What is the next step in management for a patient discharged from the ER with suspected transient ischemic attack (TIA) or stroke?

Management of Patients Discharged from ER with Suspected TIA

Patients discharged from the ER with suspected TIA require urgent outpatient evaluation within 24-48 hours, including comprehensive stroke workup with brain imaging, vascular imaging from aortic arch to vertex, ECG, and assessment by a healthcare professional with stroke expertise. 1

Risk Stratification Determines Urgency of Follow-up

The timing and intensity of outpatient management depends critically on when symptoms occurred and their characteristics:

Very High Risk (Symptoms within 48 hours)

• Patients with motor weakness, speech disturbance, or posterior circulation symptoms within the last 48 hours should have been admitted, not discharged. 1 If they were discharged, this represents a potential error in triage—they need immediate re-evaluation with brain imaging (CT or MRI) and vascular imaging (CTA or MRA from aortic arch to vertex) completed within 24 hours. 1

High Risk (Symptoms 48 hours to 2 weeks ago)

• Patients with motor weakness or speech disturbance presenting 48 hours to 2 weeks from onset require comprehensive evaluation within 24 hours of first healthcare contact. 1 This includes brain imaging, vascular imaging, ECG, and assessment by stroke expertise. 1

Moderate Risk (Symptoms 48 hours to 2 weeks ago, non-motor)

• Patients with sensory symptoms, monocular vision loss, diplopia, dysarthria, dysphagia, or ataxia without motor weakness need evaluation within 2 weeks. 1 The workup is identical but less urgent. 1

Lower Risk (Symptoms >2 weeks ago)

• Patients presenting more than 2 weeks after symptoms should see a neurologist or stroke specialist within one month. 1

Essential Outpatient Workup Components

Imaging Studies

• Brain imaging (CT or MRI) must be completed, with MRI including diffusion-weighted sequences preferred over CT. 2 This identifies acute infarction that would reclassify TIA as stroke. 2
• Vascular imaging from aortic arch to vertex (CTA or MRA) is mandatory to identify carotid stenosis requiring revascularization. 1 CTA performed with initial brain CT is ideal for assessing both extracranial and intracranial circulation. 1
• Carotid ultrasound is an acceptable alternative if CTA/MRA unavailable. 1

Cardiac Evaluation

• 12-lead ECG should be obtained to identify atrial fibrillation or other arrhythmias. 1
• Echocardiography (at least transthoracic) is reasonable when no cause identified by other workup elements. 1
• Prolonged cardiac monitoring is reasonable when vascular etiology remains unidentified. 2

Laboratory Testing

• Initial bloodwork includes complete blood count, electrolytes, coagulation studies (aPTT, INR), renal function, random glucose, and troponin. 1
• Lipid profile (fasting or non-fasting) and diabetes screening with HbA1c or oral glucose tolerance test should follow. 1

Critical Management Decisions

Antiplatelet Therapy

• For non-cardioembolic TIA, initiate antiplatelet therapy immediately—options include aspirin 50-325 mg/day, clopidogrel 75 mg daily, or aspirin plus sustained-release dipyridamole. 3
• For high-risk TIA or minor stroke (ABCD2 ≥4) without severe carotid stenosis or atrial fibrillation, dual antiplatelet therapy with aspirin and clopidogrel for 3 weeks reduces stroke risk from 7.8% to 5.2%. 4

Anticoagulation

• For cardioembolic TIA (atrial fibrillation identified), long-term oral anticoagulation with target INR 2.5 (range 2.0-3.0) is recommended. 3

Blood Pressure Management

• Target blood pressure <130/80 mm Hg with thiazide diuretics, ACE inhibitors, ARBs, or combination therapy. 3

Common Pitfalls to Avoid

• Do not discharge patients presenting within 48 hours with motor weakness or speech disturbance—these are very high risk and require admission. 1 If already discharged, arrange immediate re-evaluation.
• Do not delay vascular imaging—identifying ≥50% carotid stenosis changes management to urgent revascularization. 1
• Avoid herbal medicines (feverfew, garlic, ginkgo biloba, ginger, ginseng) that alter bleeding time, especially with warfarin. 3
• Ensure rapid-access TIA clinic availability within 24-48 hours for patients who cannot complete urgent workup in ED. 1

Follow-up Coordination

• Arrange follow-up with neurologist or stroke specialist within 2 weeks to review completed workup and optimize secondary prevention. 1, 3
• Provide clear written instructions regarding medication type, purpose, dose, frequency, and side effects. 3
• Educate patients on stroke warning signs and when to seek emergency care immediately. 3