What is the acute management of a patient with Transient Ischaemic Attack (TIA) or ischaemic stroke?

Acute Management of TIA and Ischaemic Stroke

All patients with suspected TIA or acute ischaemic stroke require immediate emergency department evaluation with advance stroke team notification, urgent brain imaging within 24 hours, and rapid initiation of appropriate reperfusion or antiplatelet therapy based on presentation timing and stroke severity. 1, 2

Prehospital and Emergency Department Triage

Immediate ED referral is mandatory for:

• Any patient presenting within 48 hours of symptom onset with motor weakness, speech disturbance, or other focal neurological deficits 1, 2
• Patients with "crescendo TIAs" (multiple, increasingly frequent episodes) require immediate hospitalization rather than any outpatient management 1
• Rapid transportation with high triage priority and early hospital notification is essential, particularly given the short window (<3-4.5 hours) for thrombolytic therapy 3

The stroke recurrence risk is highest early: 5% at 2 days and up to 10% in the first week, with approximately half occurring within the first 48 hours 1, 4, 5. Rapid assessment and immediate treatment reduces 90-day stroke risk by 80%, from historical rates of 10-20% down to 2-3% 1.

Risk Stratification Using ABCD2 Score

Use the ABCD2 tool at initial contact to guide management intensity: 3

• High-risk patients (ABCD2 ≥4): 8% stroke risk at 2 days—require immediate admission to stroke unit or specialist TIA clinic assessment within 24-48 hours 3, 4
• Low-risk patients (ABCD2 <4): 1% stroke risk at 2 days—may be managed in community with assessment within 7-10 days 3

Critical caveat: Do not use ABCD2 scores alone to exclude high-risk patients, as those with scores ≤3 may still include individuals at significant stroke risk who require early assessment 6. The presence of motor weakness or speech disturbance within 48 hours mandates immediate ED referral regardless of ABCD2 score 1, 2.

Urgent Diagnostic Workup (Within 24 Hours)

Brain Imaging

• All patients require urgent CT or MRI brain imaging within 24 hours to differentiate ischaemic stroke from haemorrhage and exclude stroke mimics 3, 1
• MRI with diffusion-weighted imaging (DWI) is superior to CT, showing 77% sensitivity within 3 hours versus only 16% for CT, and detects silent cerebral infarctions in up to 31% of TIA patients 2
• Repeat imaging urgently if the patient's condition deteriorates 3

Vascular Imaging

• Urgent carotid duplex ultrasound within 24 hours for all patients with carotid territory symptoms who are potential candidates for revascularization 3, 1
• Non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) should be performed to identify large vessel occlusions requiring mechanical thrombectomy and carotid stenosis requiring urgent revascularization 2

Cardiac Evaluation

• ECG without delay in all patients 3, 1
• Initiate cardiac rhythm monitoring to detect atrial fibrillation 2
• Echocardiography (transthoracic and transesophageal) if cardioembolic source suspected 2

Laboratory Investigations

Routine investigations for all patients: 3, 4

• Full blood count
• Electrolytes and renal function
• Glucose level
• Cholesterol/lipid panel
• Coagulation studies if anticoagulation considered

Acute Treatment for Ischaemic Stroke

Thrombolytic Therapy

For patients with disabling deficits presenting within 4.5 hours: 3, 5

• Intravenous alteplase (rt-PA) within 3 hours improves likelihood of minimal/no disability: 39% with IV rtPA vs 26% with placebo (OR 1.6) 5
• IV rtPA within 3-4.5 hours improves outcomes: 35.3% with IV rtPA vs 30.1% with placebo (OR 1.3) 5
• Should only be delivered in well-equipped emergency departments with adequate expertise for monitoring and rapid assessment 3
• Currently underutilized: only 3% of all ischaemic stroke patients (7% of those presenting within 3 hours) receive rt-PA 3

Mechanical Thrombectomy

For patients with anterior circulation large-vessel occlusions: 5

• Within 6 hours: 46.0% functionally independent vs 26.5% with medical therapy alone (OR 2.49) 5
• Within 6-24 hours: If large ratio of ischemic to infarcted tissue on imaging: 53% vs 18% achieve good outcome (OR 4.92) 5

Antiplatelet Therapy

For acute ischaemic stroke (non-thrombolysis candidates):

• Aspirin 160-300 mg/day should be commenced within 48 hours of onset of acute ischaemic stroke 3

For high-risk TIA or minor non-disabling stroke:

• Dual antiplatelet therapy (aspirin plus clopidogrel) initiated within 24 hours and continued for 3 weeks reduces stroke risk from 7.8% to 5.2% (HR 0.66), followed by single antiplatelet therapy 5, 6
• This applies to patients with ABCD2 ≥4 who do not have severe carotid stenosis or atrial fibrillation 5, 6

Critical pitfall: Do not use anticoagulation acutely for ischaemic stroke, as it increases bleeding risk more than aspirin without proven benefit 2. Anticoagulation is reserved for specific indications like atrial fibrillation after the acute phase.

Hospital Admission Criteria

Mandatory admission for: 3, 1

• All patients with acute ischaemic stroke should be admitted to a stroke unit or neurocritical care unit, as approximately 25% may have neurological worsening during the first 24-48 hours 3
• High-risk TIA patients (ABCD2 ≥4) presenting within 24-48 hours 3
• Crescendo TIAs (multiple, increasingly frequent episodes) 1
• Duration of symptoms >1 hour 1
• Symptomatic carotid stenosis >50% 1, 2
• Known cardiac embolic source (atrial fibrillation) 1
• Known hypercoagulable state 1

Urgent Carotid Revascularization

For symptomatic carotid stenosis >70%: 4, 2

• Carotid endarterectomy (CEA) or stenting should be performed urgently, as absolute benefit is highest within the first 2 weeks after the event 2
• The usefulness of emergent CEA when imaging suggests small infarct core with large penumbra is not well established (Class IIb) 3

For symptomatic carotid stenosis 50-69%:

• Urgent carotid duplex ultrasound required, with consideration for revascularization based on additional risk factors 3

Rapid-Access TIA Clinic Alternative

If immediate ED referral is not feasible for lower-risk patients: 1

• A certified rapid-access TIA clinic can evaluate patients within 24-48 hours with immediate access to neuroimaging, vascular imaging, and stroke specialists 1
• This is only appropriate for patients who do not meet high-risk criteria (ABCD2 <4, no motor/speech symptoms within 48 hours, no crescendo pattern) 1

Blood Pressure Management

For ischaemic stroke:

• Blood pressure lowering is generally not recommended in acute ischaemic stroke unless extremely elevated or patient is receiving thrombolysis 3

For intracerebral haemorrhage:

• In patients with history of hypertension, keep mean arterial pressure below 130 mmHg 3

Key Pitfalls to Avoid

• Never delay referral for crescendo TIAs—these mandate immediate hospitalization 1
• Do not attempt outpatient workup for patients with known high-risk features: symptomatic carotid stenosis >50%, atrial fibrillation, or hypercoagulable state 1
• Do not rely solely on symptom resolution to determine urgency—TIA patients require the same urgent evaluation as stroke patients 1, 7
• Do not use ABCD2 scores alone to exclude patients from urgent evaluation, as significant numbers with low scores remain at risk 6
• Avoid diagnostic delays—20-30% of cases are incorrectly labeled as stroke or TIA in emergency departments, necessitating close collaboration with stroke specialists 3