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National Hospital of Sri Lanka , Teaching Hospital Jaffna , Teaching hospital Pollannaruwa, Sri Lanka .
Corresponding Author: Vijayabala Jeevagan , 165E, Vipulasena Mawatha Colombo 10, Sri Lanka. E-mail: jeevaganv@yahoo.com.
Abstract
The definition of TIA has always been a matter of debate. The traditional definition is time based and new
definition is tissue based. Both the time based and tissue based definition are not accurate. Here we propose
the universal term acute ischemic neurovascular syndrome (AINS) for all patients with symptoms suggestive
of focal neurological deficit of presumed ischemic origin. AINS can be further divided into transient ischemic
attack (TIA), transient symptoms with infarction (TSI) and ischemic stroke (IS) on the basis of clinical and
imaging findings. Each syndrome is associated with distinct clinical, imaging and prognostic features. Extensive review that took clinical and imaging features into account suggests it might be more rational to consider
TSI as separate clinical syndrome. TSI is the most unstable syndrome, it is associated with the greatest risk of
recurrent stroke, which indicate that the underlying stroke mechanism is active.
Keywords: transient ischemic attack; stroke; transient symptoms with infarction.
Received: August 8, 2012; Accepted: September 23, 2012; Published: December 15, 2012
Introduction
Traditionally TIA is defined as sudden, focal neurological deficit of presumed vascular origin that lasts for less
than 24 hours. It is based on the assumption that the transient symptoms disappear completely because permanent
brain injury has not occurred. This was formulated in
time when there were no proper neuroimaging modalities
to identify brain infarction or ischemia [2]. With the advent of diffusion weighted magnetic resonance imaging
[DWI MRI], it is now demonstrated that many transient
ischemic events are associated with infarction [3- 6].
Even though we are very familiar with this definition,
there are drawbacks. The 24 hour threshold is arbitrary.
In fact most of the TIAs typically resolve within 60
minutes. It does not help to determine which events involve brain infarction. Both medical and non medical
personal do not realize the gravity of TIA and tend to
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Definition
TIA
TSI
IS
AINS
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It is said that the traditional definition has the potential to delay initiation of acute stroke therapies, particularly thrombolytic therapy which has a therapeutic
time window of 4.5 hours from the onset. However, in
patients with signs of improving neurological deficits
irrespective of DWI MRI finding, the risk benefit ratio
does not justify administrating thrombolytic therapy. It
is inescapable that few patients with TIA may receive
thrombolytic therapy without DWI MRI. However,
this is a minority since the majority of the TIAs are
brief, lasting less than an hour and brain infarction are
almost invariable in patients with symptoms lasting
longer. Furthermore currently there is no sufficient
evidence to use DWI MRI finding in selecting patients
for thrombolytic therapy [28, 29].
Argument 4: A 24-hour limit for transiently symptomatic cerebral ischemia is arbitrary and not reflective
of the typical duration of the events.
The traditional definition classifies stroke and TIA
depending on degree of disability and rate of subsequent recurrence. Even though the deficit is transient
in TIA, risk of early stroke is high and paradoxically,
the risk of subsequent ischemic stroke is less after
completed stroke. Almost all risk prediction models
incorporate 24 hour time limit to define TIA, despite
of TIAs typically last less than an hour [9-12, 17-19].
Therefore the 24 hour time limit has implication in
management and prognosis.
Argument 5: Disease definitions in clinical medicine,
including those for ischemic injuries, are most useful
when tissue based.
In modern day medicine nomenclature of disease
mainly based on current treatment and prognostic need
of the patients rather than pathology. Likewise in patient with acute coronary syndrome (ACS) the first
step is to differentiate the patients with ST elevation
ACS from non ST elevation ACS (not patient with
unstable angina from myocardial infarction) because it
has implication in immediate management. There is no
such thing as electrocardiography (ECG) in neurology
to differentiate patients who requires thrombolysis
from who do not. Therefore it is not convincing that
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the tissue based definition would harmonize cerebrovascular nosology with other ischemic conditions.
Conclusions
Clinical and pathological correlation is the hallmark of
modern medical diagnosis. The new definition of TIA is
solely tissue based and lack clinical correlation. Acute
ischemic neurovascular syndrome is an umbrella term for
all patients with symptoms suggestive of focal neurological deficit of presumed ischemic origin. This syndrome
is similar to acute coronary syndrome in cardiology.
Acute ischemic neurovascular syndrome can be further
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
149
http://www.intermedcentral.hk/
16.
17.
18.
19.
20.
21.
22.
23.
24.
Prabhakaran S, Chong JY, Sacco RL. Impact of abnormal diffusion-weighted imaging results on short-term outcome following
transient ischemic attack. Arch Neurol. 2007; 64: 11051109.
Redgrave JN, Coutts SB, Schulz UG, Briley D, Rothwell PM.
Systematic review of associations between the presence of acute
ischemic lesions on diffusion-weighted imaging and clinical predictors of early stroke risk after transient ischemic attack. Stroke.
2007; 38: 14821488.
Ay H, Arsava EM, Johnston SC, Vangel M, et al. Clinical- and
imaging-based prediction of stroke risk after transient ischemic
attack: the CIP model. Stroke. 2009 Jan;40(1):181-6.
Merwick A, Albers GW, Amarenco P, Arsava EM, et al. Addition of brain and carotid imaging to the ABCDscore to identify
patients at early risk of stroke after transient ischaemic attack: a
multicentre observational study. Lancet Neurol. 2010
Nov;9(11):1060-9.
E. Murat Arsava, Karen L. Furie, Lee H. Schwamm, et al. Prediction of Early Stroke Risk in Transient Symptoms With Infarction. Relevance to the New Tissue-Based Definition. Stroke.
2011; 42: 2186-2190
Giles MF, Albers GW, Amarenco P, Arsava EM, et al. Early
stroke risk and ABCD2 score performance in tissue- vs
time-defined TIA: a multicenter study. Neurology. 2011 Sep
27;77(13):1222-8.
Ay H, Koroshetz WJ, Benner T, Vangel MG, Wu O, Schwamm
LH, Sorensen AG. Transient ischemic attack with infarction: a
unique syndrome? Ann Neurol. 2005 May;57(5):679-86.
Coutts SB, Simon JE, Eliasziw M, Sohn CH, et al. Triaging
transient ischemic attack and minor stroke patients using acute
magnetic
resonance
imaging.
Ann
Neurol.
2005
Jun;57(6):848-54.
The Publications Committee for the Trial of ORG 10172 in
Acute Stroke Treatment (TOAST) Investigators. Low molecular
weight heparinoid, ORG 10172 (danaparoid), and outcome after
acute ischemic stroke: a randomized controlled trial. JAMA.
1998;279(16):1265-1272.
Lovett JK, Coull AJ, Rothwell PM. Early risk of recurrence by
subtype of ischemic stroke in population-based incidence studies.
Neurology. 2004;62(4):569-573.
http://www.intermedcentral.hk/
25.
26.
27.
28.
29.
30.
31.
Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM,
Wiebers DO. Ischemic stroke subtypes: a population-based study
of functional outcome, survival, and recurrence. Stroke.
2000;31(5):1062-1068.
International Stroke Trial Collaborative Group. The International
Stroke Trial (IST): a randomised trial of aspirin, subcutaneous
heparin, both, or neither among 19435 patients with acute ischaemic stroke. Lancet. 1997;349(9065):1569-1581.
Urs Fischer, Adrian Baumgartner, Marcel Arnold, Krassen
Nedeltchev, et al. What Is a Minor Stroke? Stroke. 2010; 41:
661-666.
Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the
early management of adults with ischemic stroke: a guideline
from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular
Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38:1655.
Del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time
window for treatment of acute ischemic stroke with intravenous
tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke
2009; 40:2945.
Gregory W Albers. Acute cerebrovascular syndrome: time for
new terminology for acute brain ischemia. Nature Reviews Cardiology 3, 521 (October 2006).
Chelsea S. Kidwell, Steven Warach. Acute Ischemic Cerebrovascular Syndrome. Diagnostic Criteria. Stroke. 2003; 34:
2995-2998.
150