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Transient Ischemic Attack

Practice Essentials

In 2009, the American Heart Association and the American Stroke Association (AHA/ASA) published a scientific statement that revised the definition of transient ischemic attack (TIA) to the following:  “a transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction.”
 Prior to this revised definition, TIA was often operationally defined based on symptom duration lasting less than 24 hours, with typical episodes lasting less than 1 hour. The de-emphasis on duration was due to multiple studies demonstrating that up to 50% of classically defined TIAs showed brain injury on magnetic resonance imaging (MRI).  

On average, the annual risk of future ischemic stroke after a TIA or initial ischemic stroke is 3–4%,
with an incidence as high as 11% over the next 7 days and 24–29% over the following 5 years.

Signs and symptoms

A TIA may last only minutes, and symptoms often resolve before the patient presents to a clinician. Thus, historical questions should be addressed not just to the patient but also to family members, witnesses, and emergency medical services (EMS) personnel regarding changes in any of the following:






Initial vital signs should include the following:


Blood pressure

Heart rate and rhythm

Respiratory rate and pattern

Oxygen saturation

The examiner should assess the patient’s overall health and appearance, making an assessment of the following:


Ability to interact with the examiner

Language and memory skills

Overall hydration status


The goals of the physical examination are to uncover any neurologic deficits, to evaluate for underlying cardiovascular risk factors, and to seek any potential thrombotic or embolic source of the event. Ideally, any neurologic deficits should be recorded with the aid of a formal and reproducible stroke scale, such as the National Institutes of Health Stroke Scale (NIHSS).

A neurologic examination is the foundation of the TIA evaluation and should focus in particular on the neurovascular distribution suggested by the patient’s symptoms. Subsets of the neurologic examination include the following:

Cranial nerve testing

Determination of somatic motor strength

Somatic sensory testing

Speech and language testing

Assessment of the cerebellar system (be sure to watch the patient walk)

See Presentation for more detail.


It is important to rule out other causes, such as metabolic or drug-induced etiologies, which can present with symptoms similar to that of TIA. The following tests are considered on an emergency basis:

A fingerstick blood glucose for hypoglycemia

Complete blood count

Serum electrolyte levels

Coagulation studies

12-lead electrocardiogram (ECG) with rhythm strip

The following tests typically are helpful and often can be performed on an urgent basis:

Erythrocyte sedimentation rate

Cardiac enzymes

Lipid profile

Additional laboratory tests, ordered as needed and on the basis of the history, include the following:

Screening for hypercoagulable states (particularly in younger patients with no known vascular risk factors)

Syphilis serology

Antiphospholipid antibodies

Toxicology screens

Hemoglobin electrophoresis

Serum protein electrophoresis

Cerebrospinal fluid examination

Imaging of the brain should be performed within 24 hours of symptom onset, as follows

Magnetic resonance imaging (MRI) with diffusion-weighted imaging (preferred)

Noncontrast computed tomography (CT; ordered if MRI is not available)

The cerebral vasculature should be imaged urgently, preferably at the same time as the brain. Vascular imaging for TIA includes the following:

Carotid Doppler ultrasonography of the neck

CT angiography (CTA)

Magnetic resonance angiography (MRA)

See Workup for more detail.


The following should be done urgently in patients with TIA


Risk stratification (eg, with the California or ABCD score

Initiation of stroke prevention therapy

For patients with a recent (≤1 week) TIA, guidelines recommend a timely hospital referral with hospitalization for the following:

Crescendo TIAs

Duration of symptoms longer than 1 hour

Symptomatic internal carotid stenosis greater than 50%

Known cardiac source of embolus (eg, atrial fibrillation)

Known hypercoagulable state

Appropriate combination of the California score or ABCD score (category 4)

In view of the high short-term risk of stroke after TIA, antithrombotic therapy should be initiated as soon as intracranial hemorrhage has been ruled out. For noncardioembolic TIA, the following antiplatelet agents are all reasonable first-line options for initial therapy:

Aspirin (50-325 mg/day)

Aspirin plus extended-release dipyridamole


Stroke prevention medication typically recommended for cardioembolic TIA is as follows:

For patients with atrial fibrillation after TIA, long-term anticoagulation with warfarin (target international normalized ratio [INR], 2-3); aspirin 325 mg/day for those unable to take oral anticoagulants

In acute myocardial infarction (MI) with left ventricular thrombus, oral anticoagulation with warfarin (target INR, 2-3; concurrent aspirin up to 162 mg/day for ischemic coronary artery disease [CAD])

In dilated cardiomyopathy, oral anticoagulation with warfarin (target INR, 2-3) or antiplatelet therapy

In rheumatic mitral valve disease, oral anticoagulation with warfarin (target INR, 2-3)

For patients with TIA due to 50-99% stenosis of a major intracranial artery, the following is recommended:

Aspirin 50-325 mg/day rather than warfarin

Maintenance of blood pressure below 140/90 mm Hg and total cholesterol below 200 mg/dL

Angioplasty or stent placement is investigational and of unknown utility

See Treatment and Medication for more detail.

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