What should be done in case of a suspected Transient Ischemic Attack (TIA or mini-stroke)?

Management of Suspected Transient Ischemic Attack (TIA)

Patients with suspected TIA should be immediately sent to an emergency department with advanced stroke care capabilities for urgent evaluation, as they are at highest risk of recurrent stroke within the first week after symptom onset. 1

Risk Stratification

The risk of recurrent stroke after TIA varies based on timing and symptoms:

HIGHEST Risk (Immediate ED Evaluation Required)

• Patients presenting within 48 hours with:
  • Transient, fluctuating, or persistent unilateral weakness (face, arm, leg)
  • Speech disturbance
  • These patients have up to 10% risk of stroke within the first week 1

HIGH Risk (Same-Day Assessment Required)

• Patients presenting within 48 hours with:
  • Symptoms without motor weakness/speech disturbance
  • Examples: hemibody sensory loss, monocular visual loss, binocular diplopia, hemivisual loss, dysmetria 1

INCREASED Risk (24-Hour Assessment Required)

• Patients presenting between 48 hours and 2 weeks from symptom onset with:
  • Motor symptoms or speech disturbance 1

LOWER Risk (Less Urgent Evaluation)

• Patients presenting more than 2 weeks after symptoms
• Patients with atypical sensory symptoms (patchy numbness/tingling) 1

Urgent Diagnostic Evaluation

For highest and high-risk patients, the following should be completed without delay:

1. Brain Imaging

   • Non-contrast CT or MRI to rule out hemorrhage and other mimics 1, 2
   • Note: Early CT sensitivity for ischemic stroke is only 25-30% in first 3 hours 2

2. Vascular Imaging

   • CTA or MRA from "arch to vertex" to assess extracranial and intracranial circulation 1
   • Carotid ultrasound is an alternative but provides less information 1

3. Cardiac Evaluation

   • ECG to assess for atrial fibrillation and other cardiac conditions 1

4. Laboratory Tests

   • Complete blood count
   • Coagulation studies (aPTT, INR)
   • Electrolytes
   • Renal function (creatinine, eGFR)
   • Blood glucose and HbA1c
   • Lipid profile 1

Common Pitfalls to Avoid

1. Delayed Evaluation: Many patients (44.4%) delay seeking medical attention for ≥1 day after TIA, even when they correctly recognize symptoms 3. This significantly increases stroke risk.

2. Weekend Effect: Greater delays in seeking care occur on weekends 3. Emphasize that TIA is a medical emergency regardless of day of week.

3. Relying Solely on Initial CT: A negative early CT does not rule out TIA/stroke. Do not delay treatment waiting for ischemic changes to appear if clinical suspicion is high 2.

4. Missing Surgical Causes: Some TIAs require surgical intervention, particularly symptomatic carotid stenosis which benefits from early revascularization 4.

Secondary Prevention (After Diagnosis Confirmation)

Once TIA is confirmed, immediate preventive therapy should be initiated:

1. Antiplatelet Therapy:

   • Aspirin 50-325mg daily, or
   • Clopidogrel alone, or
   • Combination of aspirin and extended-release dipyridamole 5, 6

2. Blood Pressure Management:

   • Initiate or optimize antihypertensive therapy 5

3. Lipid Management:

   • Start statin therapy 5

4. Anticoagulation:

   • For patients with atrial fibrillation, warfarin or direct oral anticoagulants instead of antiplatelet therapy 5

5. Lifestyle Modifications:

   • Smoking cessation
   • Reduction of excess alcohol
   • Healthy diet
   • Diabetes management 5

Special Considerations

For patients with symptomatic carotid stenosis, early surgical intervention (carotid endarterectomy) significantly reduces stroke risk, with diminishing benefit beyond 2 weeks after symptom onset 1.

For patients with cryptogenic TIA, consider:

• Extended cardiac monitoring for paroxysmal atrial fibrillation
• Echocardiography to evaluate for cardiac sources of embolism 1

Remember that TIA is a medical emergency and warning sign that requires immediate evaluation and treatment to prevent a potentially devastating stroke.