What is the appropriate workup and management for an older adult with a history of vascular disease, such as hypertension, diabetes, or hypercoagulable states, who has experienced a retinal Transient Ischemic Attack (TIA)?

Workup for Retinal TIA

Immediate Management

Patients with retinal TIA (transient monocular vision loss) must be immediately referred to the nearest emergency department affiliated with a certified stroke center, as this represents an "eye stroke" with stroke risk of 3.1% at 2 days and 5.2% at 7 days, peaking within the first week. 1 Call ahead to warn the stroke center that "a stroke patient is on the way" to facilitate rapid triage. 1

The risk of cerebral stroke is highest in the first 7 days after retinal TIA and remains elevated for 30 days. 1 Up to 24% of patients have concurrent silent brain infarction on diffusion-weighted MRI, and up to 70% have clinically significant carotid stenosis. 1, 2

Critical Initial Evaluation (Within 24 Hours)

Rule Out Giant Cell Arteritis First

• Immediately measure ESR and CRP in all patients over 50 years old to screen for giant cell arteritis, which requires emergency corticosteroid therapy to prevent bilateral blindness. 1, 3
• Ask specifically about temporal tenderness, jaw claudication, weight loss, proximal myalgia, or fever. 1
• If GCA is suspected, initiate high-dose corticosteroids immediately before any other workup. 2, 3

Neuroimaging Protocol

• Brain MRI with diffusion-weighted imaging (DWI) is the preferred imaging modality and should be obtained within 24 hours. 1 DWI detects acute cerebral infarctions in 15-30% of patients with isolated retinal TIA, even without neurologic symptoms. 1
• If MRI is unavailable, obtain head CT without contrast. 1, 2
• Silent brain infarctions on DWI predict higher risk of recurrent ischemic events. 1

Vascular Imaging

• Noninvasive imaging of cervicocephalic vessels must be performed as part of the initial evaluation. 1
• Obtain MRA (if getting brain MRI) or CTA (if getting head CT), or carotid ultrasound with transcranial Doppler depending on local availability. 1
• Internal carotid artery stenosis ≥50% requires immediate treatment and stroke unit admission. 1

Cardiac Evaluation

• ECG should be performed immediately upon arrival. 1
• Prolonged cardiac monitoring (inpatient telemetry or Holter monitor) is indicated when initial brain/vessel imaging and ECG do not identify a clear etiology. 1
• Echocardiography (at least transthoracic) is reasonable, especially when no cause is identified by other workup elements. 1
• Transesophageal echocardiography identifies left atrial thrombus, patent foramen ovale, aortic arch atherosclerosis, and valvular disease when these findings would alter management. 1

Admission Criteria

Hospitalize patients presenting within 72 hours if ANY of the following are present: 1

• Abnormal brain DWI-MRI showing acute cerebral infarction(s)
• Large artery atherosclerosis on vascular imaging (such as internal carotid artery stenosis)
• Abnormal cardiac evaluation
• Recurrent episodes (crescendo TIAs)
• Inability to provide expedited outpatient follow-up

Secondary Prevention Initiated Immediately

All patients should be discharged on: 1

• Antiplatelet agent (aspirin 50-325 mg daily, clopidogrel, or aspirin plus extended-release dipyridamole) 4
• Statin for hyperlipidemia 1
• Blood pressure control 1

Outpatient Follow-up

Arrange follow-up with a neurologist with stroke expertise within 2 weeks after discharge to review tests and optimize secondary stroke prevention. 1 Patients seen days after the episode still need urgent stroke workup and should be started on antiplatelet therapy without delay. 1

Common Pitfalls to Avoid

• Do not delay referral to perform additional testing yourself. Once retinal TIA is diagnosed, immediate ED referral is mandatory. 1
• Do not refer to primary care for outpatient evaluation. This delays appropriate care and increases stroke risk—treatment delay averages 48.5 days for retinal TIAs versus 15.2 days for hemispheric TIAs when not managed urgently. 1
• Do not underestimate the urgency. Only 35% of ophthalmologists send acute retinal artery occlusion patients to the ED immediately, compared to 73% of neurologists. 1
• The number needed to treat with carotid endarterectomy is only 5 when performed within 2 weeks, emphasizing the time-dependent benefit. 1