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Transient Ischemic Attack

T I a


Presentation

The symptoms of a transient ischemic attack are temporary and often resolve before the patient can be seen by a health care provider. Patient history is therefore of great importance. History from the family, witnesses, and emergency medical services, as well as the patient, should be obtained. History may include short-term alterations in [2]:

  • Behavior
  • Speech
  • Gait
  • Memory
  • Movement

Symptoms can vary from individual to individual and by the area of the brain affected. Frequently symptoms include [2] [4]:

The symptoms are short-lived, usually lasting less than 15 to 60 minutes. Symptoms vary in severity.

Differential diagnoses to be excluded are [2] [3] [13]:

Weakness
  • The weakness completely resolved at 2 hours after symptom onset, and there was no acute infarction on the initial diffusion-weighted magnetic resonance imaging (MRI) on the same day.[ncbi.nlm.nih.gov]
  • Transient ischemic attacks (TIA) are a common presentation to the emergency department (ED) and are associated with an estimated 9% risk of stroke within 90 days. 1 We report the case of a 72-year-old female who presented with orthostatic symptoms of facial weakness[ncbi.nlm.nih.gov]
  • A 69-year-old gentleman presented with a TIA episode (dysarthria, right-arm weakness, and numbness). Bilateral asterixis was observed and was more severe on the right side. No prior infarcts were noted in the thalamus. Liver function was normal.[ncbi.nlm.nih.gov]
  • CASE DESCRIPTION: In this report, we describe the case of a 52-year-old woman with right ICA occlusion who experienced repeated transient weakness of the left extremities during HD for chronic renal failure.[ncbi.nlm.nih.gov]
  • They happen suddenly, and include Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Difficulty walking Dizziness Loss of balance or coordination Most symptoms[nlm.nih.gov]
Coronary Artery Disease
  • Mortality was increased with any concurrent cardiometabolic comorbidity (hazard ratio, 1.89; 95% confidence interval, 1.17-3.03; P 0.0089) with multiplicative mortality risk from a combination of coronary artery disease and heart failure.[ncbi.nlm.nih.gov]
  • Age ( 75 years), obesity, congestive heart failure, hypertension, coronary artery disease, peripheral vascular disease, and valve disease are significant risk factors, with the following respective odds ratios (95% CI): 1.73 (1.39-2.16), 1.53 (1.05-2.18[ncbi.nlm.nih.gov]
  • In multivariable models, significant predictors of (1) 30-day mortality were coexisting heart failure (HF) (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.09-1.92), cardiac arrhythmia (OR: 1.74, 95% CI: 1.40-2.17), coronary artery disease (CAD[ncbi.nlm.nih.gov]
  • RESULTS: The study cohort was composed of 3876 IRIS participants, mean age 63 years, 65% male, 89% white race, and 12% with a history of coronary artery disease.[ncbi.nlm.nih.gov]
  • Patients in both trials were predominantly male (56% to 63%); most (60% to 64%) had hypertension, and 42% to 44% had coronary artery disease.[uspreventiveservicestaskforce.org]
Falling
  • Compared with neurologists, GPs considered "confusion" and "unexplained fall" more often compatible with TIA and "lower facial palsy" and "monocular blindness" less often compatible with TIA.[ncbi.nlm.nih.gov]
  • Myoclonus may occur normally, often when a person is falling asleep. For example, as people start to doze off, they may jerk awake (as if startled), or muscles in part of the body may twitch.[merck.com]
  • […] effective rehab exercises including: Activities that retrain leg muscles to restore function and strength Stride improvement exercises to help increase your walking ability High level balance exercises in a supportive environment to decrease risk of falling[alterg.com]
  • GPs were particularly doubtful about some symptoms, such as “monocular visual loss,” “confusion,” and “unexplained fall,” whereas neurologists were rather uncertain about “unsteadiness” and “diplopia.”[doi.org]
  • […] face or body Sudden double vision, or trouble seeing in 1 or both eyes Sudden trouble talking, or slurring your speech Trouble understanding other people speaking Sudden, severe headache Dizziness, loss of balance, a spinning feeling, or a sense of falling[saintlukeshealthsystem.org]
Sepsis
  • This complication is most likely associated with more seriously affected patients. 633 Bacteremia or sepsis is a potential complication.[doi.org]
Diplopia
  • Isolated TVS was significantly more common in TMB than in HLH and diplopia (88%, 62%, and 0%, respectively; P 2 score was significantly lower in patients with TMB compared with those with HLH and diplopia (median 2 [interquartile range 2-3] versus 3 [[ncbi.nlm.nih.gov]
  • We describe the case of a 53-year-old woman with a previous history of recurrent epistaxis, admitted to our unit for a transient episode of diplopia and unbalance.[ncbi.nlm.nih.gov]
  • BACKGROUND AND PURPOSE: Contrary to typical transient symptoms (TS), atypical TS, such as partial sensory deficit, dysarthria, vertigo/unsteadiness, unusual cortical visual deficit, and diplopia, are not usually classified as symptoms of transient ischemic[ncbi.nlm.nih.gov]
  • Usual symptoms of transient ischemic attacks include hemiparesis, hemiparesthesia, dysphasia, diplopia and monocular blindness, imbalance and gait disturbances, and possible disorientation.[symptoma.com]
  • GPs were particularly doubtful about some symptoms, such as “monocular visual loss,” “confusion,” and “unexplained fall,” whereas neurologists were rather uncertain about “unsteadiness” and “diplopia.”[doi.org]
Scotoma
  • […] fingers 2 3 15 2 2 18 Numbness, half body 6 8 6 12 6 4 Numbness, hand/half mouth 4 8 7 5 6 11 Confusion‡ 4 13 3 0 2 20 Convulsion 0 7 13 0 2 20 “Jerks,” face or hand 0 3 17 0 0 22 Vertigo 2 6 12 1 7 14 Urinary incontinence 5 6 9 1 0 21 Scintillating scotoma[doi.org]
Epistaxis
  • Secondary cerebrovascular prevention with antithrombotic therapy was early stopped for the worsening of epistaxis.[ncbi.nlm.nih.gov]
Confusion
  • They happen suddenly, and include Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Difficulty walking Dizziness Loss of balance or coordination Most symptoms[nlm.nih.gov]
  • Compared with neurologists, GPs considered "confusion" and "unexplained fall" more often compatible with TIA and "lower facial palsy" and "monocular blindness" less often compatible with TIA.[ncbi.nlm.nih.gov]
  • Prevailing conditions misdiagnosed as TIA were postural hypotension, syncope, vertigo, seizures, anxiety, confusion, and complete stroke.[doi.org]
  • Symptoms To Watch For: Sudden numbness in your face, arm or leg, especially on one side of the body Sudden confusion Sudden trouble seeing, talking or understanding Sudden trouble with balance or walking Sudden dizziness or loss of coordination Sudden[pinnaclehealth.org]
Headache
  • Our patient presented with thunderclap headache and transient ischemic attack like episode with obvious SAH on CT scan.[ncbi.nlm.nih.gov]
  • We suggest that the patients with TIA and headache should be carefully investigated in terms of cerebral venous thrombosis.[ncbi.nlm.nih.gov]
  • Headache, neck pain and recurrent episodes of weakness and numbness in the left limbs were the main clinical manifestations. CT and MRI revealed thickening of the dura along the falx and tentorium.[ncbi.nlm.nih.gov]
  • However, in migraine headaches, the visual disturbances are dynamic and keep moving. Whereas with TIA the vision problems tend to remain static. Also, the migraine headaches symptoms typically come on gradually.[migraine.com]
  • Memory loss (OR 9.17, 95% CI 2.89-32.50), headache (OR 3.71, 95% CI 1.07-12.78) and blurred vision (OR 2.48, 95% CI 0.90-6.59) increased the odds of TIA mimics.[ncbi.nlm.nih.gov]
Dizziness
  • They happen suddenly, and include Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Difficulty walking Dizziness Loss of balance or coordination Most symptoms[nlm.nih.gov]
  • Symptoms To Watch For: Sudden numbness in your face, arm or leg, especially on one side of the body Sudden confusion Sudden trouble seeing, talking or understanding Sudden trouble with balance or walking Sudden dizziness or loss of coordination Sudden[pinnaclehealth.org]
  • […] numbness or weakness of face, arm or leg, especially on one side of the body Sudden lack of coordination Sudden onset of confusion, trouble speaking or understanding Sudden onset of vision disturbance in one or both eyes Sudden trouble walking or sudden dizziness[wakemed.org]
Slurred Speech
  • We presented a 14-year-old patient with signs suggestive of transient ischemic attack (TIA), including triple episodic weakness on the right upper limb, slurred speech, and bucking, lasting several hours in each time 2 days ago.[ncbi.nlm.nih.gov]
  • speech, and localized weakness of… Read More[britannica.com]
  • Symptoms and signs of a mini stroke are similar to those of a major stroke, including weakness or numbness in the face, body and limbs, slurred speech or difficulty speaking, trouble seeing out of one or both eyes, and dizziness or trouble balancing.[intermountainhealthcare.org]
  • You are here Home › Transient Ischemic Attack "Mini Strokes" Should Not Be Ignored Transient ischemic attack (TIA) is a brief episode during which patients may experience symptoms similar to stroke such as slurred speech or blurry vision.[springvalleyhospital.com]
  • speech Problems thinking of or saying the right word Imbalance and falling Dizziness or fainting Diagnosing stroke To diagnose a mini stroke, physicians will first do a physical examination.[ahn.org]
Dysarthria
  • […] attacks (TIA) are a common presentation to the emergency department (ED) and are associated with an estimated 9% risk of stroke within 90 days. 1 We report the case of a 72-year-old female who presented with orthostatic symptoms of facial weakness and dysarthria[ncbi.nlm.nih.gov]
  • A 69-year-old gentleman presented with a TIA episode (dysarthria, right-arm weakness, and numbness). Bilateral asterixis was observed and was more severe on the right side. No prior infarcts were noted in the thalamus. Liver function was normal.[ncbi.nlm.nih.gov]
  • This previously healthy 27-year-old man was admitted due to several daily episodes of usually left hemiparesis and dysarthria lasting between 15 seconds and 3 minutes. He did not respond to aggressive antithrombotic treatment.[ncbi.nlm.nih.gov]
  • BACKGROUND AND PURPOSE: Contrary to typical transient symptoms (TS), atypical TS, such as partial sensory deficit, dysarthria, vertigo/unsteadiness, unusual cortical visual deficit, and diplopia, are not usually classified as symptoms of transient ischemic[ncbi.nlm.nih.gov]
  • Once these clinical features were taken into account, neither aphasia, dysarthria, sensory loss, blood pressure values nor the duration of symptoms were found to improve explanation of the underlying status.[ncbi.nlm.nih.gov]

Workup

The initial workup for individuals presenting with a transient ischemic attack should be aimed at excluding other metabolic or drug-induced causes for the symptoms. Tests that should be done immediately [2]:

  • Blood glucose to rule out hypoglycemia
  • Complete blood count
  • Serum electrolyte levels
  • Coagulation studies
  • 12-lead electrocardiogram with rhythm strip

A complete neurologic examination is a means of determining the area of neurovascular assault. The examination should include the following [2] [3]:

  • Cranial nerve testing
  • Motor strength and function
  • Sensory testing
  • Speech and language evaluation
  • Assessment of the cerebellar function, gait and balance

Physical examination should include [2] [3]:

  • Vital signs: Temperature, blood pressure, heart rate and rhythm, respiratory rate and pattern, oxygen saturation.
  • Overall health and appearance: Hydration status, development, skin color.
  • Psychosocial issues: Attentiveness, social interaction, language and memory, cognition.

Further testing may include [2] [3]:

  • Erythrocyte sedimentation rate
  • Cardiac enzymes
  • Lipid profile
  • Screening for hypercoagulate states
  • Syphilis serology
  • Anti-phospholipid antibodies
  • Toxicology screening
  • Hemoglobin electrophoresis
  • Serum protein electrophoresis
  • Cerebrospinal fluid examination

Imaging studies [2] [3] [16]:

  • Magnetic resonance imaging (MRI) with diffusion-weighted imaging
  • Non-contrast computed tomography (CT)
  • Vascular imaging: Carotid Doppler ultrasonography of the neck, computed tomography angiography (CTA), or magnetic resonance angiography (MRA)

Recommendations for evaluation and initial interventions for individuals presenting with transient ischemic attacks are [2] [5] [8]:

  • Neuroimaging evaluation of the cervical vessels and intracranial vessels is within 24 hours of symptom onset. Magnetic resonance imaging with diffusion sequences are recommended. 
  • Electrocardiography as soon as possible with prolonged cardiac monitoring and echocardiography in patients where no vascular etiology identified. 
  • Routine blood tests: Complete blood count, electrolytes, fasting blood glucose, renal and liver studies. 
  • Hospitalization of patients within 72 hours with an ABCD (2) score > 5 which indicate a high risk of recurrence [5]. 
Pericardial Effusion
  • The most common periprocedural complication was serious pericardial effusion in 22 patients (5%; 15 were treated with pericardiocentesis and 7 with surgery).[doi.org]

Treatment

Antithrombotic therapy, started once intracranial hemorrhage is ruled out, is recommended to prevent subsequent stroke [2]. Most frequently used medications are [1] [2] [13]:

  • Aspirin (50-325 mg/day)
  • Aspirin plus extended-release dipyridamole
  • Clopidogrel

For cardio-embolic transient ischemic attacks long-term anticoagulation therapy is recommended using [1] [2]:

  • Heparin (warfarin) titrated to maintain international normalized ratio, INR, at 2-3
  • Aspirin 325 mg/day for those unable to take oral anticoagulants or with intracranial stenosis

Maintaining blood pressure below 140/90 mm Hg and total cholesterol below 200 mg/dL may prevent transient ischemic attacks, their recurrence or subsequent stroke [2].

Hospitalization may be required for early lytic therapy and other medical management and secondary prevention [18].

Hospitalization is required for [16] [17]:

Angioplasty or stent placement to treat transient ischemic attacks are currently being investigated, but their usefulness is not yet known [18]. Endarterectomy versus medical treatment alone has shown that surgery reduced the risk of stroke in patients with carotid stenosis, but the benefits were substantially less when surgery was delayed more than two weeks [13].

Recombinant human Interleukin-1ra (IL-1ra) administered intravenously has been shown to effectively reduce inflammation after a transient ischemic event. Though safe, its efficacy in the early hours after the ischemic episode are limited by its slow uptake. Further research is needed to find better therapeutic agents [15].

Prognosis

Research has shown transient ischemic attacks to be a very strong predictor of subsequent stroke and death [6]. Early identification, immediate treatment, and institution of stroke prevention techniques are imperative to preventing further morbidity and mortality [2] [3].

Etiology

Transient ischemic attacks are episodes of temporary, focal cerebral dysfunction due to vascular occlusion and tissue ischemia [2] [7]. Onset is acute and abrupt and the event is of short duration, from 15 minutes to 24 hours. Resolution of symptoms is rapid as well. Transient ischemic attacks leave no residual neurological deficit [2] [8]. Differentials diagnoses include [7] migraine, epilepsy, syncope, or even neurosis

Transient ischemic attacks are classified and initially evaluated using the ABCD (2) score [9]. This evaluation tool is based on five criteria: Age > 60 years (1 point), blood pressure > 140/90 mm Hg (1 point), clinically unilateral weakness (2 points), speech impairment without weakness (1point), duration > 60 min (2 points) or 10 to 59 min (1 point) and diabetes (1 point) [10]. The higher the score the higher the risk for recurrence of transient ischemia and/or eminent stroke [9] [10]. 

Patients are classified as follows [9] [10]:

  • High risk with a score of 6-7; stroke risk 8.1%, 
  • Moderate risk with a score of 4-5; stroke risk 4.1%, 
  • Low risk with score of 0-3; stroke risk 1.0%.

Transient ischemic attacks may also be classified as typical transient ischemia or nonspecific transient neurological attacks [4] [7]. Typical transient ischemic attacks are the result of temporary vascular occlusion. Nonspecific transient neurological attacks may be due to cardiac abnormalities, such as arrhythmias [7]. The non-specific form accounts for less than half of patients and studies have shown them to be at lower risk of subsequent stroke [4] [7].

Epidemiology

The incidence of transient ischemic attacks is approximately 1 per 1000 population in the United States, accounting for 200,000-500,00 cases a year [2] [11] [12]. The reported incidence is lower in other developed countries [5] [13].

Approximately 15% of strokes occur in individuals with a history of previous transient ischemic attacks [2] [4] [13]. The incidence of transient ischemic attacks increases with age. The incidence is significantly higher in men than in women, approximately 1.5 to 1 [6].

The incidence in blacks is 1.5 times higher than that in whites [1] [6]. This may, in part, be due to an increased prevalence of diabetes and cardiovascular disease in this population group [6].

Sex distribution
Age distribution

Pathophysiology

Transient ischemic attacks are the result of a temporary decrease or cessation of cerebral blood flow to a portion of the brain [4] [8]. They may be due to an acute thromboembolic event or chronic vascular stenosis. Cerebrovascular disease and atherosclerosis are the primary causes of the syndrome, and are a group of conditions that affect the blood vessels supplying the brain [14]. Symptoms vary according to the area of the brain affected.

Other possible causes include [8] [14]:

The pathophysiology of brain ischemia is related to the action of neuro-inflammatory mediators that increase the progression of tissue damage [15]. With ischemia, increased levels of cytokines and chemokines cause the adhesion of white blood cells to the vascular endothelium [15]. This process further impairs cerebral blood flow resulting in further damage and the increased risk of subsequent stroke.

Interleukin-1 (IL-1) is a group of cytokines that regulate the immune and inflammatory responses in the body. Recent research suggests that these substances may reduce brain injury by decreasing the inflammatory progression occurring post-ischemic episode [15].

Prevention

After a transient ischemic attack, reducing stroke risk has an impact on subsequent morbidity and mortality. This will require extensive public education about the symptoms of these events and the importance of immediate evaluation, no matter the duration [11].

Maintaining blood pressure below 140/90 mm Hg and total cholesterol below 200 mg/dL, weight loss and maintenance of normal body mass index may be preventive of transient ischemic attacks [17].

Summary

Transient ischemic attacks (TIA) are defined as temporary neurologic events that last less than 24 hours. They are due to short-term cerebral, spinal cord, or retinal ischemia [1] [2] and not associated with tissue infarction and subsequent damage [2] [3]. However, better imaging techniques have indicated that minimal tissue damage may occur in the shortest of episodes [1] [3].

Usual symptoms of transient ischemic attacks include hemiparesis, hemiparesthesia, dysphasia, diplopia and monocular blindness, imbalance and gait disturbances, and possible disorientation [1] [2] [4].

The incidence of subsequent stroke in individuals who have had a transient ischemic attack may be as high as 10% within 3 months and 11 to 25% in the next 5 years [2] [5] [6].

Patient Information

What is transient ischemic attack?

A transient ischemic attack refers to a temporary sudden decrease in blood supply to the brain resulting in short-term neurological symptoms. The cause of this disorder is a sudden decrease in blood supply to a part of the brain.

What are the symptoms?

The symptoms of transient ischemic attack include:

What causes transient ischemic attack?

Transient ischemic attacks are caused by interference with the blood supply to the brain. Reasons for this include:

It is believed that much of the damage and the increased risk of stroke caused by transient ischemic attacks is due to inflammation of brain tissue as a result of ischemia, decreased oxygen supply.

Who gets transient ischemic attack?

Anyone who has cerebrovascular disease or disorders is at risk for transient ischemic attacks. The risk increases with age. The incidence is higher in men than in women and in blacks than in whites.  Those at particular risk are individuals with high blood pressure, high cholesterol, diabetes, elevated body mass index (BMI), and atherosclerosis.

How is it diagnosed?

The symptoms of the disorder are of such short duration, often 1 to 60 minutes, that they may be gone before the individual can be seen by a healthcare provider. Transient ischemic attacks are diagnosed initially by the history of the event, symptoms, duration, and residual effects. Diagnosis is then a matter of excluding other possible diagnoses such as migraines, seizures, and hypoglycemia. Once it is determined that the symptoms are caused by a transient ischemic episode, the underlying cause of the decreased blood flow must be identified and that issued needs to be treated.

How is transient ischemic attack treated?

If it is determined that the transient ischemic attack is due to an embolism or clotting problem medications to decrease the formation of clots can be effective. These medications include warfarin (Coumadin) or heparin in the acute phase, and/ aspirin.
If the underlying cause is occlusion due to embolus or stenosis (clot or narrowing of blood vessel) surgical intervention may be needed. New medications are currently being researched for use in transient ischemic events. These medication reduce the inflammation caused by brain ischemia and may help to prevent subsequent strokes.

What are the complications of transient ischemic attack?

The main complication of transient ischemic attacks is cerebral vascular accidents or stroke. Research has shown that 15-25% of people who experience a transient ischemic attack will experience a stroke within 3 months to 5 years. Strokes result in permanent disability or death.

How can transient ischemic attacks be prevented?

After a transient ischemic attack, reducing stroke risk has an impact on subsequent morbidity and mortality. Maintaining blood pressure below 140/90 mm Hg and total cholesterol below 200 mg/dL, weight loss and maintenance of normal body mass index may help to preventive transient ischemic attacks and stroke.

References

Article

  1. Albers GW, Caplan LR, Easton JD, Fayad PB, Mohr JP, Saver JL, et al. Transient ischemic attack--proposal for a new definition. N Engl J Med. 2002;347(21):1713-6.
  2. Bray JE, Coughlan K, Bladin C. Can the ABCD Score be dichotomised to identify high-risk patients with transient ischaemic attack in the emergency department?. Emerg Med J. 2007;24(2):92-5.
  3. Edlow JA, Kim S, Pelletier AJ, Camargo CA. National Study on Emergency Department Visits for Transient Ischemic Attack, 1992–2001. Academic Emergency Medicine. 2006; 13:666–672.
  4. Bos MJ, van Rijn MJ, Witteman JC, Hofman A, Koudstaal PJ, Breteler MM. Incidence and prognosis of transient neurological attacks. JAMA. 2007;298(24):2877-85. 
  5. Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2009;40(6):2276-93.
  6. Kleindorfer D, Panagos P, Pancioli A. Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke. 2005;36(4):720-3.
  7. Bots ML, van der Wilk EC, Koudstaal PJ, Hofman A, Grobbee DE. Transient neurological attacks in the general population. Prevalence, risk factors, and clinical relevance. Stroke. 1997;28(4):768-73.
  8. Giles MF, Albers GW, Amarenco P, Arsava EM, Asimos AW, Ay H, et al. Early stroke risk and ABCD2 score performance in tissue vs time-defined TIA: A multicenter study. Neurology. 2011;77(13):1222-8.
  9. Fothergill A, Christianson TJ, Brown RD Jr, Rabinstein AA. Validation and refinement of the ABCD2 score: a population-based analysis. Stroke. 2009;40(8):2669-73.
  10. Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007;369(9558):283-92.
  11. Johnston SC, Fayad PB, Gorelick PB, Hanley DF, Shwayder P, van Husen D, et al. Prevalence and knowledge of transient ischemic attack among US adults. Neurology. 2003;60(9):1429-34.
  12. Chandratheva A, Lasserson DS, Geraghty OC, Rothwell PM. Population-based study of behavior immediately after transient ischemic attack and minor stroke in 1000 consecutive patients: lessons for public education. Stroke. 2010;41(6):1108-14.
  13. Halliday AW, Lees T, Kamugasha D. Waiting times for carotid endarterectomy in UK: observational study. BMJ. 2009;338:b1847.
  14. Andrade SE, Harrold LR, Tjia J, Cutrona SL, Saczynski JS, Dodd KS, et al. A systematic review of validated methods for identifying cerebrovascular accident or transient ischemic attack using administrative data. Pharm Epidem and Drug Safety. 2012; 21(S1): 100–128.
  15. Amantea D, Nappi G, Bernardi G, Bagetta G, Corasaniti MT. Post-ischemic brain damage: pathophysiology and role of inflammatory mediators. FEBS Journal. 2009;276:13–26.
  16. White H, Boden-Albala B, Wang C, Elkind MS, Rundek T, Wright CB, et al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study. Circulation. 2005;111(10):1327-31.
  17. Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA, et al. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol. 2006;60(3):301-13.

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Last updated: 2019-07-11 20:33