ignorance of the symptoms of transient ischaemic

Conclusion

The risk of recurrent stroke during the first few days after a transient ischaemic attack or minor stroke is much higher than previously estimated. Risk scores can identify patients at particularly high risk of stroke and there is increasing evidence that early preventive treatment is effective. Further research is needed to determine the effect of emergency prevention targeted on the basis of reliable clinical diagnosis, prognosis, and detailed brain and vascular imaging.

Search strategy and selection criteria

This non-systematic review is based on material known to the authors or identified by searches of MEDLINE (up to January 2006) for original research using combinations of the terms “transient ischaemic attack”, “ischaemic stroke”, “prognosis”, and “treatment”. Selection of material for inclusion was based on quality and relevance.

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