Risk Stratification tools for Transient Ischemic Attack: Which patients require hospital admission?

Stroke and transient ischemic attack (TIA) arise from identical etiologies and many fatal or disabling strokes are preceded by a TIA. Ten percent of patients presenting with a TIA will suffer a stroke within 3 months with half occurring in the first 48 hours. Still, many patients with a TIA do not receive timely evaluation or therapy. Hospitalization offers the opportunity for rapid evaluation and secondary prevention, reduced time to thrombolysis for early second strokes, and can be cost effective for high risk patients. Stratification tools are now available which allow individualized assessment of risk for early second strokes based on patient characteristics on presentation. The use of scoring systems such as the ABCD(2) score to predict risk of stroke after TIA are useful in making an evidence-based judgment regarding need for hospitalization. High-risk patients have an 8.1% risk for stroke in the 48 hours after a TIA and warrant hospital admission. Intermediate-risk patients have a 4.1% risk of early second stroke and may be considered for admission, observation, or expedited clinic evaluation. Low-risk patients have a 2-day stroke risk of only 1% and are likely appropriate for prompt outpatient evaluation. TIA is a medical emergency, similar to unstable angina, and high risk patients should receive treatment and prevention measures instituted with comparable urgency.