Clinical Assessment and Emergency Management of Transient Ischemic Attack
Abstract
Background: Transient ischemic attack (TIA) is a neurological emergency characterized by temporary focal ischemia without permanent infarction. It serves as a critical warning for impending stroke, with the highest risk occurring within 48 hours post-event.
Aim: To review the clinical assessment, emergency management, and preventive strategies for TIA, emphasizing early recognition and intervention to reduce stroke risk.
Methods: This review synthesizes current evidence and guidelines on TIA evaluation and management, including neuroimaging, vascular and cardiac assessment, laboratory investigations, and risk stratification using the ABCD² score. It also examines therapeutic approaches such as antiplatelet therapy, anticoagulation, and lifestyle modification.
Results: Early and comprehensive evaluation significantly reduces stroke risk. MRI with diffusion-weighted imaging is preferred for diagnosis, while vascular imaging and cardiac monitoring identify treatable sources. Dual antiplatelet therapy for 21–30 days post-TIA, followed by monotherapy, is effective in non-cardioembolic cases. Carotid endarterectomy benefits patients with high-grade stenosis, and anticoagulation is indicated for cardioembolic TIA. Integrated strategies combining pharmacologic therapy and lifestyle changes can reduce recurrent stroke risk by up to 80%.
Conclusion: TIA requires urgent, multidisciplinary management. Rapid diagnosis, risk stratification, and targeted interventions are essential to prevent subsequent ischemic events. Evidence supports a multifaceted approach involving imaging, pharmacologic therapy, and risk factor modification to optimize outcomes.
Full text article
References
Gennai S, Giordano-Orsini G, Lefour S, Cuisenier P. [Transient Ischemic Attack: Limits and challenges of early management]. Presse medicale (Paris, France : 1983). 2018 Nov-Dec:47(11-12 Pt 1):934-937. doi: 10.1016/j.lpm.2018.09.008.
Yousufuddin M, Young N, Shultz J, Doyle T, Fuerstenberg KM, Jensen K, Arumaithurai K, Murad MH. Predictors of Recurrent Hospitalizations and the Importance of These Hospitalizations for Subsequent Mortality After Incident Transient Ischemic Attack. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2019 Jan:28(1):167-174. doi: 10.1016/j.jstrokecerebrovasdis.2018.09.028.
Kim J, Thrift AG. A Promising Skills-Based Intervention to Reduce Blood Pressure in Individuals With Stroke and Transient Ischemic Attack. JAMA neurology. 2019 Jan 1:76(1):13-14. doi: 10.1001/jamaneurol.2018.2935.
Navis A, Garcia-Santibanez R, Skliut M. Epidemiology and Outcomes of Ischemic Stroke and Transient Ischemic Attack in the Adult and Geriatric Population. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2019 Jan:28(1):84-89. doi: 10.1016/j.jstrokecerebrovasdis.2018.09.013.
Cereda CW, Olivot JM. Emergency Department (ED) Triage for Transient Ischemic Attack (TIA). Current atherosclerosis reports. 2018 Sep 25:20(11):56. doi: 10.1007/s11883-018-0755-5.
Liu L, Ding J, Leng X, Pu Y, Huang LA, Xu A, Wong KSL, Wang X, Wang Y. Guidelines for evaluation and management of cerebral collateral circulation in ischaemic stroke 2017. Stroke and vascular neurology. 2018 Sep:3(3):117-130. doi: 10.1136/svn-2017-000135.
Bibok MB, Votova K, Balshaw RF, Penn M, Lesperance ML, Harris DR, Sedgwick C, Nealis M, Farrell B, Mathieson JR, Penn AM. Retrospective evaluation of a clinical decision support tool for effective computed tomography angiography utilization in urgent brain imaging of suspected TIA/minor stroke in the emergency department. CJEM. 2019 May:21(3):343-351. doi: 10.1017/cem.2018.449.
Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA, Hankey GJ, Hart RG, Levine SR, Biller J, Brown RD Jr, Sacco RL, Kappelle LJ, Koudstaal PJ, Bogousslavsky J, Caplan LR, van Gijn J, Algra A, Rothwell PM, Adams HP, Albers GW. National Stroke Association guidelines for the management of transient ischemic attacks. Annals of neurology. 2006 Sep:60(3):301-13
Cutting S, Regan E, Lee VH, Prabhakaran S. High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack. Cerebrovascular diseases extra. 2016:6(3):76-83. doi: 10.1159/000450692.
Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, Flaherty K, Duley L, England TJ, Havard D, Heptinstall S, James M, Kasonde C, Krishnan K, Markus HS, Montgomery AA, Pocock S, Randall M, Ranta A, Robinson TG, Scutt P, Venables GS, Sprigg N. Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT. Health technology assessment (Winchester, England). 2018 Aug:22(48):1-76. doi: 10.3310/hta22480.
Boulanger JM, Lindsay MP, Gubitz G, Smith EE, Stotts G, Foley N, Bhogal S, Boyle K, Braun L, Goddard T, Heran M, Kanya-Forster N, Lang E, Lavoie P, McClelland M, O'Kelly C, Pageau P, Pettersen J, Purvis H, Shamy M, Tampieri D, vanAdel B, Verbeek R, Blacquiere D, Casaubon L, Ferguson D, Hegedus Y, Jacquin GJ, Kelly M, Kamal N, Linkewich B, Lum C, Mann B, Milot G, Newcommon N, Poirier P, Simpkin W, Snieder E, Trivedi A, Whelan R, Eustace M, Smitko E, Butcher K. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. International journal of stroke : official journal of the International Stroke Society. 2018 Dec:13(9):949-984. doi: 10.1177/1747493018786616.
Ranta A, Dovey S, Gommans J, Tilyard M, Weatherall M. Impact of General Practitioner Transient Ischemic Attack Training on 90-Day Stroke Outcomes: Secondary Analysis of a Cluster Randomized Controlled Trial. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2018 Jul:27(7):2014-2018. doi: 10.1016/j.jstrokecerebrovasdis.2018.02.064.
Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JN, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC, Welch SJ, Bosch S, Alexander FC, Silver LE, Gutnikov SA, Mehta Z, Early use of Existing Preventive Strategies for Stroke (EXPRESS) study. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet (London, England). 2007 Oct 20:370(9596):1432-42
Hackam DG, Spence JD. Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study. Stroke. 2007 Jun:38(6):1881
Wang Y, Johnston SC, Wang Y. Clopidogrel with aspirin in minor stroke or transient ischemic attack. The New England journal of medicine. 2013 Oct 3:369(14):1376-7. doi: 10.1056/NEJMc1309713.
Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY, Clinical Research Collaboration, Neurological Emergencies Treatment Trials Network, and the POINT Investigators. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. The New England journal of medicine. 2018 Jul 19:379(3):215-225. doi: 10.1056/NEJMoa1800410.
Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu D, Klucznik RP, Clark JM, McDougall CG, Johnson MD, Pride GL Jr, Torbey MT, Zaidat OO, Rumboldt Z, Cloft HJ, SAMMPRIS Trial Investigators. Stenting versus aggressive medical therapy for intracranial arterial stenosis. The New England journal of medicine. 2011 Sep 15:365(11):993-1003. doi: 10.1056/NEJMoa1105335.
Clare CS. Role of the nurse in stroke rehabilitation. Nursing standard (Royal College of Nursing (Great Britain) : 1987). 2018 Oct 1:33(7):59-66. doi: 10.7748/ns.2018.e11194.
Basaraba JE, Picard M, George-Phillips K, Mysak T. Pharmacists as Care Providers for Stroke Patients: A Systematic Review. The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques. 2018 Jan:45(1):49-55. doi: 10.1017/cjn.2017.233.
Authors
Copyright (c) 2025 Faleh Turki Hammad Alanazi, Hussain Ali Jubran Shafei, Omar Mahmoud Abduljawad, Nooh Thawab Almotiri, Abdullah Hussain Ghazi Alghazi, Ibrahim Mohammed Ibrahim Otudi, Ayoub Ali Mohamed Aldarbi, Faisal Saud Almutaiti, Eman Mohammed Almadan, Anfal Abdulrazaq Alabdulwahed, Safer Atif Alqahtani, Itidal Zaid Hassan Alnahari, Manal Ali Hassan Makin
This work is licensed under a Creative Commons Attribution 4.0 International License.