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 infarction on imaging.

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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

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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

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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