| Clinical features |
- Typical TIAs are characterized by transient, focal neurologic symptoms that can be localized to a single vascular territory within the brain, including one or more of the following:
- Transient monocular blindness (amaurosis fugax)
- Aphasia or dysarthria
- Hemianopia
- Hemiparesis and/or hemisensory loss (complete or partial)
- Atypical TIAs may present with transient isolated neurologic symptoms:
- Isolated vertigo
- Isolated ataxia
- Isolated diplopia
- Isolated speech disturbance (slurred speech) without aphasia
- Isolated bilateral decreased vision
- Isolated unilateral sensory loss involving only one body part
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| Differential diagnosis |
- Seizure
- Migraine aura
- Syncope
- Transient global amnesia
- Central nervous system demyelinating disorder (eg, multiple sclerosis)
- Peripheral vestibulopathy
- Metabolic disorder (eg, hypoglycemia)
- Myasthenia gravis
- Cranial/peripheral neuropathy
- Cerebral amyloid angiopathy
- Subdural hematoma
- Subarachnoid or intracerebral hemorrhage
- Transient neurologic attack not otherwise specified
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| Immediate treatment while evaluating the ischemic mechanism |
- For patients with TIA or minor, nondisabling acute ischemic stroke (and thus not eligible for thrombolytic therapy or mechanical thrombectomy), start antiplatelet therapy immediately while the evaluation is in progress:
- Start DAPT (aspirin plus clopidogrel, or aspirin plus ticagrelor) for patients with one of the following:
- High-risk TIA, defined by an ABCD2 score ≥4
- Time-based TIA with a relevant large artery stenosis or DWI lesion on MRI (if imaging available at this stage)
- Minor, nondisabling ischemic stroke, defined by an NIHSS score ≤5
- Start aspirin monotherapy for patients who do not meet the above criteria (ie, TIA with an ABCD2 score <4 and no relevant large artery stenosis or DWI lesion on MRI [if imaging available at this stage])
- Once the ischemic mechanism is determined, antithrombotic therapy can be modified as necessary
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| Urgent evaluation |
- Brain imaging with diffusion-weighted MRI (preferred) or CT to identify infarction and rule out nonischemic causes
- Vascular imaging of extracranial and intracranial large arteries with MRA or CTA to identify large artery cause
- Cardiac evaluation (ECG, cardiac monitoring, echocardiography) to identify atrial fibrillation or other cardioembolic source
- Laboratories: CBC, PT and PTT, serum electrolytes, creatinine, fasting blood glucose or HbA1c, lipids, and (as indicated for selected patients) ESR and CRP
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| Targeted treatment by mechanism for secondary prevention |
- Cardiogenic embolism due to atrial fibrillation: Stop antiplatelet agents and start long-term anticoagulation
- Symptomatic internal carotid artery stenosis: Carotid revascularization with CEA or CAS and long-term antiplatelet therapy
- Intracranial large artery atherosclerosis with 70 to 99% stenosis: Continue DAPT for 21 to 90 days, then switch to long-term single-agent antiplatelet therapy
- Small vessel disease, extracranial vertebral artery stenosis, intracranial large artery atherosclerosis with 50 to 69% stenosis, or cryptogenic:
- Continue DAPT for 21 days, then switch to long-term single-agent antiplatelet therapy for:
- High-risk TIA (ABCD2 score ≥4), or TIA with a relevant DWI lesion on MRI, or extracranial stenosis not amenable to revascularization
- Minor ischemic stroke (NIHSS ≤5)
- Continue long-term single-agent antiplatelet therapy for low-risk TIA (ABCD2 score <4), and TIA without a relevant large artery stenosis or DWI lesion on MRI
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| Intensive risk factor management |
- Antihypertensive therapy for patients with known or newly established hypertension
- LDL-cholesterol lowering with high-intensity statin therapy
- Glucose control to near normoglycemic levels for patients with diabetes
- Lifestyle modification as appropriate:
- Moderate to vigorous exercise most days of the week for those capable
- Smoking cessation for recent or current tobacco users
- Mediterranean diet
- Weight reduction for patients with obesity
- Reduced alcohol consumption for heavy drinkers
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