Transient neurological attack

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"disturbances of vision in one or both eyes consisting of flashes, objects, distorted-view tunnel vision, or image moving on change of posture; alteration of muscle strength consisting of tiredness or heavy sensation in one or more limbs, either unilateral or bilateral; sensory symptoms alone (unilateral or bilateral) or a gradual spread of sensory symptoms; brain stem symptoms and coordination difficulties consisting of isolated disorder of swallowing or articulation, double vision, dizziness, or uncoordinated movements; and accompanying symptoms including unconsciousness, limb jerking, tingling of the limbs or lips, disorientation, and amnesia."

In contract, for focal symptoms, see Transient ischemic attack.

Etiology[edit | edit source]

14% have acute stroke (diffusion-weighted imaging [DWI]–positive)^[3]

Symptoms[edit | edit source]

The most common symptoms are:^[4]

Loss in consciousness (including syncope) or less commonly a decrease in consciousness
Dizziness (not including vertigo)
Amnesia
Unsteadiness

Witness observations can add to diagnostic accuracy, especially in distinguishing epilepsy from syncope^[5]. Witnesses are less able to help distinguish syncope from psychogenic nonepileptic seizures (PNES)^[5].

Prognosis[edit | edit source]

Atypical neurologic symptoms increase the risk of stroke^[6].

In a cohort study of 6062 adults about 5% had a TNA over 10 years found rates of subsequent stroke and dementia were increased depending on type of transient neurological attack (see table).^[4]

Rates of subsequent stroke and dementia after transient neurological attack^[4]
	Stroke	Dementia
	Stroke	Any	Vascular
Focal attacks (transient ischemic attacks)	2.14	0.94	1.12
Nonfocal attacks	1.56	1.59	4.97
Mixed attacks	2.48	3.46	18.8

Among nonfocal symptoms:

Vision disorders such as blurring or dimming may portend a subsequent stroke^[7]^[8]. If the patient truly has symptoms in both eyes, the patient's symptoms should be a homonymous hemianopsia visual field defect.^[9]. If the symptoms are just in one eye, then the patient may have disease of the carotid or retinal artery causing amaurosis fugax.^[10]
Transient global amnesia is not a risk factor subsequent stroke.^[11]
Nonrotary dizziness may^[12] or may not^[7] be a risk factor for subsequent stroke.

References[edit | edit source]

↑ Bots ML, van der Wilk EC, Koudstaal PJ, Hofman A, Grobbee DE (1997). "Transient neurological attacks in the general population. Prevalence, risk factors, and clinical relevance". Stroke. 28 (4): 768–73. PMID 9099194.
↑ "A classification and outline of cerebrovascular diseases. II". Stroke. 6 (5): 564–616. 1975. PMID 1179466.
↑ Coutts SB, Moreau F, Asdaghi N, Boulanger JM, Camden MC, Campbell BCV et al. (2019) Rate and Prognosis of Brain Ischemia in Patients With Lower-Risk Transient or Persistent Minor Neurologic Events. JAMA Neurol ():. DOI:10.1001/jamaneurol.2019.3063 PMID: 31545347
↑ ^4.0 ^4.1 ^4.2 Bos MJ, van Rijn MJ, Witteman JC, Hofman A, Koudstaal PJ, Breteler MM (2007). "Incidence and Prognosis of Transient Neurological Attacks". JAMA. 298 (24): 2877–2885. doi:10.1001/jama.298.24.2877. PMID 18159057.
↑ ^5.0 ^5.1 Chen M, Jamnadas-Khoda J, Broadhurst M, Wall M, Grünewald R, Howell SJL; et al. (2019). "Value of witness observations in the differential diagnosis of transient loss of consciousness". Neurology. 92 (9): e895–e904. doi:10.1212/WNL.0000000000007017. PMID 30804064.
↑ Tuna, Maria A; Rothwell, Peter M (2021). "Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis". The Lancet. 397 (10277): 902–912. doi:10.1016/S0140-6736(20)31961-9. ISSN 0140-6736.
↑ ^7.0 ^7.1 Evans JG (1990). "Transient neurological dysfunction and risk of stroke in an elderly English population: the different significance of vertigo and non-rotatory dizziness". Age Ageing. 19 (1): 43–9. PMID 2316424.
↑ Dennis MS, Bamford JM, Sandercock PA, Warlow CP (1989). "Lone bilateral blindness: a transient ischaemic attack". Lancet. 1 (8631): 185–8. doi:10.1016/S0140-6736(89)91203-8. PMID 2563098.
↑ Pessin MS, Kwan ES, DeWitt LD, Hedges TR, Gale D, Caplan LR (1987). "Posterior cerebral artery stenosis". Ann. Neurol. 21 (1): 85–9. doi:10.1002/ana.410210115. PMID 3827217.
↑ Gautier JC (1993). "Amaurosis fugax". N. Engl. J. Med. 329 (6): 426–8. PMID 8326979.
↑ Pantoni L, Bertini E, Lamassa M, Pracucci G, Inzitari D (2005). "Clinical features, risk factors, and prognosis in transient global amnesia: a follow-up study". Eur. J. Neurol. 12 (5): 350–6. doi:10.1111/j.1468-1331.2004.00982.x. PMID 15804264.
↑ Heyman A, Wilkinson W, Pfeffer R, Vogt T. 'Dizzy' spells in the elderly—a predictor of stroke? Tram Am Neurol Assoc 1980; 105:169-71.

[pmid9099194-1] Bots ML, van der Wilk EC, Koudstaal PJ, Hofman A, Grobbee DE (1997). "Transient neurological attacks in the general population. Prevalence, risk factors, and clinical relevance". Stroke. 28 (4): 768–73. PMID 9099194.

[pmid1179466-2] "A classification and outline of cerebrovascular diseases. II". Stroke. 6 (5): 564–616. 1975. PMID 1179466.

[pmid31545347-3] Coutts SB, Moreau F, Asdaghi N, Boulanger JM, Camden MC, Campbell BCV et al. (2019) Rate and Prognosis of Brain Ischemia in Patients With Lower-Risk Transient or Persistent Minor Neurologic Events. JAMA Neurol ():. DOI:10.1001/jamaneurol.2019.3063 PMID: 31545347

[pmid18159057-4] 4.0 ^4.1 ^4.2 Bos MJ, van Rijn MJ, Witteman JC, Hofman A, Koudstaal PJ, Breteler MM (2007). "Incidence and Prognosis of Transient Neurological Attacks". JAMA. 298 (24): 2877–2885. doi:10.1001/jama.298.24.2877. PMID 18159057.

[pmid30804064-5] 5.0 ^5.1 Chen M, Jamnadas-Khoda J, Broadhurst M, Wall M, Grünewald R, Howell SJL; et al. (2019). "Value of witness observations in the differential diagnosis of transient loss of consciousness". Neurology. 92 (9): e895–e904. doi:10.1212/WNL.0000000000007017. PMID 30804064.

[TunaRothwell2021-6] Tuna, Maria A; Rothwell, Peter M (2021). "Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis". The Lancet. 397 (10277): 902–912. doi:10.1016/S0140-6736(20)31961-9. ISSN 0140-6736.

[pmid2316424-7] 7.0 ^7.1 Evans JG (1990). "Transient neurological dysfunction and risk of stroke in an elderly English population: the different significance of vertigo and non-rotatory dizziness". Age Ageing. 19 (1): 43–9. PMID 2316424.

[pmid2563098-8] Dennis MS, Bamford JM, Sandercock PA, Warlow CP (1989). "Lone bilateral blindness: a transient ischaemic attack". Lancet. 1 (8631): 185–8. doi:10.1016/S0140-6736(89)91203-8. PMID 2563098.

[pmid3827217-9] Pessin MS, Kwan ES, DeWitt LD, Hedges TR, Gale D, Caplan LR (1987). "Posterior cerebral artery stenosis". Ann. Neurol. 21 (1): 85–9. doi:10.1002/ana.410210115. PMID 3827217.

[pmid8326979-10] Gautier JC (1993). "Amaurosis fugax". N. Engl. J. Med. 329 (6): 426–8. PMID 8326979.

[pmid15804264-11] Pantoni L, Bertini E, Lamassa M, Pracucci G, Inzitari D (2005). "Clinical features, risk factors, and prognosis in transient global amnesia: a follow-up study". Eur. J. Neurol. 12 (5): 350–6. doi:10.1111/j.1468-1331.2004.00982.x. PMID 15804264.

[12] Heyman A, Wilkinson W, Pfeffer R, Vogt T. 'Dizzy' spells in the elderly—a predictor of stroke? Tram Am Neurol Assoc 1980; 105:169-71.

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