Workup for Transient Ischemic Attack (TIA)
Patients with suspected TIA should be treated as a medical emergency requiring immediate evaluation and management, as the risk of stroke is highest in the first week after TIA (up to 13% in the first 90 days).1
Initial Risk Stratification
Immediately assess stroke risk using the ABCD2 score which evaluates: Age (≥60 years = 1 point), Blood pressure (>140/90 mmHg = 1 point), Clinical features (unilateral weakness = 2 points, speech disturbance without weakness = 1 point), Duration of symptoms (≥60 min = 2 points, 10-59 min = 1 point), and Diabetes (present = 1 point) 2, 3
Highest risk patients (those with transient, fluctuating, or persistent unilateral weakness or speech disturbance within 48 hours of symptom onset) should be immediately sent to an emergency department with advanced stroke care capabilities 1
Patients with ABCD2 score ≥4 are considered high-risk and should be hospitalized or evaluated within 24-48 hours in a specialized TIA unit 2, 3
Immediate Diagnostic Workup
Urgent brain imaging (CT or MRI) should be completed without delay to differentiate between ischemic and hemorrhagic events and exclude stroke mimics 1, 4
Non-invasive vascular imaging should be performed urgently:
Electrocardiogram (ECG) should be completed immediately to identify potential cardiac sources of embolism 1, 6
Essential laboratory studies include:
Management Based on Etiology
For non-cardioembolic TIA:
For cardioembolic TIA (e.g., atrial fibrillation):
Blood pressure management:
Hospitalization vs. Outpatient Management
Admission to a specialized stroke unit is recommended for high-risk patients (ABCD2 ≥4) 2, 6, 8
Low-risk patients (ABCD2 ≤4) without other concerning features may be managed as outpatients with evaluation within 7-10 days 2, 9
For facilities without dedicated stroke units, focus on priority elements of comprehensive stroke care including interprofessional team approach and stroke care protocols 6
Follow-up and Secondary Prevention
Arrange follow-up with a neurologist or stroke specialist within 2 weeks of discharge 6, 9
Provide clear instructions regarding medication type, purpose, dose, frequency, and side effects 6
Educate patients about symptoms of worsening cerebral ischemia and when to seek emergency care 4, 6
Implement vascular risk factor reduction strategies including smoking cessation, diet modification, and exercise 9, 7
Common Pitfalls and Considerations
TIAs are often ignored by patients or underestimated by physicians because symptoms resolve spontaneously, delaying critical intervention 3, 9
Amaurosis fugax (transient monocular blindness) should be recognized as a form of TIA, commonly associated with ipsilateral carotid artery disease 1, 7
Some herbal medicines (feverfew, garlic, ginkgo biloba, ginger, and ginseng) may alter bleeding time and should not be used with anticoagulants 6
Patients who experience TIA while already hospitalized for other conditions often receive delayed care, emphasizing the need for rapid recognition protocols 6
The benefit of carotid endarterectomy for symptomatic stenosis diminishes significantly beyond 2 weeks after symptom onset 1