From the Guidelines
The workup after a Transient Ischemic Attack (TIA) should focus on vascular imaging, such as CT angiography (CTA), MR angiography (MRA), or Doppler ultrasound (DUS), to assess the carotid arteries as a possible cause of the ischemic stroke, with an emphasis on secondary prevention. This approach is supported by the American Society of Neuroradiology, the American College of Radiology, and the Society of Neurointerventional Surgery, as stated in their joint statement 1.
The initial evaluation should include:
- Brain imaging with either CT or MRI to rule out hemorrhage or other structural lesions
- Vascular imaging of the head and neck using carotid ultrasound, CT angiography, or MR angiography to identify potential stenosis or occlusions
- Cardiac evaluation, including an ECG to detect arrhythmias, particularly atrial fibrillation, and an echocardiogram to identify cardiac sources of emboli
- Extended cardiac monitoring for at least 24 hours to detect paroxysmal atrial fibrillation
- Laboratory tests, such as complete blood count, coagulation studies, lipid panel, blood glucose, and HbA1c
According to the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease, early recognition of TIA, identification of patients at risk, and risk factor modification are important stroke prevention measures 1.
The goal of the workup is to identify the etiology of the TIA, which guides appropriate secondary prevention strategies, including antiplatelet therapy, anticoagulation if atrial fibrillation is detected, and risk factor modification, such as blood pressure control, lipid management, and lifestyle changes. Emphasis should be placed on prompt and comprehensive evaluation, ideally within 24-48 hours of symptom onset, to reduce the risk of recurrent ischemic events.
From the Research
Workup after a Transient Ischemic Attack (TIA)
The workup after a TIA is crucial in preventing future cerebral ischemia and complications related to the initial ischemic event. The following are key components of the workup:
- A detailed history and examination to determine the cause of the TIA 2, 3
- Imaging of the brain and extracranial and intracranial blood vessels to identify potential contributing mechanisms 2, 4, 5
- Cardiac investigations, such as ECG, to evaluate for etiological risk factors 2, 4
- Serum studies to evaluate for risk factors, such as hypertension, dyslipidemia, and diabetes 2, 3
- Carotid imaging in patients with anterior circulation symptoms 4
- Early brain imaging, such as CT or MRI, to rule out stroke and identify potential causes of the TIA 4, 5
Diagnostic Evaluation
The diagnostic evaluation of TIA should focus on answering the following questions:
- Are the symptoms consistent with a cerebral infarction or TIA? 3
- Where does the ischemic event localize? 3
- What etiologies and mechanisms of cerebral infarction and TIA are possible? 3
- What is the prevalence of each potential etiology? 3
- What treatments are available for this etiology? 3
- What tests and studies are useful to evaluate this etiology? 3
Risk Stratification
Risk stratification is essential in determining the best course of treatment for patients with TIA. The ABCD2 score is a useful tool in identifying patients at high risk of early stroke 6. Patients with a high ABCD2 score, symptomatic stenosis, newly detected atrial fibrillation, or recurrent TIA should be referred to a stroke unit for further evaluation and treatment 6.
Treatment and Management
The management of TIA should focus on stroke prevention strategies, including:
- Initiation of appropriate antiplatelet therapy 2, 5
- Encouraging a healthy lifestyle 2
- Managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes 2, 3
- Carotid revascularization for symptomatic carotid artery stenosis 5
- Anticoagulation for atrial fibrillation 5
- Vascular risk factor reduction strategies 5