What are the key differences in management and treatment between Cerebrovascular Accident (CVA) and Transient Ischemic Attack (TIA)?

Key Differences in Management and Treatment Between CVA and TIA

The primary difference between CVA and TIA management is that CVA requires immediate reperfusion therapy and long-term rehabilitation, while TIA requires urgent risk stratification and secondary prevention to prevent a subsequent stroke.

Definition and Diagnosis

• TIA is conventionally defined as a syndrome of acute neurological dysfunction referable to the distribution of a single brain artery with symptoms lasting <24 hours, while CVA (ischemic stroke) involves symptoms and signs of neurological deficit persisting longer than 24 hours 1
• With advances in brain imaging, many patients with symptoms briefer than 24 hours are found to have cerebral infarction, leading to a revised definition of TIA specifying symptoms that last <1 hour 1
• Both conditions present with similar symptoms including unilateral weakness, sensory loss, visual disturbances, speech difficulties, and coordination problems depending on the affected vascular territory 1

Initial Assessment and Triage

TIA Management

• Patients with suspected TIA should be risk-stratified using validated tools such as the ABCD2 score, which considers Age, Blood pressure, Clinical features, Duration of symptoms, and Diabetes 1
• High-risk TIA patients (ABCD2 score >4) should be admitted to a stroke unit or referred to a specialist TIA clinic if assessment can be completed within 24-48 hours 1
• Low-risk TIA patients (ABCD2 score ≤4) may be managed in the community or referred to a specialist TIA clinic to be seen within 7-10 days 1

CVA Management

• All patients with suspected acute stroke require immediate emergency department evaluation and should be transported by ambulance with high priority 1
• Stroke patients should be taken to hospitals with organized stroke unit care and capacity for advanced stroke management 1
• Time is critical in CVA management, with the goal of rapid assessment to determine eligibility for reperfusion therapies 1

Imaging and Diagnostic Workup

TIA Workup

• Urgent brain imaging (CT or MRI) and non-invasive vascular imaging (CTA or MRA from arch to vertex) should be completed within 24 hours 1, 2
• Carotid imaging is essential for TIA patients with anterior circulation symptoms to identify candidates for carotid revascularization 1, 2
• ECG and basic laboratory tests should be performed promptly to identify cardiac sources of embolism and other contributing factors 1, 2

CVA Workup

• Immediate brain imaging is essential to differentiate ischemic stroke from intracerebral hemorrhage and exclude stroke mimics 1
• MRI is more sensitive than CT for detecting early ischemic changes but CT is more readily available and adequate for initial assessment 1
• More extensive vascular and cardiac imaging may be required based on the suspected etiology 1

Acute Treatment

TIA Treatment

• Antiplatelet therapy should be initiated immediately for non-cardioembolic TIA 2
• Options include aspirin (50-325 mg/day), clopidogrel (75 mg daily), or combination of aspirin and sustained-release dipyridamole 2
• For cardioembolic TIA, long-term oral anticoagulation with a target INR of 2.0-3.0 is recommended 2

CVA Treatment

• Eligible ischemic stroke patients should receive intravenous thrombolysis with rt-PA within 3 hours of symptom onset 1
• Endovascular therapy may be considered for selected patients with large vessel occlusion 1
• Aspirin (160-300 mg/day) should be commenced within 48 hours of onset of acute ischemic stroke if not receiving thrombolysis 1
• Management of intracerebral hemorrhage focuses on blood pressure control, reversal of anticoagulation if applicable, and consideration of surgical intervention in selected cases 3

Secondary Prevention and Follow-up

TIA Secondary Prevention

• Blood pressure management with a target of <130/80 mm Hg 2
• Lipid management with statin therapy 2
• Carotid revascularization for significant symptomatic carotid stenosis 4
• Lifestyle modifications including smoking cessation, diet, and exercise 4

CVA Secondary Prevention

• Similar secondary prevention measures as TIA but with additional focus on rehabilitation 1
• Early mobilization and rehabilitation to optimize functional recovery 1
• Prevention of complications such as deep vein thrombosis, pressure sores, and aspiration pneumonia 1, 3

Prognosis and Monitoring

• TIA carries a high risk of early stroke, with risk as high as 10% within the first week of symptom onset 1
• Timely initiation of secondary prevention significantly reduces the risk of major stroke after TIA 1
• CVA has higher morbidity and mortality, with outcomes dependent on stroke severity, location, timeliness of treatment, and quality of rehabilitation 1

Common Pitfalls and Considerations

• Failure to recognize TIA as a medical emergency requiring urgent assessment 1, 5
• Inadequate risk stratification of TIA patients leading to inappropriate disposition decisions 1
• Delayed treatment of CVA due to failure to recognize symptoms or delays in seeking medical attention 1
• Incomplete diagnostic workup leading to missed opportunities for targeted secondary prevention 1, 6
• Underutilization of reperfusion therapies for eligible stroke patients 1