Background: Transient ischemic attack (TIA) patients are at high risk of short-term stroke, myocardial infarction and vascular death. Stroke risk is reduced by immediate treatment initialization. Stroke unit treatment is recommended for TIA patients. We established an outpatient TIA clinic to address the question whether outpatient evaluation of suspected TIA is safe. Methods: TIA workup included cerebral imaging, duplex sonography, transcranial Doppler screening for patent foramen ovale, electrocardiography, blood tests, ABCD2 score and ankle-brachial index within one day. TIA patients received secondary prophylaxis immediately. TIA patients fulfilling predefined criteria for high early stroke risk (ABCD2 score ≧4 points and TIA within 72 h, symptomatic stenosis, newly detected atrial fibrillation, recurrent TIA) were referred to the stroke unit. The remaining patients were discharged home. 90-day telephone follow-up was obtained. Results: 123 consecutive patients with suspected TIA (53 male, age 59 ± 17.2 years) were prospectively evaluated. TIA or minor stroke was diagnosed in 69 (56%), and TIA mimics in 54 (44%) patients. Median time from symptom onset to presentation was 48 h (1 h to 3 months). Patients with TIA/minor stroke presented significantly more frequently with ABCD2 score ≧4 points (p = 0.021). Twelve patients (9.8%) were admitted to the stroke unit. There were 2 strokes during follow-up. The stroke rate was 1.6% within all patients, and 2.9% within the subgroup of patients with TIA/minor stroke, compared to 5.7% predicted by the ABCD2 score. Other vascular end points were not found. Conclusion: Based on risk stratification, outpatient evaluation of TIA is safe. TIA mimics are frequent.

Keywords:
Transient ischemic attack, TIA clinic, Risk stratification after TIA
1.
Johnston SC, Gress DR, Browner WS, Sidney S: Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901–2906.
2.
Touze E, Varenne O, Chatellier G, Peyrard S, Rothwell PM, Mas JL: Risk of myocardial infarction and vascular death after transient ischemic attack and ischemic stroke: a systematic review and meta-analysis. Stroke 2005;36:2748–2755.
3.
Meves SH, Diehm C, Berger K, Pittrow D, Trampisch HJ, Burghaus I, Tepohl G, Allenberg JR, Endres HG, Schwertfeger M, Darius H, Haberl RL: Peripheral arterial disease as an independent predictor for excess stroke morbidity and mortality in primary-care patients: 5-year results of the getABI study. Cerebrovasc Dis 2010;29:546–554.
4.
Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S: Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007;369:283–292.
5.
Chandratheva A, Mehta Z, Geraghty OC, Marquardt L, Rothwell PM: Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009;72:1941–1947.
6.
Candelise L, Gattinoni M, Bersano A, Micieli G, Sterzi R, Morabito A: Stroke-unit care for acute stroke patients: an observational follow-up study. Lancet 2007;369:299–305.
7.
Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D: Thrombolysis with alteplase 3 to 4.5 h after acute ischemic stroke. N Engl J Med 2008;359:1317–1329.
8.
Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Hoxter G, Mahagne MH, et al: Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 1995;274:1017–1025.
9.
Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JN, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC, Welch SJ, Bosch S, Alexander FC, Silver LE, Gutnikov SA, Mehta Z: Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007;370:1432–1442.
10.
Luengo-Fernandez R, Gray AM, Rothwell PM: Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison. Lancet Neurol 2009;8:235–243.
11.
Lavallee PC, Meseguer E, Abboud H, Cabrejo L, Olivot JM, Simon O, Mazighi M, Nifle C, Niclot P, Lapergue B, Klein IF, Brochet E, Steg PG, Leseche G, Labreuche J, Touboul PJ, Amarenco P: A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007;6:953–960.
12.
Wasserman J, Perry J, Dowlatshahi D, Stotts G, Stiell I, Sutherland J, Symington C, Sharma M: Stratified, urgent care for transient ischemic attack results in low stroke rates. Stroke 2010;41:2601–2605.
13.
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35–41.
14.
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.
15.
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.
16.
Eliasziw M, Kennedy J, Hill MD, Buchan AM, Barnett HJ: Early risk of stroke after a transient ischemic attack in patients with internal carotid artery disease. CMAJ 2004;170:1105–1109.
17.
Gulli G, Khan S, Markus HS: Vertebrobasilar stenosis predicts high early recurrent stroke risk in posterior circulation stroke and TIA. Stroke 2009;40:2732–2737.
18.
Purroy F, Montaner J, Rovira A, Delgado P, Quintana M, Alvarez-Sabin J: Higher risk of further vascular events among transient ischemic attack patients with diffusion-weighted imaging acute ischemic lesions. Stroke 2004;35:2313–2319.
19.
Purroy F, Montaner J, Molina CA, Delgado P, Ribo M, Alvarez-Sabin J: Patterns and predictors of early risk of recurrence after transient ischemic attack with respect to etiologic subtypes. Stroke 2007;38:3225–3229.
20.
Castle J, Mlynash M, Lee K, Caulfield AF, Wolford C, Kemp S, Hamilton S, Albers GW, Olivot JM: Agreement regarding diagnosis of transient ischemic attack fairly low among stroke-trained neurologists. Stroke 2010;41:1367–1370.
21.
Wu CM, Manns BJ, Hill MD, Ghali WA, Donaldson C, Buchan AM: Rapid evaluation after high-risk TIA is associated with lower stroke risk. Can J Neurol Sci 2009;36:450–455.
22.
Calvet D, Lamy C, Touze E, Oppenheim C, Meder JF, Mas JL: Management and outcome of patients with transient ischemic attack admitted to a stroke unit. Cerebrovasc Dis 2007;24:80–85.
23.
Dengler R, Diener HC, Schwartz A, Grond M, Schumacher H, Machnig T, Eschenfelder CC, Leonard J, Weissenborn K, Kastrup A, Haberl R: Early treatment with aspirin plus extended-release dipyridamole for transient ischaemic attack or ischaemic stroke within 24 h of symptom onset (EARLY trial): a randomised, open-label, blinded-endpoint trial. Lancet Neurol 2010;9:159–166.
24.
Ferro JM, Falcao I, Rodrigues G, Canhao P, Melo TP, Oliveira V, Pinto AN, Crespo M, Salgado AV: Diagnosis of transient ischemic attack by the nonneurologist. A validation study. Stroke 1996;27:2225–2229.
25.
Ois A, Cuadrado-Godia E, Rodriguez-Campello A, Jimenez-Conde J, Roquer J: High risk of early neurological recurrence in symptomatic carotid stenosis. Stroke 2009;40:2727–2731.
26.
Ovbiagele B, Cruz-Flores S, Lynn MJ, Chimowitz MI: Early stroke risk after transient ischemic attack among individuals with symptomatic intracranial artery stenosis. Arch Neurol 2008;65:733–737.
27.
Droste DW, Schmidt-Rimpler C, Wichter T, Dittrich R, Ritter M, Stypmann J, Ringelstein EB: Right-to-left-shunts detected by transesophageal echocardiography and transcranial Doppler sonography. Cerebrovasc Dis 2004;17:191–196.
28.
Daffertshofer M, Mielke O, Pullwitt A, Felsenstein M, Hennerici M: Transient ischemic attacks are more than ‘ministrokes’. Stroke 2004;35:2453–2458.
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2011
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