From the Guidelines
The workup for a transient ischemic attack (TIA) should include immediate brain imaging, vascular assessment, cardiac evaluation, and laboratory tests, as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.
Initial Assessment
The initial assessment should include brain imaging, noninvasive vascular imaging, and cardiac evaluation.
- Brain imaging: Start with a non-contrast CT or MRI of the brain to rule out hemorrhage or other pathology, as recommended by the Canadian stroke best practice recommendations 1.
- Vascular imaging: Follow with vascular imaging including carotid ultrasound, CT angiography, or MR angiography to identify potential stenosis or occlusion, with CT angiography being the ideal way to assess both extracranial and intracranial circulation 1.
- Cardiac evaluation: Cardiac evaluation should include an ECG to assess cardiac rhythm and identify atrial fibrillation or flutter, as well as echocardiogram and rhythm monitoring for at least 24 hours to detect atrial fibrillation 1.
Laboratory Tests
Laboratory tests should include:
- Complete blood count
- Coagulation studies
- Lipid panel
- HbA1c
- Renal function These tests are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
Treatment
Initiate antiplatelet therapy promptly with aspirin 325mg initially, followed by 81mg daily, or consider dual antiplatelet therapy with aspirin plus clopidogrel 75mg daily for 21 days in high-risk patients.
- Statin therapy should be started regardless of baseline lipid levels, typically with atorvastatin 80mg daily.
- Blood pressure management is crucial, targeting <140/90 mmHg. This comprehensive approach is essential because TIAs represent warning signs of potential future stroke, with highest risk in the first 48 hours, and proper evaluation can identify treatable causes and guide appropriate secondary prevention strategies to significantly reduce stroke risk 1.
From the Research
TIA Workup
- A TIA workup typically involves imaging of the brain and intracranial and extracranial blood vessels using CT, CT angiography, carotid Doppler ultrasound, and MRI 2
- The goal of the workup is to identify the cause of the TIA and to assess the risk of recurrent stroke, with up to 80% of strokes after TIA being preventable with urgent assessment and treatment 2
- Treatment options for TIA include anticoagulation for atrial fibrillation, carotid revascularization for symptomatic carotid artery stenosis, antiplatelet therapy, and vascular risk factor reduction strategies 2
Diagnostic Assessment
- Patients presenting with TIA should undergo a thorough diagnostic assessment, including imaging studies and laboratory tests, to determine the underlying cause of the TIA 3
- The ABCD2 instrument can be used to assess the risk of stroke after TIA, with a score of 4 or higher indicating a high-risk TIA 3
- Patients with high-risk TIA should receive dual antiplatelet therapy with aspirin and clopidogrel within 24 hours of presentation, followed by single antiplatelet therapy 3
Treatment Options
- Antiplatelet therapy is a key component of TIA treatment, with aspirin being a commonly used medication 4
- The dose of aspirin required for TIA treatment varies depending on the individual patient and the specific indication, with higher doses required for certain conditions such as atrial fibrillation and acute ischemic stroke 4
- Statins, such as atorvastatin, may also be used in combination with aspirin to reduce the risk of recurrent stroke and to improve outcomes in patients with ischemic cerebrovascular disease 5