What is the recommended workup for a patient with a Transient Ischemic Attack (TIA) on a weekday?

Recommended Workup for TIA on a Weekday

The recommended workup for a patient with Transient Ischemic Attack (TIA) on a weekday should include immediate brain imaging, vascular imaging, cardiac evaluation, and laboratory tests, with prompt initiation of appropriate secondary prevention therapy. 1

Immediate Diagnostic Evaluation

Brain Imaging

• Non-contrast CT or MRI should be completed as soon as possible to rule out hemorrhage and identify acute ischemia 1
• MRI with diffusion-weighted imaging is preferred when available as it has higher sensitivity for detecting acute ischemic changes

Vascular Imaging

• Non-invasive vascular imaging from aortic arch to vertex should be completed within 24-48 hours 1
• Options include:
  • Carotid duplex ultrasonography (particularly for anterior circulation TIAs)
  • CT angiography (CTA)
  • MR angiography (MRA)

Cardiac Evaluation

• 12-lead ECG should be performed without delay to screen for atrial fibrillation and other cardiac conditions 1
• Consider prolonged cardiac monitoring if initial ECG is negative but cardioembolic source is suspected

Laboratory Tests

• Blood glucose levels (immediately)
• Complete blood count with platelet count
• Coagulation studies
• Serum electrolytes
• Renal function tests 1

Risk Stratification

The ABCD2 score should be calculated to assess stroke risk:

• Age ≥60 years (1 point)
• Blood pressure ≥140/90 mmHg (1 point)
• Clinical features: unilateral weakness (2 points) or speech disturbance without weakness (1 point)
• Duration: ≥60 minutes (2 points) or 10-59 minutes (1 point)
• 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 1

Management and Treatment

Antiplatelet Therapy

• Initiate within 24 hours if no contraindications exist 1
• Options include:
  • Aspirin (initial dose 160-325mg, then 81-100mg daily)
  • Clopidogrel 75mg daily
  • Aspirin-dipyridamole extended-release combination
  • For noncardioembolic TIA, combination of aspirin (50mg) and sustained-release dipyridamole (200mg twice daily) is a reasonable first choice 2

Anticoagulation

• For patients with persistent or paroxysmal atrial fibrillation who have had a cardioembolic TIA, long-term oral anticoagulation is recommended with target INR of 2.5 (range, 2.0-3.0) 2, 1
• If anticoagulation is contraindicated in atrial fibrillation, aspirin (325mg/day) or clopidogrel (75mg) is recommended 2

Blood Pressure Management

• Target blood pressure <140/90 mmHg
• Avoid excessive blood pressure lowering in the first few days post-TIA 1

Lipid Management

• High-intensity statin therapy regardless of baseline cholesterol
• Target LDL <100 mg/dL 1

Surgical Intervention

• For symptomatic carotid stenosis >70%, carotid endarterectomy (CEA) ideally within 2 weeks for stable patients 1
• Patients undergoing endarterectomy should receive aspirin therapy (50-325mg) beginning before surgery 2

TIA Clinic Model

TIA clinics have emerged as an effective model for managing TIAs on weekdays, providing:

• Rapid access to specialist assessment
• Comprehensive investigations
• Immediate initiation of secondary prevention
• Cost-effectiveness by avoiding unnecessary hospitalizations 3, 4

Common Pitfalls and Caveats

1. Delayed Evaluation: TIA should be treated as a medical emergency due to high risk of recurrent stroke (up to 10% within the first week) 1

2. Incomplete Vascular Assessment: Ensure appropriate vascular imaging based on symptom territory (anterior vs. posterior circulation)

3. Missing Cardioembolic Sources: Consider prolonged cardiac monitoring in patients with cryptogenic TIA

4. Medication Interactions: Be aware that herbal medicines such as feverfew, garlic, ginkgo biloba, ginger, and ginseng may alter bleeding time and should not be used concomitantly with warfarin 2

5. Inadequate Risk Factor Management: Aggressive management of modifiable risk factors (hypertension, diabetes, smoking, etc.) is essential for preventing recurrent events 1

6. Driving Restrictions: Advise patients about driving restrictions (typically 1-4 weeks for private drivers, longer for commercial drivers) 1

By following this structured approach to TIA workup on weekdays, clinicians can ensure timely evaluation, appropriate risk stratification, and effective secondary prevention to reduce the risk of subsequent stroke.