Contents
Transient ischemic attack (TIA) is a brief, reversible episode of focal neurologic dysfunction due to ischemia without
acute infarction.
American Heart Association and the American Stroke Association (AHA/ASA) definition:
Brief episode of neurological dysfunction with a vascular cause, with clinical symptoms, typically lasting < 1 hour, and without evidence of
infarctionon imaging.
Clinical features
Focal neurologic deficits (include, but not limited to):
- Amaurosis fugax (painless, temporary loss of vision)
- One-sided facial droop
- One-sided motor weakness
- Diplopia (double vision)
- Problems with balance and spatial orientation
- Other symptoms:
- Unilateral weakness, amaurosis fugax, and double vision
- Memory loss, headache, and blurred vision
Diagnosis
Imaging
American Heart Association and American Stroke Association Stroke Council recommendation: Patients with TIA should have head imaging within 24 hours of symptom onset, preferably with MRI, including diffusion sequences
- Magnetic resonance angiography (MRA)
- CT angiography (CTA)
- Carotid ultrasonography/transcranial doppler ultrasonography
Differential diagnosis
- Brain tumor
- Severe unilateral headache with nausea and vomiting
- Central nervous system infection (e.g., meningitis, encephalitis)
- Fever, headache, confusion, neck stiffness, nausea, vomiting, photophobia, change in mental status
- Falls/trauma
- Headache, confusion, bruising
- Hypoglycemia
- Confusion, weakness, diaphoresis
- Migraines
- Severe headaches ± photophobia, younger age
- Multiple sclerosis
- Diplopia, limb weakness, paresthesia, urinary retention, optic neuritis
- Seizure disorder
- Confusion with or without loss of consciousness, urinary incontinence, tongue biting, tonic-clonic movements
- Subarachnoid haemorrhage
- Severe headache with sudden onset and photophobia
- Vertigo (central or peripheral)
- Generalized dizziness and diaphoresis with or without hearing loss
Management
Antiplatelet medications:
Secondary prophylaxis of stroke after most TIA
- Aspirin therapy:
- Aspirin + extended-release dipyridamole
- Aspirin + Clopidogrel
- Aspirin alone
- Clopidogrel alone
- Exception: TIAs due to blood clots originating from the heart, in which case anticoagulants are generally recommended
Anticoagulant medications:
- If the TIA due to atrial fibrillation:
- Warfarin
- Direct acting oral anticoagulants (DOACs): Apixaban
- Generally, anticoagulants and antiplatelets are not used in combination, as they result in increased bleeding risk without a decrease in stroke risk
- Symptomatic coronary artery disease + atrial fibrillation:
- Antiplatelet + anticoagulant therapy
Blood pressure control:
Indicated after TIA to reduce the risk of ischemic stroke (hypertension, SBP > 140 mmHg, or DBP > 90 mmHg)
- Diuretics
- Diuretics + angiotensin converter enzyme (ACE) inhibitors
Cholesterol control:
- Statin therapy
Diabetes control (reduce stroke risk):
- Metformin, pioglitazone and semaglutide
Surgery:
- Techniques:
- Carotid endarterectomy
- Carotid artery stenting
- Medical management: Antiplatelets, statins, and other interventions
Lifestyle modification:
- Mediterranean diet
- Rich in fruits, vegetables and whole grains, and limited in red meats and sweets
- Vitamin supplementation
- Not beneficial in secondary prophylaxis