What are the symptoms and management of a Transient Ischemic Attack (TIA)?

Transient Ischemic Attack (TIA): Symptoms and Management

Clinical Presentation

TIA presents with sudden-onset focal neurological deficits that resolve completely, typically within minutes to hours, but the diagnosis requires urgent evaluation regardless of symptom resolution. 1

Key Symptoms to Recognize

• Unilateral weakness affecting face, arm, and/or leg (highest risk feature) 1, 2
• Speech or language disturbance including difficulty speaking or understanding 1, 2
• Transient monocular vision loss (amaurosis fugax) from retinal ischemia 1, 3
• Hemibody sensory symptoms without motor weakness 1
• Posterior circulation symptoms including binocular diplopia, dysarthria, dysphagia, ataxia, or hemifield vision loss 1, 4

Critical pitfall: Patients and families often dismiss TIA because symptoms resolve spontaneously, but this is precisely when intervention prevents devastating stroke. 5, 6

Risk Stratification Using ABCD2 Score

All patients require immediate risk assessment using the ABCD2 tool at first healthcare contact. 1, 3

ABCD2 Components:

• Age ≥60 years (1 point) 5
• Blood pressure ≥140/90 mmHg (1 point) 5
• Clinical features: unilateral weakness (2 points) or speech disturbance without weakness (1 point) 5
• Duration: ≥60 minutes (2 points) or 10-59 minutes (1 point) 5
• Diabetes (1 point) 5

High-risk patients (ABCD2 ≥4) have an 8% stroke risk at 2 days versus 1% for low-risk patients (ABCD2 <4). 1

Time-Critical Management by Risk Category

VERY HIGH RISK (Within 48 Hours + Motor/Speech Symptoms)

These patients require immediate ED referral with advance stroke team notification—this is a medical emergency, not an outpatient problem. 1, 2

Stroke risk reaches 5% at 2 days and up to 10% in the first week, with half occurring within 48 hours. 1, 4, 7

Immediate Actions (Within 24 Hours):

• Brain imaging (CT or MRI) completed urgently 1, 2
• Vascular imaging (CTA or MRA from aortic arch to vertex) to identify carotid stenosis or intracranial disease 1, 2
• 12-lead ECG without delay to detect atrial fibrillation 1, 2
• Laboratory tests: CBC, electrolytes, renal function, glucose, lipid panel 1, 3, 2
• Carotid duplex ultrasound urgently for anterior circulation symptoms in revascularization candidates 1, 3

Admission to stroke unit or specialized TIA clinic if assessment can occur within 24-48 hours 1, 3

HIGH RISK (48 Hours to 2 Weeks + Motor/Speech Symptoms)

Comprehensive evaluation by stroke specialist within 24 hours of healthcare contact, ideally. 1

• Same imaging and laboratory workup as very high-risk patients 1
• Can be managed through rapid-access TIA clinic if available within 24-48 hours 2

MODERATE RISK (48 Hours to 2 Weeks + Non-Motor/Speech Symptoms)

Evaluation by stroke specialist within 2 weeks for isolated sensory symptoms, monocular vision loss, or posterior circulation symptoms. 1

LOWER RISK (>2 Weeks from Symptom Onset)

Neurologist evaluation within 1 month, though still requires complete workup. 1

Evidence-Based Treatment Initiation

Antiplatelet Therapy (Non-Cardioembolic TIA)

Start antiplatelet therapy immediately upon diagnosis—this is the single most important intervention for stroke prevention. 3, 5

• Aspirin plus dipyridamole (extended-release) is a reasonable first-line option 3
• Alternative: clopidogrel monotherapy or dual antiplatelet therapy (aspirin + clopidogrel) for high-risk patients 5

Anticoagulation (Cardioembolic TIA)

For atrial fibrillation or other cardioembolic sources, initiate oral anticoagulation with target INR 2.5 (range 2.0-3.0) or direct oral anticoagulant. 3

Carotid Revascularization

For symptomatic carotid stenosis >70%, carotid endarterectomy significantly reduces stroke risk and should be performed urgently. 3, 2

• Even 50-69% stenosis may warrant revascularization in appropriate candidates 5
• Timing is critical: benefit greatest when performed within 2 weeks of symptoms 2

Additional Interventions

• Statin therapy initiated immediately 5
• Antihypertensive therapy for blood pressure control 5
• Diabetes management optimization 4

Critical Evidence on Outcomes

Rapid assessment and immediate treatment reduces 90-day stroke risk by 80%, from historical rates of 10-20% down to 2-3%. 1, 2, 8

With specialized stroke center care, stroke recurrence rates have dropped to 1.5% at 2 days and 2.1% at 7 days. 1, 4

Without urgent treatment, population-based studies show stroke risk of 11% at 7 days. 1

Advanced Imaging Considerations

MRI with diffusion-weighted imaging (DWI) detects silent cerebral infarctions in up to 31% of TIA patients, identifying highest-risk individuals. 1

• Positive DWI findings indicate higher stroke recurrence risk 1
• Multiple small infarctions suggest embolic source requiring aggressive workup 1
• Even retinal TIAs (amaurosis fugax) show cerebral infarctions in 11.8-30.8% of cases 1

Common Pitfalls to Avoid

Never delay referral for "crescendo TIAs" (multiple, increasingly frequent episodes)—these mandate immediate hospitalization. 2

Do not attempt outpatient workup for patients with known high-risk features: symptomatic carotid stenosis >50%, atrial fibrillation, or hypercoagulable states. 2

Do not dismiss isolated sensory symptoms or posterior circulation symptoms as "low risk"—they still require urgent evaluation. 1, 4

Recognize that up to 80% of post-TIA strokes are preventable with proper urgent management. 8