Critical Alerts

• TIA is a stroke warning - 10-15% risk of stroke within 90 days
• Highest risk is in first 48-72 hours - urgent evaluation essential
• 30% of "TIAs" have DWI lesions on MRI - actually minor strokes
• Start antiplatelet therapy immediately - aspirin ± clopidogrel
• Expedited workup identifies treatable causes - carotid disease, AF

Key Diagnostics

• MRI brain with DWI (detect acute ischemia)
• CT head (initial; excludes hemorrhage)
• Carotid imaging (ultrasound, CTA, or MRA)
• ECG (atrial fibrillation)
• Echocardiogram (cardiac source)
• Labs: Glucose, lipids, HbA1c, coagulation

Emergency Treatments

• Aspirin: 162-325 mg loading immediately
• Dual antiplatelet: Aspirin + clopidogrel 75 mg for high-risk TIA
• Statins: High-intensity statin
• Blood pressure: Permissive acutely; control chronic HTN
• Carotid intervention: Endarterectomy/stenting if ≥70% stenosis

Transient ischaemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. The classical definition of symptom resolution within 24 hours has been updated to a tissue-based definition - TIA implies no permanent brain injury.

Key Concepts

Epidemiology

• Incidence: 200,000-500,000 TIAs per year in US
• Stroke risk after TIA: 10-15% at 90 days; 3-5% at 48 hours
• With urgent treatment: Risk reduced by 80%
• 30% of strokes: Preceded by TIA

Why TIA Matters

"TIA is a warning - the opportunity to prevent stroke"

• High short-term stroke risk
• Identifies modifiable risk factors
• Window to intervene before permanent damage
• Carotid disease treatable
• Atrial fibrillation treatable

High-Risk Features

"Crescendo TIAs"

• Multiple TIAs over short time
• Suggests unstable plaque or high-grade stenosis
• Very high stroke risk
• Warrants admission and expedited workup

Stroke vs TIA

Other Causes of Transient Neurological Symptoms

Risk Stratification

ABCD2 Score

Score Interpretation:

Additional High-Risk Features Not in ABCD2:

• Carotid stenosis ≥50%
• DWI lesion on MRI
• Dual TIA (recurrent)
• Atrial fibrillation

Imaging

CT Head (Initial)

• Excludes hemorrhage
• May show old infarcts
• Cannot detect acute ischemia reliably

MRI Brain with DWI (Preferred)

• Detects acute ischemia (30% of "TIAs")
• Informs prognosis and mechanism
• Should be done within 24 hours if possible

Carotid Imaging (Essential)

Cardiac Evaluation

Laboratory Studies

Admission Criteria

Consider admission if:

• ABCD2 score ≥4
• Crescendo TIAs
• Symptomatic carotid stenosis ≥50%
• Known cardioembolic source (AF)
• Cannot complete urgent outpatient workup
• Residual deficits (may be stroke)
• Unable to return quickly if symptoms recur

TIA Clinic / Expedited Outpatient

Appropriate if:

• Low-risk features (ABCD2 0-3)
• Brain imaging and carotid imaging completed or arranged within 24 hours
• Antiplatelet started
• Reliable patient with ability to return
• Close follow-up arranged (1-2 days)

Discharge Requirements

• Antiplatelet therapy initiated
• Statin started
• MRI and carotid imaging completed or scheduled
• Cardiac monitoring arranged
• Clear return precautions given
• Follow-up within 24-48 hours

Follow-up Recommendations

Understanding TIA

• A TIA is a "warning stroke" - brain ischemia without permanent damage
• The risk of a complete stroke is highest in the next few days
• Urgent treatment and evaluation can prevent stroke
• Medication and lifestyle changes are essential

Stroke Signs (FAST)

• Face drooping
• Arm weakness
• Speech difficulty
• Time to call 911

Medication Importance

• Take aspirin (and clopidogrel if prescribed) every day
• Take statin every day
• Control blood pressure
• Do not stop medications without medical advice

When to Seek Emergency Care Immediately

• Any new weakness, numbness, or paralysis
• New speech difficulty
• New vision changes
• Severe headache
• Symptoms similar to your TIA that return

Young Adults (<45)

• Consider dissection, PFO, hypercoagulable states
• Thorough cardiac workup including bubble study
• May need more extensive investigation

Elderly

• Higher stroke risk
• More likely to have carotid disease and AF
• Balance intervention risk with benefit
• Polypharmacy considerations

Atrial Fibrillation Patients

• Anticoagulation essential
• DOACs preferred over warfarin
• May need bridging if surgery planned

Prior Stroke Patients

• Already on secondary prevention
• Reassess medication adherence
• Consider adding/changing therapy

Performance Indicators

Documentation Requirements

• Time of symptom onset and resolution
• Detailed neurological exam
• ABCD2 score
• Imaging results
• Antiplatelet and statin prescribed
• Carotid imaging results or plan
• Cardiac evaluation (ECG, echo plan)
• Disposition rationale
• Return precautions given

Diagnostic Pearls

1. TIA is a clinical diagnosis - symptoms resolved, MRI may be negative
2. 30% of "TIAs" have DWI lesions - technically minor strokes
3. ABCD2 score underestimates risk - add imaging findings and carotid status
4. Amaurosis fugax suggests carotid source
5. AF may be paroxysmal - extended monitoring needed

Treatment Pearls

1. Start aspirin immediately - don't wait for imaging
2. Consider dual antiplatelet for high-risk TIA (21 days)
3. Carotid surgery within 2 weeks for ≥70% stenosis
4. High-intensity statin for all
5. BP control - but permissive in acute phase

Disposition Pearls

1. Low-risk TIA can be outpatient if urgent workup ensured
2. High-risk (ABCD2 ≥4, carotid disease) - consider admission
3. Crescendo TIAs warrant admission
4. Close follow-up is essential - highest risk in first 48 hours
5. Patient education on stroke signs is critical