• Transient Ischemic Attack (TIA) is a medical emergency
  • despite its seemingly mild course, TIA is a serious predictor of subsequent ischemic stroke and death
    • following TIA, the risk of recurrent stroke is 8% in the first week, 11.5% at 1 month, and 17.3% at 3 months    [Coull, 2004]
  • true incidence and prevalence of TIA are challenging to determine because of inconsistent criteria
    • the reported crude annual incidence rate of TIA was 35.2 per 100 000 (95% CI, 30.6–40.3); TIAs are rare in young adults (<45 years) and relatively rare in subjects aged 45–64 years; then the incidence steeply increases, peaking in subjects aged 85 years  [Degan, 2017]
  • evaluation of TIA and initiation of multimodal therapeutic interventions should be urgent to reduce the risk of subsequent stroke
    • particularly TIAs within 24-48 h should be managed as a stroke
Recurrent stroke risk after transient ischemic attack (TIA) and minor stroke (Coull, 2004)

TIA definition

  • the former definition of TIA (sudden focal neurological deficit lasting < 24h of presumed vascular origin) has become obsolete
    • about 30-50% of such defined TIA patients have infarct lesions on DWI   [Oppenheim, 2004]
    • the likelihood of a DWI lesion increases with symptoms duration; DWI is positive in over 60% of TIA cases lasting > 30 minutes  [Inatomi, 2004]
New TIA definition [Albers, 2002]
Transient episode of neurologic dysfunction due to the focal brain, spinal cord, or retinal ischemia, usually lasting < 1 hour, without acute infarction or tissue injury.

TIA or stroke?

  • TIA – short duration of symptoms (usually minutes, 24h maximum) with complete resolution of symptoms and negative DWI
  • stroke – infarct lesion on imaging and/or persistent clinical symptoms lasting > 24h

    • symptomatic stroke (evidence of brain, spinal cord, or retinal injury)
      • persistent symptoms (stroke is diagnosed even in case of negative imaging; other etiology must be ruled out)
      • transient symptoms with positive DWI
    • clinically asymptomatic stroke (incidental finding on imaging)  Asymptomatic DWI lesion
Male 75 years with short lasting mild rightsided hemiparesis. According to new definition it is a stroke with transient symptoms , not TIA


Clinical presentation

  • TIA symptoms are sudden in onset
  • TIAs usually last a few minutes with complete resolution of symptoms and signs
  • the signs and symptoms of a TIA are similar to those of a stroke:
    • hemiparesis, quadruparesis
    • hemihypesthesia
    • speech disorders
      • aphasia
      • slurred speech (dysarthria)
    • vision disturbances
      • blindness in one or both eyes, visual field deficit
      • double vision
    • vestibular syndrome
    • cerebellar syndrome (ataxia, dysmetria)
  • global symptoms (lightheadedness, isolated delirium, syncope) and positive symptoms (scintillations) are not typical for TIA

Diagnostic evaluation

  • TIAs very often occur hours or days before a stroke; they can thus serve as both a warning of a future stroke and an opportunity to prevent it
  • prompt evaluation and identification of potentially treatable conditions are essential
    • evaluation by a specialist within 24 hours of symptom onset is recommended (ESO guidelines 2021)
    • review in a TIA clinic or admission to a stroke unit are reasonable options (depending on local resources and patient preference)
  • the main goals of a TIA evaluation:
    • to prove the vascular origin of the symptoms and to exclude a nonischemic origin
      • neurologic examiantion is usually negative at the time of presentation, so the history of symptoms must be carefully discussed (may help to diagnose TIA or even its etiology)
      • uniform, repeated attacks indicate either pathology at the level of a peripheral branch or perforator or stroke mimics (migraine, etc.)
    • determine the underlying mechanism to select the optimal therapy
      • exclude significant carotid stenosis and major cardioembolic source
      • palpitations, arrhythmias, and valvular defects, together with symptoms and signs from various territories, suggest cardiac etiology (TOAST 2)

Who should be hospitalized?

  • high-risk patients should be hospitalized or managed via a specialized TIA clinic
    • it is not yet known which is the best healthcare setting to treat TIA
  • indication for admission to the hospital depends on the following:
    • time since the last TIA
    • rapid availability of necessary diagnostic tests on an outpatient basis
    • ABCD2 score + clinical judgment + imaging findings  (ideally CT+CTA or DWI+MRA, neurosonology)
      • recent ESO guidelines suggest not to use prediction tools alone to identify high-risk patients and to make triage and treatment decisions (ESO guidelines 2021)
      • a low ABCD2 score should not be a reason to delay diagnostic evaluation and treatment (those with an ABCD2 score ≤ 3 still include a significant number of individual patients at high risk of recurrent stroke who require early evaluation and treatment)
  • it would be optimal to hospitalize all patients with TIA within 24-48 h, which would ensure rapid diagnostic evaluation and initiation of therapy
  • novel score ABCD3-I  was published, which further improves the detection of high-risk patients  [Song, 2013]
    • the items repeated TIA (Dual TIA) and imaging (I-Imaging – DWI, ICA stenosis > 50%) were added – all scored 2 points
    • 14 points are the maximum

Acute evaluation of TIA patient

  • focused history
    • onset, duration, timing, symptoms specification, any aggravating or relieving factors
    • risk factors, comorbidities (CAD or PAD, smoking, drug abuse, obesity, diabetes, dyslipidemia, and hypertension)
  • clinical examination
    • assess neurological deficits, including speech disturbances, visual field defects, etc. (→ NIHSS)
    • cardiac examination
    • carotid auscultation to detect carotid bruit
  • brain imaging (preferred modality is DWI within 24h or CT+CTP  if DWI cannot be performed) (ESO 2021)  (AHA/ASA 2013 I/B)
    • DWI has a greater sensitivity than CT for detecting small infarcts
  • vascular examinationneurosonology  or  CTA/MRA (urgent in recent TIA) ( AHA/ASA guidelines 2013 I/A)
    • ESO guidelines 2021 suggest using MRA/CTA for confirmation of large artery stenosis ≥ 50% detected by ultrasound to guide further management
    • strength of MRA compared to ultrasound and CTA is its relative insensitivity to arterial calcifications
  • blood tests
    • complete blood count (CBC) + coagulation tests + ESR
    • basic metabolic panel
    • lipid panel
    • diabetes screening
    • urine drug screening in selected cases
  • ECG
    • standard ECG  (AFib?)
    • continue with Holter ECG or prolonged ECG monitoring for at least three weeks (loop recorder)
    • prolonged cardiac rhythm monitoring is reasonable, especially in patients with cortical infarcts with no clear source, to exclude paroxysmal AFib
  • TTE (transthoracic echocardiogram) + TEE (transesophageal echocardiogram)
    • search for PFO,  valvular disorder, and other intracardial abnormities
    • assess aortic plaques
  • EEG in DDx of stroke mimics

Differential diagnosis

  • differentiate TIA from stroke mimics (on-vascular conditions presenting with symptoms similar to those of stroke)

Therapy and prevention

  • immediately start multimodal therapeutic intervention
  • treatment may substantially reduce the risk of a future stroke or recurrent TIA (by 80%) – EXPRESS trial 

    • the same-day assessment and initiation of standard risk-modification measures following TIA decreased the 90-day risk of stroke from 10.3 to 2.1% compared with delayed (or routine) outpatient evaluation and treatment
    • early treatment did not increase the risk of intracerebral hemorrhage or other bleeding

Antithrombotic therapy

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Surgery and endovascular procedures

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Vascular risk factors management and others

  • start aggressive blood pressure treatment (⇒ BP < 130/80 mm Hg, ACE-I are preferred)   → acute blood pressure management
  • treat dyslipidemia
  • manage other vascular risk factors
  • consider specific treatment of some particular underlying etiologies (vasculitis, etc.)
  • even TIA patients can develop post-traumatic stress disorder (PTSD) with depression or anxiety  (Kiphuth, 2014]
    • train adaptive coping skills and carefully explain the realistic risk of stroke associated with TIA
    • use anxiolytics or antidepressants if necessary

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Transient ischemic attack (TIA)
link: https://www.stroke-manual.com/transient-ischemic-attack-tia/