What is the treatment for a minor stroke (transient ischemic attack)?

Treatment for Minor Stroke (Transient Ischemic Attack)

Patients with transient ischemic attack (TIA) require immediate medical attention and urgent initiation of dual antiplatelet therapy with aspirin plus clopidogrel for 21-90 days, followed by long-term single antiplatelet therapy to prevent recurrent stroke. 1

Risk Stratification and Initial Management

Very High Risk TIAs (symptoms within 48 hours)

• Patients with transient, fluctuating, or persistent unilateral weakness (face, arm, leg) or speech disturbance should be:
  • Immediately sent to an emergency department with advanced stroke care capabilities 1
  • Undergo urgent brain imaging (CT or MRI) and vascular imaging (CTA or MRA) within 24 hours 1
  • Have ECG completed without delay 1

High Risk TIAs (symptoms between 48 hours and 2 weeks)

• Patients with transient, fluctuating, or persistent unilateral weakness or speech disturbance should be assessed within 24-48 hours 1
• Same imaging and diagnostic workup as very high-risk patients

Acute Treatment

1. Antiplatelet Therapy:

   • First 21-90 days: Dual antiplatelet therapy with aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) started within 24 hours of symptom onset 1
   • After initial period: Single antiplatelet therapy with one of the following:
     • Aspirin 81-325 mg daily
     • Clopidogrel 75 mg daily
     • Aspirin-dipyridamole extended-release combination 1

2. Blood Pressure Management:

   • Initiate antihypertensive therapy within 24 hours after TIA 1
   • Target blood pressure <140/90 mmHg 1
   • Avoid excessive BP lowering in the first few days post-event 1

3. Lipid Management:

   • Start high-intensity statin therapy (e.g., atorvastatin 80 mg) regardless of baseline cholesterol levels 1, 2
   • Target LDL <100 mg/dL (or reduction by ≥50%) 1

Specific Management Based on Etiology

Large Artery Atherosclerosis

• For 50-99% intracranial stenosis: Aspirin 325 mg/day is recommended over warfarin 1
• For 70-99% ipsilateral extracranial carotid stenosis: Refer for carotid endarterectomy within 6 months of the event 1
• For 50-69% ipsilateral extracranial carotid stenosis: Consider endarterectomy for selected patients 1
• Angioplasty and stenting should NOT be performed as initial treatment for intracranial stenosis 1

Cardioembolic TIA

• For atrial fibrillation: Prescribe oral anticoagulation unless contraindicated 1
• Prefer direct oral anticoagulants (apixaban, dabigatran, edoxaban, rivaroxaban) over warfarin except for patients with mechanical heart valves or moderate-severe mitral stenosis 1

Follow-up Care

• Initial follow-up within 2-4 weeks after the event 3
• Subsequent follow-up every 3-6 months 3
• Monitor and manage all modifiable risk factors:
  • Hypertension
  • Diabetes (target HbA1c ≤7%)
  • Dyslipidemia
  • Smoking cessation
  • Weight management
  • Physical activity

Common Pitfalls to Avoid

1. Delayed Treatment: The risk of recurrent stroke is highest in the first 48 hours after TIA. Delaying treatment can lead to preventable strokes 4

2. Inadequate Risk Stratification: Not all TIAs carry the same risk. Use the ABCD² score to help determine urgency of evaluation 3

3. Failure to Recognize Symptoms: Up to 70% of patients do not correctly recognize TIA symptoms, leading to treatment delays. Patient education is crucial 5, 6

4. Substituting Antiplatelet Therapy for Acute Stroke Treatment: Antiplatelet therapy should not replace IV alteplase or mechanical thrombectomy in eligible patients 1

5. Underestimating Outpatient Management: For appropriate patients, outpatient management in specialized TIA clinics can be as effective as inpatient care and more cost-efficient 7

The EXPRESS study demonstrated that urgent assessment and immediate treatment of TIA reduced the 90-day risk of recurrent stroke by 80% compared to usual care (from 10.3% to 2.1%) 4. This highlights the critical importance of rapid evaluation and treatment initiation for all patients with TIA.