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Transient ischemic attack

Transient ischemic attacks (TIA) are defined clinically as quickly arising focal and is more rare diffuse (cerebral) than infringement of function of a brain which are caused by a local ischemia and pass within no more days.

To major factors of risk TIA carry age, an arterial hypertension, a hypercholesterolemia, an atherosclerosis cerebral and precerebral (sleepy and vertebral) arteries, smoking, heart diseases (a vibrating arrhythmia, a heart attack of a myocardium, an aneurysm of the left ventricle, the artificial valve of heart, rheumatic defeat of valves of heart, myocardiopathy, bacterial endocarditis, a diabetes). TIA approximately in 90-95% of cases are caused by an atherosclerosis cerebral and precerebral arteries, defeat of small cerebral arteries owing to an arterial hypertension, a diabetes or cardiogenic embolism. In more rare occurences they are caused vasculitis, hematologic by diseases (erythremia, sickle cell an anemia, thrombocythemia, leukosis), immunological infringements (antiphospholipid a syndrome), a venous thrombosis, stratification precerebral or cerebral arteries, a migraine, at women - reception of oral contraceptives.

Pathogenesis TIA has similarity to an ischemic stroke: atherosclerosis thromboembolism, defeat of small punching arteries of a brain, haemodynamic and rheological infringements. The clinical outcome of ischemic infringement of brain blood circulation (TIA or a stroke) is defined basically by localization and speed of development of corking of a brain artery, a condition collateral blood circulations and rheological properties of blood.

Clinical symptoms TIA usually arise suddenly and reach the maximum degree within several seconds or one-two minutes, they remain throughout 10-15 minutes, is much more rare - several hours (about one days). Ochagovye symptoms of defeat of a brain are various and are defined by localization of an ischemia of a brain in carotid or vertebralno-baziljarnom pool. Often TIA are shown by easy neurologic infringements (numbness persons and hands, easy hemiparesis or a hand monoparesis) though are possible and the expressed frustration (hemiplegia, a total aphasia). Short-term decrease in sight on one eye (amavrosis fugas) is quite often observed that is caused by blood circulation infringement in an orbital artery.

TIA can often repeat or arise only one-two time. In many cases patients don't give to passing short-term frustration of essential value and don't address for consultation to the doctor, therefore it is difficult to estimate prevalence TIA. However at 30-40% of the patients who have transferred TIA, the next 5 years the stroke develops. More than 20 % of these strokes occur within the first month, and almost half - in the first year after TIA. The risk of a stroke makes approximately 10% in the first year, and then about 5% annually. Probability of development of a stroke above at repeated TIA and increase in age of the patient (the probability of a stroke raises almost in 1,5 times at increase in age at 10 years). The forecast is slightly better, when TIA is shown only in the form of passing blindness on one eye. It is important to notice that the most frequent cause of death (about 50 % of death) after TIA - heart diseases (mainly a myocardium heart attack).

Clinic

Diagnosis TIA is often established retrospectively on the basis of the anamnesis: development of passing symptoms focal defeats of a brain at the patient having risk factors of ischemic infringement of brain blood circulation. The differential diagnosis is spent with other diseases shown by passing neurologic infringements: a migraine, epileptic an attack, illness of Menera syndromes, a multiple sclerosis, a brain tumor, a hypoglycemia, a faint, drop-attacks, etc.

At a migraine short-term neurologic infringements (migraine aura in a kind hemianesthesia, hemiparesis, aphasias, unilateral infringement of sight) which are in most cases accompanied by a typical attack of a headache are possible. Migraine attacks usually begin at young age. Ochagovye symptoms migraine auras usually develop in time more slowly (within 20-30 minutes), than at TIA and are often combined with visual infringements typical for a migraine.

Partial epileptic attacks can be shown by the passing impellent, sensitive, visual or speech frustration reminding TIA. At partial attacks unlike TIA distribution sensitive is quite often observed and (or) impellent infringements on an extremity (Jacksonian a march), there can be clonic spasms or again generalized epileptic attack. Data EEG revealing characteristic changes for an epilepsy can have great value.

At illness of Menera, good-quality item dizziness and vestibular neural there is a sudden dizziness quite often in a combination to a nausea and vomiting that is possible and at TIA in vertebrobasilar pool. However in all these cases of vestibular dizziness it is observed only horizontal or rotator nystagmus and it is not marked symptoms of defeat of a trunk (vertical nystagmus, doublings, frustration of sensitivity, swallowing, etc.). Extremely seldom TIA in vertebrobasilar to system it is shown only by the isolated vestibular dizziness, but it should be considered at patients of advanced age with risk factors TIA.

In a multiple sclerosis debut the passing neurologic infringements reminding TIA can be observed. Clinically indiscernible from TIA symptoms are possible also at tumors of a brain, small intracerebral hemorrhages or subdural hematomas, In these cases sometimes only results of a computer tomography (CT) or a magnitno-resonant tomography (MRI) heads allow to make the correct diagnosis.

Hypoglikemichesky conditions can give similar with TIA a clinical picture. In all cases when sick of a diabetes shows complaints to passing neurologic infringements (especially at night, at awakening or after physical exercises), research of level of glucose in blood in such conditions is necessary. In hypoglycemia cases fast improvement of a condition after parenteral introduction of glucose is characteristic.

TIA in vertebralno-baziljarnom pool are very seldom shown only by unconscious or preunconscious conditions. These conditions are most often caused vasovagal by paroxysms, diseases of heart or an epilepsy. Attacks of falling (drop-attack) also seldom are a consequence TIA in vertebralno-baziljarnom pool. They are caused by sudden loss Postural a tone not clear genesis, arise mainly at women and have no any serious prognostic value. In cases TIA before falling usually there is a dizziness or doubling, after falling of the patient can't rise at once in spite of the fact that hasn't put itself a trauma.

Diagnostics

The patients who have transferred TIA, demand inspection for finding-out of the reason of a passing ischemia of a brain for the purpose of the prevention of a stroke and other diseases of cardiovascular system. The important information results physical can yield inspections. Arrhythmia presence (fibrillation auricles), revealing of noise in heart allows to assume cardioembolic character TIA. The Sistolichesky noise listened behind a corner of the bottom jaw (area bifurcation the general carotid) - a sign of a stenosis of an internal or general carotid. Strengthening of a pulsation of branches of an external carotid is possible at corking or a considerable stenosis of an internal carotid on this party. Easing (or absence) pulse and reduction the HELL specify on stenosing defeat of an arch of an aorta and subclavial arteries. For finding-out of reason TIA use noninvasive ultrasonic methods of research of vessels among which are most informative duplex scanning precerebral head arteries (last years and cerebral arteries) and transcranial d oppler cerebral arteries. Now the increasing development for defeat diagnostics precerebral and cerebral arteries receive magnitno-resonant angiography and spiral computer angiography. The inspection plan includes the developed general analysis of blood, the biochemical analysis of blood with definition of cholesterol and its fractions, hemostasis research, an electrocardiogram. At suspicion on cardioembolic genesis TIA consultation of the cardiologist and more profound research of heart (Echocardiography, Holter monitoring) is shown. In cases not clear genesis TIA profound researches of plasma of blood are shown: Definition coagulation factors and fibrinolysis, level lupus anticoagulant and anticardiolipin antibodies, etc. When comes to light hemodynamically a significant stenosis of an internal carotid and is planned surgical treatment, preliminary spent cerebral angiography (traditional or subtraction digital) for acknowledgement of results of noninvasive ultrasonic methods of research and an estimation of intracerebral blood circulation.

Carrying out CT or MRI heads is desirable in all cases TIA, but it is necessary in diagnostically not clear cases for an exception of other possible reasons of passing neurologic infringements (a brain tumor, a small intracerebral hemorrhage, traumatic subdural a hematoma, etc.). At the majority of patients with TIA CT and MRI a head doesn't reveal focal changes, but in 10-25 % of cases (more often when neurologic infringements remained throughout several hours) the brain heart attack that specifies in certain convention of term TIA comes to light. When the ischemic center is found out in the patient with TIA in corresponding area of a brain according to CT or MRI heads, it is necessary to leave diagnosis TIA, instead of to change it to an ischemic stroke.

Treatment

In most cases TIA treatment isn't spent owing to short-term character of neurologic infringements and the reference to the doctor after their recourse. In cases of a long episode of neurologic infringements, treatment is carried out as at an ischemic stroke. At patients TIA preventive maintenance of an ischemic stroke has great value.

Stroke preventive maintenance is directed on correction of risk factors of a stroke. To the most significant correctable to factors carry an arterial hypertension, heart diseases, smoking of cigarets, a diabetes, abusing alcohol, a drug taking.

At the patients who have transferred TIA, prognostic value concerning development of a repeated stroke has level the HELL. The above level the HELL, the above risk of development of a stroke. Direct communication between level the HELL and frequency of development of a stroke is established as at elderly (60 years and more), and at the young patients who have transferred TIA.

At sick of an arterial hypertension and a diabetes achievement and maintenance of ideal weight of a body is recommended that in most cases demands decrease in the general caloric content of food. Excess weight decrease of all on 5-10 kg can lead to essential decrease in the raised arterial pressure. Except a diet, for weight reduction great value regular physical activities (have playing sports, the pedestrian walks) which intensity is individual and coordinated with the doctor.

For preventive maintenance of a repeated stroke to the patients who have transferred TIA, it is recommended within 1-2 years or constantly reception antiplatelets: acetilsalicylic acid, dipyridamole, ticlopidine or klopidrogel. Acetilsalicylic acid can be used in a dose from 80 to 1300 mg/sut, small doses from 80 to 325 mg/sut are considered more preferably in connection with smaller risk of complications from a gastroenteric path and absence of oppression prostacyclin the vascular wall, possessing antithrombotic as action. To reduce irritating action of a preparation by a stomach, apply aspirin in a cover which is not dissolved in a stomach. Ticlopidine 2 times are applied on 250 mg; it is a little more effective, than acetilsalicylic acid, but therapy ticlopidine much more expensively and demands regular control of the general analysis of blood (each 2 weeks within the first 3 months of treatment) because of danger leukopenia. Klopidrogel it is used on 75 mg/sut; It more effectively also has less by-effects, than acetilsalicylic acid, but its cost considerably above. The combination of aspirin of 100 mg and 225 mg dipyridamole a day is possible.

Preparations appoint for the purpose of blood supply increase in an ischemic fabric. The assumption is come out that they possess neuroprotective action. Piracetam Vinpotsetin is used inside on 1,2-4,8 mg/day 10-20 mg/day on 500 ml of a physiological solution are applied. Cinnarizine 3 times a day are appointed inside on 25 mg. Nicardipine - inside on 20 mg 2 times a day.

At patients with a vibrating arrhythmia, an intraventricular blood clot, the artificial valve of heart and other pathology fraught with development cardioembolic of a stroke, in the absence of contra-indications most an effective utilization of indirect anticoagulants (warfarin on 5 mg/day, fenilina on 60-90 mg/day), however it demands regular control of a prothrombin (increase of the international normalizing factor to 3,0-4,0 or decrease prothrombin an index to 50-60%) that quite often happens inconveniently. When use of anticoagulants is counter-indicative or control over their application is complicated, reception is recommended.

At revealing of a stenosis of an internal carotid surgical treatment - carotid intimectomy is discussed. Now efficiency carotid intimectomy is proved at expressed (narrowing of 70-99% of diameter) a stenosis of an internal carotid at the patients who have transferred TIA. Carotid intimectomy can be spent and at moderate degree (narrowing of 30-69% of diameter) stenosis of an internal carotid; however efficiency of surgical treatment in these cases isn't proved yet. At the decision of a question on surgical treatment it is necessary to consider not only degree of a stenosis of a carotid, but also prevalence of atherosclerotic defeat precerebral and cerebral arteries, expressiveness of a pathology of coronary arteries, presence of accompanying somatic diseases.

Smoking of cigarets raises risk of development of a stroke almost on 40% at men and on 60% at women. Refusal of smoking is accompanied by gradual essential decrease in risk of a stroke, and after 5 years of abstention from smoking the risk of development of a stroke at the former smoker differs from risk of development of a stroke at never smoking person a little.

Preventive maintenance

The great value in atherosclerosis preventive maintenance is given to a diet with the low maintenance of fat (reduction of consumption of fat to 30% from the general caloric content of food and cholesterol to 300 mg a day). In revealing cases hyperlipidemia (increase of level of the general cholesterol more than 6,5 mmol/l, triglycerides more than 2 mmol/l and phospholipids more than 3 mmol/l, level decrease lipoprotein 0,9 mmol/l there is less than high density) more strict diet (reduction of consumption of fat to 20% from the general caloric content of food and cholesterol to level less than 150 mg a day) is recommended. At atherosclerotic defeat of sleepy and vertebral arteries the diet with very low maintenance of fat (decrease in consumption of cholesterol to 5 mg a day) for the prevention of progressing of an atherosclerosis can be used. If within 6 months of a diet it is not possible to reduce essentially hyperlipidemia reception antihyperlipidemic preparations (lovastatin, simvastatin, pravastatin or other is recommended) But only in the absence of contra-indications to their application.

To the women who have transferred TIA, it is not recommended to use oral contraceptives with the high maintenance of an estrogen, it is expedient to apply contraceptives with the low maintenance of an estrogen or to pass to other ways of the prevention of pregnancy.

Abusing alcohol (the regular use more than 70 g pure ethanol in day, alcoholic hard drinkings) is connected with the raised risk of development of a stroke. The termination of abusing by alcohol gradually reduces risk of development of a stroke at the former alcoholics. Moderate alcohol intake (no more than 20-30 g pure ethanol a day) is discussed as a warning facility of an atherosclerosis and reduction of risk of development of an ischemic stroke.

At more than half of the patients who have had a stroke or TIA, there is a depression that complicates process of rehabilitation of such patients. For treatment depressive a syndrome the psychotherapy or energizers, for example, fluoxetine 20 mg of 1 times a day is used. In certain cases (at development epileptic attacks) carbamazepine appointment on 600 mg a day is shown.

The question on efficiency of hypotensive therapy for secondary preventive maintenance of a stroke at the patients who have transferred TIA, long time wasn't clear, though directly proportional communication between risk of development of a stroke and level the HELL was marked. The above the HELL after transferred TIA, the is more risk of development of a repeated stroke. Meta-analysis 9 researches which have included about 7 thousand of persons, testified only to a tendency to decrease in a stroke and cardiovascular diseases at carrying out of hypotensive therapy at patients TIA. However according to a multicenter randomized double blind placebo of controllable research PROGRESS (Perindopril Protection Against Recurrent Stroke Study) which results have been reported in 2001 in Milan (Italy) at IX European meeting on an arterial hypertension, efficiency of the hypotensive therapy based on perindopril, inhibitor APF, for secondary preventive maintenance of a stroke is proved. Results of the conducted research have shown that the hypotensive therapy based on perindopril, reduces risk of development of a stroke on the average on 28%, all cardiovascular diseases - on the average on 26%. Frequency of development of a stroke decreased not only at patients with an arterial hypertension, but also at patients with normal the HELL. Being based on results of research PROGRESS, to the patients who have transferred TIA, it is necessary to recommend as hypotensive therapy perindopril on 4 mg/sut (separately or in a combination with TIA-s diuretic indapamide on 2,5 mg/day) for secondary preventive maintenance of a stroke.

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