How do neurologists diagnose transient ischemic attack: A systematic review

Abstract

Background: Identifying and treating patients with transient ischemic attack is an effective means of preventing stroke. However, making this diagnosis can be challenging, and over a third of patients referred to stroke prevention clinic are ultimately found to have alternate diagnoses.

Aims: We performed a systematic review to determine how neurologists diagnose transient ischemic attack.

Summary of review: A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using MEDLINE, Embase, and the Cochrane Library databases. Publications eligible for inclusion were those that included information on the demographic or clinical features neurologists use to diagnose transient ischemic attacks or transient ischemic attack-mimics. Of 1666 citations, 210 abstracts were selected for full-text screening and 80 publications were ultimately deemed eligible for inclusion. Neurologists were more likely to diagnose transient ischemic attack based on clinical features including negative symptoms or speech deficits. Patients with positive symptoms, altered level of consciousness, or the presence of nonfocal symptoms such as confusion or amnesia were more likely to be diagnosed with transient ischemic attack-mimic. Neurologists commonly include mode of onset (i.e. sudden versus gradual), recurrence of attacks, and localizability of symptoms to a distinct vascular territory in the diagnostic decision-making process. Transient ischemic attack diagnosis was more commonly associated with advanced age, preexisting hypertension, atrial fibrillation, and other vascular risk factors.

Conclusions: Neurologists rely on certain clinical and demographic features to distinguish transient ischemic attacks from mimics, which are not currently reflected in widely used risk scores. Clarifying how neurologists diagnose transient ischemic attack may help frontline clinicians to better select patients for referral to stroke prevention clinics.

Keywords: Transient ischemic attack; decision analysis; stroke; stroke mimic; stroke prevention.

Figure 1.

PRISMA flow diagram.

Figure 2.

Commonly identified clinical features suggestive of TIA. Symptoms are depicted in light gray bubbles and qualitative features are depicted in dark gray bubbles. N = number of publications making reference to each differentiating feature. The percentage of included studies is shown in parentheses. TIA: transient ischemic attack.

Figure 3.

Commonly identified clinical features suggestive of TIA–mimic. Symptoms are depicted in light gray bubbles and qualitative features are depicted in dark gray bubbles. N = number of publications making reference to each differentiating feature. The percentage of included studies is shown in parentheses. TIA: transient ischemic attack.

Figure 4.

Risk factors and demographic features commonly identified as predictors of TIA diagnosis and TIA–mimic diagnosis. N = number of publications making reference to each risk factor. The percentage of included studies is shown in parentheses. TIA: transient ischemic attack.