Transient Ischemic Attack
Transient Ischemic Attack
Resolved neurologic deficit without altered mental status or depressed level of consciousness
ABCD3 Score < 8
No acute findings on Head CT + CTA; if indeterminate findings on CT, neurology consult obtained in ED
IH Stroke Order set initiated in ED
Workup may be completed within 24 hours
Supportive home environment at discharge
No evidence of seizure
NIHSS (National Institute of Health Stroke Scale)= ZERO
At baseline level of mobility
Unstable vital signs
Abnormal head CT (acute CVA, hemorrhage, mass)
Carotid stenosis (> 70%) with need for vascular consult
Any persistent neurologic deficit or crescendo TIAs
Non-focal neurologic symptoms: confusion, seizure, generalized weakness
Severe headache or evidence of temporal arteritis
Prior large CVA (making serial neurologic examinations problematic)
For All TIA Patients going to CDU
Screening for Afib - Cardiac monitoring
If Afib noted at any time, start anticoagulation
Consult Neurology
Nursing bedside swallow evaluation to be completed prior to oral intake
Neuro Checks: Neurological checks every 2 hours x 12 hours then every 4 hours for a total of 24 hours
Anti-Platelets: If head CT negative for hemorrhagic stroke and Stroke Mimic (e.g. complex migraine not highly suspected)
Start Plavix 75 mg PO daily and ASA 81 mg PO daily x 21 days. Give first dose NOW (don't wait for tomorrow morning)
MRI: Obtain MRI brain without contrast. While this will generate a STAT order, It is not necessary to call in a tech from home to complete this study.
Vascular Imaging: If CTA not done on initial evaluation (due to CKD or contrast allergy) obtain MRA head or BL Carotid Duplex to r/o critical carotid stenosis
Lipids: Check lipid panel
If LDL > 100, start high intensity statin (Atorvastatin 40 mg or 80 mg, Rosuvastatin 20 mg or 40 mg)
Diabetes Screening
Hemoglobin A1C. May defer management to PCP
Nursing Stroke Education Prior to Discharge
For Select Patients
Echo if EKG abnormal or concern for embolic source. Bubble study if < 60 yo
Rehab (PT/OT +/- SLP) Eval if indicated by clinical eval
Disposition
No recurrent deficits
Negative workup
Core measures met (see above)
Stable vital signs
Arrange for PCP followup
MRI Positive for Stroke
Recurrent symptoms or deficit
Evidence of embolic source requiring treatment, i.e. mural thrombus, valvular afib requiring VKA etc.
Other workup requiring continued workup and evaluation