Richard Jackson, MD

Oudeman EA, Greving JP, Van den Berg-Vos RM, Biessels GJ, Bron EE, van Oustenbrugge R, et al. Nonfocal Transient Neurological Attacks Are Associated With Cerebral Small Vessel Disease. Stroke. 2019;50:3540–3544.

Oudeman et al. have published a paper on non-focal TIA’s which have been called transient neurological attacks (TNAs). As neurologists, we are always trained to localize first, but anyone who has taken stroke calls from the ER knows that not all the presentations and calls are localizable, such as those mentioned in this paper and described as “bilateral weakness, unsteadiness, or confusion.” In the introduction, the authors mention that these were historically thought to be secondary to hypoperfusion, but recent imaging have shown them to be associated with ischemia. Underlying risk factors are common to traditional TIA’s, such as smoking and hypertension, but not atherosclerotic disease or atrial fibrillation, which led to the current investigation for an association between small vessel disease and TNAs.

The study was a 3-year multicenter cohort of 304 patients between 2015 and 2018 in Holland as part of the HBC study, which focuses on cardiovascular contributions to cognitive impairment. The current study excluded patients with a previous history of TIA or stroke, dementia, or MMSE <20. Symptoms were analyzed using a questionnaire of 8 non-focal symptoms in the preceding 6 months, and TNA was defined as a symptom of unconsciousness, confusion, amnesia, unsteadiness, bilateral leg weakness,  blurred vision, non-rotatory dizziness or parasthesias lasting longer than 30 seconds but less than 24 hours. All patients underwent MRI for white matter disease and previous lacunar infarcts. 63 patients fit the inclusion criteria.

Patients with TNAs were found to have higher rates of hypertension, lacunes OR 2.32, and white matter disease OR 2.65. Previous studies had also found that TNAs compared to TIAs were associated with cortical more than subcortical infarcts but not large artery atherosclerosis or atrial fibrillation. The limitations were related to the self-report method of data collection, and more investigation is needed.

I find articles such as this information for ER-related calls and decision-making regarding treatment and discharge planning. My current primary stroke center has a TIA pathway for ER discharges, but most are admitted for inpatient stroke work-up. Further work in this area might allow for inclusion of these symptoms into a model similar to the ABCD2 model for treatment starting in the ER and follow-up in the clinic decreasing the need for inpatient admission and increasing the amount of patients receiving treatment for cerebral cardiovascular disease.