What is the management plan for a patient who has experienced a transient ischemic attack (TIA)?

Management of Transient Ischemic Attack

Patients presenting within 48 hours of TIA with motor weakness, speech disturbance, or other focal neurological symptoms must be immediately sent to an emergency department with advanced stroke care capabilities. 1

Immediate Triage and Disposition

The critical decision point is timing and symptom type:

• If within 48 hours AND motor/speech symptoms present → Immediate ED referral with advance notification to stroke team 1
• The stroke recurrence risk is 1.5% at 2 days and 2.1% at 7 days, with historical rates as high as 10% in the first week 1
• Patients with symptomatic carotid disease face a 90-day ipsilateral stroke risk of 20.1% 2

Mandatory Hospitalization Criteria

Hospitalization is required for: 3

• First TIA within the last 24-48 hours
• Crescendo TIAs (multiple, increasingly frequent episodes) 1
• Symptom duration greater than 1 hour 3
• Symptomatic carotid stenosis >50% 1, 3
• Known cardiac embolic source (atrial fibrillation) 1, 3
• Known hypercoagulable state 1, 3

Required Investigations in the ED Setting

All investigations should be completed within 24 hours: 1

Neuroimaging

• Brain imaging (CT or MRI) within 24 hours to identify infarction despite transient symptoms 1, 2
• Modern imaging identifies brain infarction in many patients with symptoms lasting less than 24 hours 2

Vascular Imaging

• CTA or MRA from aortic arch to vertex within 24 hours 1
• Immediate identification of large vessel stenosis requiring urgent revascularization is crucial 1
• Doppler ultrasound of the neck is useful for studying carotid or vertebral artery disease and selecting patients for surgical or endovascular treatment 3

Cardiac Evaluation

• ECG without delay to identify cardioembolic sources requiring anticoagulation 1, 3

Laboratory Work

• CBC, electrolytes, creatinine, glucose, and lipid panel 1

Alternative to ED: Rapid-Access TIA Clinic

Only if a certified rapid-access TIA clinic is available that can evaluate patients within 24-48 hours with immediate access to neuroimaging, vascular imaging, and stroke specialists 1

• Rapid access to specialized stroke care through ED-based protocols or dedicated TIA clinics reduces 90-day stroke risk from 10.3% to 2.1% 1
• Patients not hospitalized must have access to urgent evaluation within 12 hours 3

Secondary Prevention and Treatment Initiation

Once diagnostic workup is complete:

Antiplatelet Therapy

• Rapid initiation of dual antiplatelet therapy 1
• Aspirin should be given to all patients except those requiring anticoagulation 4

Revascularization

• If significant carotid stenosis (>70%) is identified, carotid endarterectomy should be considered 3, 4
• The value of endarterectomy increases with higher degrees of stenosis and decreases rapidly with time elapsed from the TIA 4

Risk Factor Modification

• Aggressive blood pressure control 1, 3
• Diabetes management 1, 3
• Smoking cessation 3
• Lipid management 1, 3

Critical Pitfalls to Avoid

• Do not delay referral for crescendo TIAs – these mandate immediate hospitalization rather than any outpatient management 1
• Do not attempt outpatient workup for patients with known high-risk features (symptomatic carotid stenosis >50%, atrial fibrillation, hypercoagulable state) 1
• Do not miss the opportunity for early intervention – failure to quickly recognize and evaluate TIA could mean missing the chance to prevent permanent disability or death 5