Next Steps for Inpatient TIA Management
Patients with TIA should be admitted to a specialized stroke unit as soon as possible, ideally within 6 hours of hospital arrival, for comprehensive evaluation and management to reduce the risk of recurrent stroke. 1
Immediate Inpatient Assessment
All TIA patients should undergo a relevant medical assessment including neurological, cardiological, and radiological evaluations to define the nature of the event and guide further management 1
Brain imaging (CT or MRI) and non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed as soon as possible within 24 hours of admission 1
An electrocardiogram (ECG) should be completed without delay to identify potential cardiac sources of embolism 1
Routine blood tests including complete blood count with platelets, chemistry panel, hemoglobin A1C, prothrombin time, partial thromboplastin time, and fasting lipid panel should be performed 1
In patients older than 50 years, erythrocyte sedimentation rate and C-reactive protein should be checked to screen for giant cell arteritis 1
Specialized Stroke Unit Care
Patients should be admitted to a geographically defined hospital unit dedicated to stroke management with an interprofessional team of healthcare professionals with stroke expertise 1
The core interprofessional team should include physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, clinical nutritionists, and hospital pharmacists 1
For facilities without a dedicated stroke unit, care should focus on priority elements of comprehensive stroke care including clustering patients, interprofessional team approach, early rehabilitation, stroke care protocols, case rounds, and patient education 1
Secondary Prevention Measures
Antiplatelet Therapy
For patients with non-cardioembolic TIA, antiplatelet therapy should be initiated immediately 2
Options include:
For patients with cardioembolic TIA (e.g., atrial fibrillation), long-term oral anticoagulation with a target INR of 2.5 (range 2.0-3.0) is recommended 2
Blood Pressure Management
Blood pressure treatment should be initiated before discharge with a target of <130/80 mm Hg 3
First-line agents include thiazide diuretics, ACE inhibitors, ARBs, or combination treatment consisting of a thiazide diuretic plus ACE inhibitor 3
ACE inhibitors combined with a thiazide diuretic are particularly favored as they can reduce stroke risk in TIA patients with or without a diagnosis of hypertension 3
Discharge Planning and Follow-up
Before hospital discharge, patients should be informed about symptoms of worsening myocardial ischemia and stroke, and instructed in how and when to seek emergency care 1
Patients should be provided with clear, easily understood instructions regarding medication type, purpose, dose, frequency, and side effects 1
Patients should be educated that if anginal discomfort or stroke symptoms last more than 2-3 minutes, they should discontinue physical activity and take appropriate action (e.g., calling emergency services) 1
Follow-up with a neurologist or stroke specialist should be arranged within 2 weeks of discharge 1
Common Pitfalls and Considerations
The combination of aspirin and clopidogrel increases bleeding risk and is not routinely recommended for long-term therapy, though it may be beneficial in the acute phase 2, 4
For patients with a TIA while taking aspirin, there is no evidence that increasing the aspirin dose provides additional benefit 2
Patients who experience a stroke while already hospitalized for other conditions often have more severe strokes, worse outcomes, and do not receive care in as timely a fashion, emphasizing the need for rapid recognition and management protocols 1
Some herbal medicines (feverfew, garlic, ginkgo biloba, ginger, and ginseng) may alter bleeding time and should not be used concomitantly with warfarin 1