Background: There is insufficient evidence regarding which clinical features are best suited to distinguish between transient ischemic attack (TIA) and disorders mimicking TIA (TIA mimics). Methods: We compared the frequency, clinical characteristics and outcome of patients with TIA and TIA mimics in a prospective, single-center emergency department cohort over 2 years. Results: Of 303 patients, 248 (81.8%) had a TIA and 55 (18.2%) had TIA mimics. Epileptic seizures (26/55; 43.7%) and migraine attacks (13/55; 23.6%) were the most common TIA mimics. In patients presenting with unilateral paresis, TIA mimics were less likely than in patients without unilateral paresis [odds ratio (OR) 0.35, 95% confidence interval (CI) 0.17–0.68]. Memory loss (OR 9.17, 95% CI 2.89–32.50), headache (OR 3.71, 95% CI 1.07–12.78) and blurred vision (OR 2.48, 95% CI 0.90–6.59) increased the odds of TIA mimics. Once these clinical features were taken into account, neither aphasia, dysarthria, sensory loss, blood pressure values nor the duration of symptoms were found to improve explanation of the underlying status. At 3 months, stroke, recurrent TIA and myocardial infarction were absent in patients with TIA mimics but occurred in 13 (5.2%), 20 (8.1%) and 3 (1.2%) TIA patients, respectively. Conclusions: About 1 in every 5 patients with suspected TIA had a TIA mimic. Paresis suggested TIA, while other clinical variables used in risk assessment scores after TIA were not shown to distinguish between the two entities. Patients with TIA mimics had a better short-term prognosis.

Keywords:
Clinical symptoms, Outcome, Transient ischemic attack, Mimics, Emergency medical services
1.
Coutts SB, Eliasziw M, Hill MD, Scott JN, Subramaniam S, Buchan AM, Demchuk AM: An improved scoring system for identifying patients at high early risk of stroke and functional impairment after an acute transient ischemic attack or minor stroke. Int J Stroke 2008;3:3–10.
2.
Eliasziw M, Kennedy J, Hill MD, Buchan AM, Barnett HJM: Early risk of stroke after a transient ischemic attack in patients with internal carotid artery disease. CMAJ 2004;170:1105–1109.
3.
Ois A, Gomis M, Rodríguez-Campello A, Cuadrado-Godia E, Jiménez-Conde J, Pont-Sunyer C, Cuccurella G, Roquer J: Factors associated with a high risk of recurrence in patients with transient ischemic attack or minor stroke. Stroke 2008;39:1717–1721.
4.
Kleindorfer D, Panagos P, Pancioli A, Khoury J, Kissela B, Woo D, Schneider A, Alwell K, Jauch E, Miller R, Moomaw C, Shukla R, Broderick JP: Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke 2005;36:720–723.
5.
Purroy F, Montaner J, Molina CA, Delgado P, Ribo M, Alvarez-Sabín J: Patterns and predictors of early risk of recurrence after transient ischemic attack with respect to etiologic subtypes. Stroke 2007;38:3225–3229.
6.
Rothwell PM, Coull AJ, Silver LE, Fairhead JF, Giles MF, Lovelock CE, Redgrave JNE, Bull LM, Welch SJV, Cuthbertson FC, Binney LE, Gutnikov SA, Anslow P, Banning AP, Mant D, Mehta Z: Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study). Lancet 2005;366:1773–1783.
7.
Johnston SC, Gress DR, Browner WS, Sidney S: Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901–2906.
8.
Hill MD, Yiannakoulias N, Jeerakathil T, Tu JV, Svenson LW, Schopflocher DP: The high risk of stroke immediately after transient ischemic attack: a population-based study. Neurology 2004;62:2015–2020.
9.
Paciaroni M, Agnelli G, Bertolini A, Pezzini A, Padovani A, Caso V, Venti M, Alberti A, Palmiero RA, Cerrato P, Silvestrelli G, Lanari A, Previdi P, Corea F, Balducci A, Ferri R, Falcinelli F, Filippucci E, Chiocchi P, Grandi FC, Ferigo L, Musolino R, Bersano A, Ghione I, Sacco S, Carolei A, Baldi A, Ageno W: Risk of recurrent cerebrovascular events in patients with cryptogenic stroke or transient ischemic attack and patent foramen ovale: the FORI (Foramen Ovale Registro Italiano) study. Cerebrovasc Dis 2011;31:109–116.
10.
Nakajima M, Hirano T, Naritomi H, Minematsu K: Symptom progression or fluctuation in transient ischemic attack patients predicts subsequent stroke. Cerebrovasc Dis 2010;29:221–227.
11.
Dennis MS, Bamford JM, Sandercock PA, Warlow CP: Incidence of transient ischemic attacks in Oxfordshire, England. Stroke 1989;20:333–339.
12.
Hand PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM: Distinguishing between stroke and mimic at the bedside: the brain attack study. Stroke 2006;37:769–775.
13.
Winkler DT, Fluri F, Fuhr P, Wetzel SG, Lyrer PA, Ruegg S, Engelter ST: Thrombolysis in stroke mimics: frequency, clinical characteristics, and outcome. Stroke 2009;40:1522–1525.
14.
Fallon C, Noone I, Ryan J, O’Shea D, O’Laoide R, Crowe M: Assessment and management of transient ischaemic attack – the role of the TIA clinic. Ir J Med Sci 2006;175:24–27.
15.
Josephson SA, Sidney S, Pham TN, Bernstein AL, Johnston SC: Higher ABCD2 score predicts patients most likely to have true transient ischemic attack. Stroke 2008;39:3096–3098.
16.
Quinn TJ, Cameron AC, Dawson J, Lees KR, Walters MR: ABCD2 scores and prediction of noncerebrovascular diagnoses in an outpatient population: a case-control study. Stroke 2009;40:749–753.
17.
Sheehan OC, Merwick A, Kelly LA, Hannon N, Marnane M, Kyne L, McCormack PME, Duggan J, Moore A, Moroney J, Daly L, Harris D, Horgan G, Kelly PJ: Diagnostic usefulness of the ABCD2 score to distinguish transient ischemic attack and minor ischemic stroke from noncerebrovascular events: the North Dublin TIA Study. Stroke 2009;40:3449–3454.
18.
Weisskopf F, Fluri F, Amort M, Katan M, Bingisser R, Engelter ST, Lyrer PA: Prozessanalyse des Abklärungs- und Behandlungskonzeptes für Patienten mit Transitorischer Ischämischer Attacke im Universitätsspital Basel. Schweiz Arch Neurol Psychiatr 2010;161:166–172.
19.
Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, Hatsukami TS, Higashida RT, Johnston SC, Kidwell CS, Lutsep HL, Miller E, Sacco RL: 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;40:2276–2293.
20.
Koudstaal PJ, Gerritsma JG, van Gijn J: Clinical disagreement on the diagnosis of transient ischemic attack: is the patient or the doctor to blame? Stroke 1989;20:300–301.
21.
Kraaijeveld CL, Van Gijn J, Schouten HJ, Staal A: Interobserver agreement for the diagnosis of transient ischemic attacks. Stroke 1984;15:723–725.
22.
Fluri F, Hatz F, Voss B, Lyrer PA, Engelter ST: Restenosis after carotid endarterectomy: significance of newly acquired risk factors. Eur J Neurol 2010;17:493–498.
23.
Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JNE, Warlow CP, Mehta Z: A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 2005;366:29–36.
24.
Wood SN: Fast stable direct fitting and smoothness selection for generalized additive models. J R Stat Soc B 2008;70:495–518.
25.
Cox DR, Snell EJ: Analysis of Binary Data. London, Chapman and Hall, 1989.
26.
Hirji KF, Mehta CR, Patel NR: Computing distributions for exact logistic regression. Am Stat Assoc 1987;82:1110–1117.
27.
Hirji KF, Tsiatis AA, Mehta CR: Median unbiased estimation for binary data. Am Stat 1989;43:7–11.
28.
StataCorp: Stata Statistical Software, release 10. College Station, StataCorp, 2007.
29.
Akaike H: Information theory and an extension of the maximum likelihood principle; in Petrov BN, Csádki F (eds): Second International Symposium on Information Theory, Tsahkadsor, Armenia, USSR, September 2–8, 1971. Budapest, Akadémiai Kiadó, 1973, pp 267—281.
30.
Brier GW: Verification of forecasts expressed in terms of probability. Mon Weather Rev 1950;78:1–3.
31.
Efron B: Improvements on cross-validation: the 632+ bootstrap method. J Am Stat Assoc 1997;93:548–560.
32.
RDCT: R: A Language and Environment for Statistical Computing. Vienna, R Foundation for Statistical Computing, 2009. http://www.R-project.org.
33.
Prabhakaran S, Silver AJ, Warrior L, McClenathan B, Lee VH: Misdiagnosis of transient ischemic attacks in the emergency room. Cerebrovasc Dis 2008;26:630–635.
34.
Harbison J, Hossain O, Jenkinson D, Davis J, Louw SJ, Ford GA: Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke 2003;34:71–76.
35.
Kothari RU, Pancioli A, Liu T, Brott T, Broderick J: Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med 1999;33:373–378.
36.
Nor AM, Davis J, Sen B, Shipsey D, Louw SJ, Dyker AG, Davis M, Ford GA: The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol 2005;4:727–734.
37.
Hanlon RE, Lux WE, Dromerick AW: Global aphasia without hemiparesis: language profiles and lesion distribution. J Neurol Neurosurg Psychiatry 1999;66:365–369.
38.
Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA: Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med 2007;167:2417–2422.
39.
Fisher RS, van Emde Boas W, Blume W, Elger C, Genton P, Lee P, Engel J: Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia 2005;46:470–472.
40.
Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24 (suppl 1):9–160.
© 2011 S. Karger AG, Basel
2011
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.