European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack

Published by ESO on May 20, 2021

Disclaimer

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Jose M Ferro received research and travel grants, speakers fees and honorarium for clinical trials coordination from Boheringer Ingelheim and research grant and honorarium for clinical trials coordination from Bayer. Jean Marc Olivot: financial disclosures – Consulting Abbvie, Aptoll, Bristol Myers squibb, Medtronic. Peter Kelly: intellectual disclosures – Lead Investigator, HRB Stroke Clinical Trials Network Ireland; Financial disclosures: Fees for Steering Committee membership, ETNA-AF study (Daichii Sankyo), research grants (HRB Ireland, Irish Heart Foundation. SCTNI received unrestricted educational and research funding from Bayer, Boehringer Ingelheim, BMS, Pfizer, Daichii Sankyo, Amgen, A Menarini.

Sponsors

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the development of these guidelines was provided by the European Stroke Organisation, Basel, Switzerland.

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Abstract

The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

Language

en

PICOS

PICO 1.1

Population
In patients suspected of TIA
Intervention
ABCD2 ≥ 4
Comparator
ABCD2 <4
Outcomes

PICO 1.1

Population
Patients with suspected acute TIA
Intervention
Aspirin
Comparator
Control
Outcomes

PICO 2.1

Population
Patients with non-cardioembolic acute TIA
Intervention
Double antiplatelets
Comparator
Single antiplatelet
Outcomes