What is the typical management of a patient presenting with a Transient Ischaemic Attack (TIA)?

Management of Transient Ischemic Attack (TIA)

Patients with TIA should be treated as a medical emergency requiring immediate evaluation and management due to the high risk of recurrent stroke (up to 10% within the first week), with the highest risk occurring within the first 48 hours after the event. 1, 2

Clinical Presentation and Diagnosis

Typical Signs and Symptoms

• Focal neurological deficits with sudden onset and complete resolution (usually within minutes to hours)
• Common presentations include:
  • Unilateral weakness (face, arm, and/or leg)
  • Speech disturbance (dysarthria or aphasia)
  • Monocular visual loss (amaurosis fugax)
  • Sensory deficits
  • Ataxia or incoordination
  • Vertigo (when accompanied by other neurological symptoms)

Differential Diagnosis

• Migraine with aura
• Seizure (especially focal seizures)
• Hypoglycemia
• Peripheral vestibular disorders
• Syncope
• Multiple sclerosis
• Conversion disorder
• Intracranial mass lesions
• Arterial dissection
• Vasculitis
• Thrombotic diatheses
• Blood dyscrasias

Risk Stratification

ABCD² Score for TIA Risk Assessment 1

• A: Age ≥60 years (1 point)
• B: Blood pressure ≥140/90 mmHg (1 point)
• C: Clinical features:
  • Unilateral weakness (2 points)
  • Speech disturbance without weakness (1 point)
• D: Duration:
  • ≥60 minutes (2 points)
  • 10-59 minutes (1 point)
• D: Diabetes (1 point)

Risk interpretation:

• High risk (6-7 points): ~8.1% stroke risk at 2 days
• Moderate risk (4-5 points): ~4.1% stroke risk at 2 days
• Low risk (0-3 points): ~1.0% stroke risk at 2 days

Immediate Management

Highest Risk Patients (within 48 hours of symptom onset) 3, 1

1. Immediate referral to emergency department with stroke care capabilities
2. Urgent brain imaging:
   • CT scan immediately to rule out hemorrhage
   • MRI (if available) to identify acute ischemia
3. Vascular imaging:
   • CTA or MRA from aortic arch to vertex to identify carotid stenosis or other vascular abnormalities
4. Cardiac evaluation:
   • 12-lead ECG immediately
   • Consider echocardiogram if cardiac source suspected

Laboratory Tests

• Blood glucose levels
• Complete blood count with platelet count
• Coagulation studies
• Serum electrolytes
• Renal function tests
• Lipid profile

Medical Management

Antiplatelet Therapy 1

• Initiate within 24 hours if no contraindications:
  • Aspirin (initial dose 160-325mg, then 81-100mg daily)
  • Clopidogrel 75mg daily
  • Aspirin-dipyridamole extended-release combination

Blood Pressure Management 1

• Target BP <140/90 mmHg
• Avoid excessive BP lowering in first few days post-TIA

Lipid Management 1

• High-intensity statin therapy regardless of baseline cholesterol
• Target LDL <100 mg/dL

Anticoagulation 1

• For patients with atrial fibrillation:
  • Long-term oral anticoagulation (warfarin with INR 2.0-3.0 or direct oral anticoagulants)
  • If anticoagulation contraindicated: aspirin 325mg/day or clopidogrel 75mg

Surgical Management

Carotid Revascularization 3, 1

• Carotid endarterectomy (CEA) for patients with:
  • Symptomatic carotid stenosis >70%
  • Hemispheric TIAs (after excluding lacunar events and cardiogenic embolism)
• Timing: Early CEA (within 2 weeks) provides highest benefit for stable patients
• Caution: Emergent CEA generally not recommended for unstable patients with evolving stroke or crescendo TIA due to high risk of complications

Follow-up and Monitoring 1

• Short-term monitoring with close observation during first 48 hours
• Initial follow-up at 2-4 weeks after the event
• Subsequent follow-up every 3-6 months
• Ongoing risk factor management and medication adherence

Risk Factor Management 1, 4

• Hypertension control (target <140/90 mmHg)
• Diabetes management
• Smoking cessation
• Moderate alcohol consumption
• Weight management
• Regular physical activity
• Dietary modifications

Pitfalls and Caveats

1. Misdiagnosis: TIA symptoms can mimic other conditions; thorough evaluation is essential to avoid mismanagement
2. Delayed treatment: The highest risk of stroke is within the first 48 hours; delays in evaluation and treatment increase stroke risk
3. Incomplete vascular imaging: Failure to identify significant carotid stenosis can miss opportunities for surgical intervention
4. Overlooking cardiac sources: Atrial fibrillation and other cardiac sources require specific management strategies
5. Inadequate risk factor modification: Long-term stroke prevention requires aggressive management of modifiable risk factors

The management of TIA represents a critical opportunity for stroke prevention. Rapid assessment, appropriate imaging, and prompt initiation of preventive therapies can significantly reduce the risk of subsequent stroke and associated disability.