What is the immediate management for a patient who has experienced a transient ischaemic attack (TIA)?

Immediate Management of Transient Ischemic Attack

All patients presenting within 48 hours of suspected TIA with motor weakness, speech disturbance, or other focal neurological symptoms must be immediately sent to an emergency department with advanced stroke care capabilities. 1, 2

Why TIA is a Medical Emergency

The stroke recurrence risk is 1.5% at 2 days and 2.1% at 7 days with specialized stroke care, but reaches 10-11% at 7 days without urgent treatment—with half of all strokes occurring within the first 48 hours. 3, 4 Proven management strategies can reduce relative stroke risk by 80%. 3

Immediate Risk Stratification and Triage

High-Risk Features Requiring Immediate ED Referral (Within 24 Hours)

• Unilateral motor weakness (face, arm, and/or leg) 5, 1
• Speech or language disturbance 5, 1
• Transient monocular vision loss (amaurosis fugax) 1, 2
• Presentation within 48 hours of symptom onset 5, 1
• ABCD2 score ≥4 (8% stroke risk at 2 days vs. 1% for score <4) 3, 6

Moderate-Risk Features (Evaluation Within 2 Weeks)

• Hemibody sensory loss without motor weakness 5
• Binocular diplopia 5
• Hemivisual loss 5
• Dysmetria or ataxia 5
• Presentation between 48 hours and 2 weeks 5

Mandatory Diagnostic Workup (Complete Within 24 Hours for High-Risk Patients)

Brain Imaging

• MRI with diffusion-weighted imaging (DWI) is preferred over CT, as it detects silent cerebral infarctions in up to 31% of TIA patients and identifies highest-risk individuals 1, 3
• CT brain is acceptable if MRI is unavailable and must be completed within 24 hours 5, 1

Vascular Imaging

• CT angiography from aortic arch to vertex should be performed immediately, ideally at the time of initial brain CT, to assess both extracranial and intracranial circulation 5, 1, 3
• Carotid duplex ultrasound is an acceptable alternative for extracranial vascular imaging when CTA is unavailable 5, 1
• MR angiography is another alternative based on immediate availability 5

Cardiac Evaluation

• 12-lead ECG immediately upon arrival to identify atrial fibrillation or other cardioembolic sources 5, 3
• Consider 24-48 hour cardiac monitoring if initial ECG is normal but cardioembolic mechanism suspected 5

Laboratory Investigations

• Complete blood count 5
• Electrolytes 5
• Coagulation studies (aPTT, INR) 5
• Renal function (creatinine, eGFR) 5
• Capillary glucose level 5
• Lipid panel 2

Immediate Treatment Initiation

Antiplatelet Therapy

Immediate initiation of antiplatelet therapy upon diagnosis for non-cardioembolic TIA 1, 6, 4

Dual Antiplatelet Therapy

Dual antiplatelet therapy should be rapidly initiated in appropriate patients 1

Anticoagulation

Oral anticoagulant therapy for patients with cardioembolic TIA (atrial fibrillation) 6

Statin Therapy

Statin therapy is recommended for most patients after atherothromboembolic TIA, with a goal LDL <100 mg/dL 1

Blood Pressure Management

Target blood pressure <140/90 mm Hg (or <130/80 mm Hg for diabetics) using ACE inhibitors alone or in combination with a diuretic, or with angiotensin receptor blockers 1

Mandatory Hospitalization Criteria

Hospitalization is strongly recommended for: 3, 2

• Acute cerebral infarction on imaging 3
• Large artery atherosclerosis 3
• Symptomatic carotid stenosis >50% 3, 2
• Cardioembolic source (atrial fibrillation) 3, 2
• Crescendo TIAs (multiple, increasingly frequent episodes) 3, 2
• Known hypercoagulable state 3, 2
• Symptom duration >1 hour at presentation 3, 2

Urgent Carotid Revascularization

Urgent carotid endarterectomy or stenting for symptomatic carotid stenosis >70% should be performed as soon as possible, ideally within 2 weeks of symptom onset. 1 The benefit of carotid endarterectomy is greatly diminished beyond 2 weeks because the highest recurrent ischemic event risk is in this early period. 3

Rapid-Access TIA Clinic Alternative

If a certified rapid-access TIA clinic is available, it can evaluate patients within 24-48 hours with immediate access to neuroimaging, vascular imaging, and stroke specialists—but only for lower-risk patients who do not meet high-risk criteria. 3, 2 Rapid assessment and immediate treatment reduces 90-day stroke risk from 10.3% to 2.1%. 2

Critical Pitfalls to Avoid

• Never discharge patients with crescendo TIAs under any circumstances—they mandate immediate hospitalization 3, 2
• Do not rely solely on ABCD2 scores for disposition decisions—they supplement but do not replace comprehensive evaluation 3
• Do not delay carotid imaging in anterior circulation TIAs, as urgent revascularization may be needed 3
• Do not attempt outpatient workup for patients with known high-risk features (symptomatic carotid stenosis >50%, atrial fibrillation, hypercoagulable state) 2
• Never discharge without confirming outpatient follow-up arrangements 3

Safe Discharge Criteria (After 24 Hours)

Patients can be safely discharged after 24 hours only if complete diagnostic workup shows: 3

• No embolic source requiring immediate treatment
• No acute infarction on brain imaging
• No significant carotid stenosis
• Patients must be fully educated about the need to return immediately if symptoms recur 2