What is the appropriate workup for a Transient Ischemic Attack (TIA)?

From the Guidelines

The workup for a transient ischemic attack (TIA) should include immediate brain imaging, preferably MRI with diffusion-weighted imaging, or CT if MRI is unavailable, as well as vascular imaging of the head and neck with CT angiography or MR angiography to identify potential stenosis or occlusions, as recommended by the most recent guidelines 1. The evaluation of patients with clinical carotid TIA or minor stroke requires rapid vascular imaging of the cervical carotid arteries in addition to brain parenchymal imaging. Some key points to consider in the workup and management of TIA include:

• Immediate brain imaging to rule out hemorrhage and identify areas of infarction
• Vascular imaging to identify potential sources of emboli or stenosis
• Cardiac evaluation, including ECG and cardiac monitoring, to detect atrial fibrillation or other cardiac sources of emboli
• Laboratory tests, including complete blood count, basic metabolic panel, coagulation studies, lipid profile, and HbA1c
• Echocardiography, preferably transesophageal, to identify cardiac sources of emboli
• Antiplatelet therapy, typically with aspirin 81-325mg daily, clopidogrel 75mg daily, or aspirin-dipyridamole extended-release, for secondary prevention
• High-dose statin therapy, regardless of baseline cholesterol levels, to reduce the risk of recurrent stroke
• Blood pressure management targeting <130/80 mmHg and lifestyle modifications, including smoking cessation, diet improvement, and regular exercise, to reduce the risk of recurrent stroke and other vascular events
• Consideration of carotid endarterectomy or stenting for patients with significant carotid stenosis (>70%) The risk of stroke after TIA is high, with the greatest risk occurring within the first 48 hours, making prompt diagnosis and treatment essential for preventing potentially devastating neurological damage 1. The American Heart Association and American Stroke Association recommend urgent evaluation and management of TIA, including immediate brain imaging, vascular imaging, and cardiac evaluation, as well as initiation of antiplatelet therapy and statin therapy, and consideration of carotid endarterectomy or stenting for patients with significant carotid stenosis 1. Overall, the management of TIA requires a comprehensive and multidisciplinary approach, including urgent evaluation, prompt initiation of therapy, and close follow-up to reduce the risk of recurrent stroke and other vascular events.

From the Research

TIA Workup

• TIA workup includes cerebral imaging, duplex sonography, transcranial Doppler screening for patent foramen ovale, electrocardiography, blood tests, ABCD(2) score, and ankle-brachial index within one day 2
• The ABCD(2) score is used to predict the risk of stroke after a TIA, with a score of 4 or higher indicating a high risk of stroke 2, 3
• TIA patients who fulfill predefined criteria for high early stroke risk, such as an ABCD(2) score of 4 or higher, symptomatic stenosis, newly detected atrial fibrillation, or recurrent TIA, should be referred to a stroke unit 2

Management of TIA

• Management of TIA patients in outpatient clinics has been shown to be safe and cost-effective, avoiding full hospitalization in most cases 2, 4
• The "TIA clinic" model of management is associated with the lowest long-term cardio-cerebrovascular recurrence rate ever reported 5
• Dual antiplatelet therapy with aspirin and clopidogrel or ticagrelor should be initiated within 24 hours of presentation for patients with high-risk TIA or minor stroke 6, 3
• Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation 3

Risk Stratification

• Risk stratification is crucial in the management of TIA patients, with those at high risk of stroke requiring immediate treatment and referral to a stroke unit 2, 5
• The ABCD(2) score is a useful tool for risk stratification, with a score of 4 or higher indicating a high risk of stroke 2, 3
• Other factors, such as symptomatic stenosis, newly detected atrial fibrillation, and recurrent TIA, should also be considered in the risk stratification of TIA patients 2