What is the management approach for a middle-aged to elderly individual presenting with transient global amnesia (TGA)?

Management of Transient Global Amnesia

Transient global amnesia requires supportive care and reassurance only—no specific medical treatment, antiplatelet therapy, anticoagulation, or cardiovascular risk modification is indicated, as TGA does not increase stroke risk or mortality. 1

Initial Diagnostic Confirmation

The diagnosis is purely clinical and must meet all of the following witnessed criteria:

• Abrupt onset of severe anterograde amnesia with repetitive questioning, typically lasting 1-8 hours but always resolving within 24 hours 2, 3
• No focal neurological deficits—motor, sensory, speech, visual field, coordination, and cranial nerve functions must remain intact 1, 3
• Preserved alertness and cognition except for memory—patients can perform previously learned tasks like driving or cooking 4
• No recent head trauma within the preceding weeks 1
• Age typically 40-80 years, most commonly over 50 3, 4

Critical Differential Diagnoses to Exclude First

The most critical error is misdiagnosing TIA or stroke as TGA, as these conditions require urgent intervention and carry significantly worse prognosis. 1

Red flags that indicate stroke/TIA rather than TGA:

• Motor weakness or hemibody sensory loss 1
• Speech disturbance (aphasia, dysarthria) 1
• Visual field defects 1
• Ataxia or diplopia 1
• Any focal neurological deficit 1

Other differential diagnoses to consider:

• Epileptic seizures—may present with acute confusion and memory impairment 5
• Head trauma—must be explicitly ruled out by history 1

Neuroimaging Strategy

Routine MRI is not recommended in typical TGA without focal neurological signs. 2, 1, 5

Consider MRI only if:

• Focal neurological symptoms are present 1, 5
• Episodes are recurrent or unusually brief (atypical duration) 2, 1
• Significant cerebrovascular risk factors exist 2, 5
• Alternative diagnoses are suspected 1, 5

If MRI is performed:

• Characteristic punctate lesions in the hippocampus on diffusion-weighted imaging (DWI) may support the diagnosis, appearing in 50-90% of cases when scanned 24-72 hours after symptom onset 6, 4
• These lesions are distributed 2/3 unilaterally and 1/3 bilaterally 4
• Early MRI (within 4 hours) may be negative, with lesions appearing on repeat imaging at 24 hours 6

Treatment Approach

No specific medical treatment is required for TGA. 1, 3

What NOT to do:

• Avoid antiplatelet therapy—TGA does not increase cardiovascular event risk 1, 5
• Avoid anticoagulation—bleeding risks without any proven benefit 1, 5
• Do not initiate statin therapy based solely on a TGA episode 1
• Do not treat as TIA—aggressive cardiovascular risk factor modification is not warranted 5

Appropriate management:

• Provide reassurance to the patient and anxious relatives about the benign and self-limited nature of the episode 3, 4
• Supportive care only during the episode 1, 3
• Observation until symptoms resolve (typically within 24 hours) 3, 7

Disposition and Follow-Up

• No stroke prevention clinic referral is needed, unlike TIA patients who require urgent evaluation within 24-48 hours 1
• No specific follow-up is required for typical TGA 3, 7
• Recurrence rate is 2.9-23.8% over a lifetime, with at least 10% experiencing 1-5 recurrences 4, 8
• No increased risk of stroke or mortality in patients who have had TGA 1, 5, 8

Common Pitfalls to Avoid

The key distinguishing feature is that TIA produces focal deficits, while TGA produces isolated memory impairment with preserved motor, sensory, language, and visuospatial function. 1

• Do not confuse the repetitive questioning and disorientation of TGA with "confusion"—cognition is preserved except for memory 3
• Do not miss a TIA by incorrectly diagnosing it as TGA—any focal deficit mandates stroke workup 1
• Do not cause patient anxiety about stroke risk—TGA is benign and does not predispose to cerebrovascular events 5, 8