What is the management protocol for an adult patient with a Transient Ischemic Attack (TIA) and resolved deficits, with a normal Magnetic Resonance Imaging (MRI) scan, and potential history of vascular risk factors such as Hypertension (HTN), Diabetes Mellitus (DM), or Hyperlipidemia (HLP)?

Management Protocol for TIA with Resolved Deficits and Normal MRI

For a patient with TIA and resolved deficits but normal MRI, you must still initiate comprehensive secondary prevention immediately—the absence of visible infarction does not eliminate stroke risk, and aggressive risk factor modification reduces 90-day stroke recurrence from 10% to approximately 2%. 1, 2

Immediate Diagnostic Completion (Within 24-48 Hours)

Even with a normal brain MRI, complete the following workup urgently:

• Vascular imaging (CTA from aortic arch to vertex or carotid duplex ultrasound) to identify stenosis requiring urgent revascularization 3, 1
• Cardiac evaluation including ECG to screen for atrial fibrillation and echocardiography if cardioembolic source suspected 1, 2
• Laboratory work including lipid panel, hemoglobin A1c, and fasting glucose 2

The normal MRI does not rule out TIA—DWI detects lesions in only 40% of TIA patients, meaning 60% have truly normal imaging despite genuine ischemic events 3. A negative MRI with high clinical suspicion still warrants full secondary prevention. 4

Antiplatelet Therapy (Start Immediately)

Initiate dual antiplatelet therapy (aspirin plus clopidogrel) within 24 hours of symptom onset for patients without cardioembolic source or severe carotid stenosis. 1, 2, 5

• Continue dual therapy for 21 days, then transition to single antiplatelet agent 5
• This reduces stroke risk from 7.8% to 5.2% (hazard ratio 0.66) 5
• If cardioembolic source (atrial fibrillation) identified, switch to anticoagulation instead 5

Blood Pressure Management (Start Within 7-14 Days)

Begin antihypertensive therapy within 7-14 days even with normal MRI, targeting <140/90 mmHg (<130/80 mmHg if diabetic). 3, 4

• Use ACE inhibitor alone or combined with thiazide diuretic, or angiotensin receptor blocker 3, 4
• Critical exception: Do not aggressively lower blood pressure if vascular imaging reveals high-grade carotid stenosis >70% 4
• The 7-14 day delay allows cerebral autoregulation to stabilize while avoiding permissive hypertension that could propagate ischemia 3

Lipid Management (Start Immediately)

Initiate high-intensity statin therapy immediately regardless of baseline LDL level. 3, 1

• Target LDL <100 mg/dL (some guidelines suggest <70 mg/dL for very high-risk patients) 3
• Statin therapy is recommended for most patients after atherothromboembolic TIA independent of cholesterol levels 3

Glucose Control (If Diabetic)

Target fasting glucose <126 mg/dL (7 mmol/L) using diet, exercise at least three times weekly, and pharmacotherapy as needed. 3, 1

Urgent Carotid Revascularization (If Indicated)

If vascular imaging reveals symptomatic carotid stenosis >70%:

• Perform carotid endarterectomy or stenting within 2 weeks of symptom onset (ideally as soon as medically feasible) 1, 5
• This is the highest-yield intervention for preventing recurrent stroke in this subset 1
• Continue single antiplatelet therapy perioperatively 5

Cardiovascular Risk Assessment

Evaluate for coexistent cardiac disease that may shorten life expectancy or cause morbidity. 3, 1

• Screen for coronary artery disease, cardiac arrhythmias (especially atrial fibrillation), congestive heart failure, and valvular disease 3, 1
• These conditions are common in TIA patients and require appropriate treatment 3

Critical Pitfalls to Avoid

• Do not dismiss the diagnosis because MRI is normal—approximately 60% of true TIAs have negative DWI 3
• Do not delay antiplatelet therapy waiting for complete workup—start immediately upon clinical diagnosis 1, 2
• Do not start blood pressure medications in the first 24-48 hours unless severely elevated—wait 7-14 days to avoid hypoperfusion 3, 4
• Do not aggressively lower blood pressure if high-grade carotid stenosis is present, as cerebral perfusion may depend on elevated systemic pressure 4
• Do not use dual antiplatelet therapy if cardioembolic source identified—use anticoagulation instead 5

Smoking Cessation and Lifestyle Modification

All smokers must stop immediately—smoking cessation has major and immediate health benefits for stroke prevention. 1

• Recommend AHA Step II diet (30% calories from fat, <7% saturated fat, <200 mg/day cholesterol) 3
• Maintain ideal body weight and engage in regular physical activity 3

Patient Education

Educate patients to return immediately if symptoms recur—stroke risk is highest in the first 48 hours (1.5% at 2 days, 5% within one week). 2, 5