1. Exam after suspected TIA/CVA: 
-Mental status, recent/remote memory
-Cranial nerves, with special focus on II (visual fields), III/IV/VI (gaze palsies), VII (facial strength asymmetry)
-Strength: Deltoid, Biceps, Triceps, Wrist extension, Grip, Intrinsic Hand, Quadriceps, Hamstrings, Tibialis Anterior (dorsiflexion), Gastrocnemius, Extensor hallucis longus.
-Pronator drift (very sensitive for UE weakness)
-Sensation to pin and touch
-Deep tendon reflexes: biceps, triceps, brachiorad, patellar, ankle. Babinski, Hoffman.
-Romberg: loss of balance may indicate vertebral-basilar ischemic pathology
-Gait: ataxia may indicate vertebral-basilar ischemic pathology
-Coordination
-FAST test: face-arm-speech to quickly assess for risk of CVA-- face (ask them to smile, look for asymmetry), arm (raise both arms, check for downward drift), speech (ask to repeat sentence, check for incorrect or slurred response). PPV ~65-75%
-NIH stroke scale for formal, standardized stroke testing. Video demonstration of this exam.
2. Cardiovascular exam after suspected TIA/CVA
-CV: listen to heart-- new onset murmur may indicate valve pathology, mural thrombi that led to CVA
-Auscultate carotids for bruits-- narrowing, thrombi.
-EKG: r/o MI or arrhythmia leading to decreased cerebral perfusion.
3. Get up and go test to assess mobility: have someone sit in a chair, and without using their arms, stand up, walk 10 feet forward, turn around and walk back. Time starts when they start getting up and ends when they sit down. Give them 1 practice round and 3 timed rounds, average 3 times.
If they complete it in an average of:
-<10 seconds: full mobility
-10-20 seconds: mostly independent
-20-30 seconds: variable mobility
->30 seconds: impaired mobility
4. DDx of suspected TIA: Seizure (acute onset weakness, syncope/near syncope, fall, temporary altered mental status, etc)
-Can have aura in the form of alterations in sensorium (vision, hearing, touch, etc; believed to originate from temporal lobe), or dizziness/lightheadedness.
-Can lead to fall
-Post-ictal AMS
-Post-ictal unilateral paralysis (Todd's paralysis, lasting 30 min-30 hours, median 15 hours) or neurologic findings.
-Generally associated with amnesia during and after the seizure event.
-Can be associated with temporary spike in blood pressure.
-A seizure is UNLIKELY if the following are true: patient was responsive during event or had recall of the experience, lack of post ictal confusion/amnesia, no focal neurologic signs, oral injury, or fecal/urinary soiling.
5. DDX of suspected TIA: Stroke
-Risk factors: heart (irregular rhythm, known a-fib or dilation), hypertension, hypercholesterolemia
-Can be preceded by dizziness or lightheadedness 2/2 mild ischemia to brain
-May presenent as sudden onset of focal neurologic deficit (weakness, changes in sensorium, dysarthria, ataxia) or sudden onset of confusion or severe headache.
-Visual changes can occur if the stroke occurred in an opthalmic/retinal artery, if the stroke affects the visual cortex, or if it grossly affects the R brain (visuo-spatial reasoning)
-+/- LOC
6. DDX of suspected TIA: Cardiac dysfunction
-Anything cardiac that leads to fluctuating CPP will lead to TIA like events.
-MI
-Acute valve failure
-PE
-Arrhythmias
7. DDx of suspected TIA: Medications that cause TIA like symptoms
-Anything that affects electrolyte levels (hypoK can cause numbness, weakness, arrhythmias leading to embolic CVA) - diuretics
-Anything that causes hypoglycemia - sulfonylureas
-Anything that causes hypotension - antihypertensives
-Anything that causes orthostatic hypotension - anything that has a-1 blocking effects, like prazosin, and all drugs that have been used for depression except SSRIs.
8. DDx of suspected TIA: space-occupying lesion
-Generally not associated with dizziness/lightheadedness
-Generally associated with headache, n/v
-25% of patients with brain tumor report weakness in UE, 25% report visual changes
-Gradual changes in behavior and cognition are common, sudden LOC or AMS are less common (unless there is a bleed)
9. DDx of suspected TIA: hypoglcyemia
-Can present with weakness, dizziness, focal neuro findings, ataxia, paresthesias, sweating.
-Treat with glucose immediately to prevent long-term damage.
10. DDx of suspected TIA: Zebras
-Temporal arteritis: amaurosis fugax, jaw claudication, headache, TTP/pain over temporal bone, mostly women in their 70s.
-Hemiplegic migraine: migraine + unilateral weakness or sensory deficits, more common in childhood/adolescence, tends to fade by adulthood.
-Hypokalemic periodic paralysis: periodic events of general or focal paralysis, often occurs in rest period after physical activity. Often begins in childhood.