Internal Medicine

Transient ischemic attack (TIA)

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.

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



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


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


  • Techniques:
    • Carotid endarterectomy
    • Carotid artery stenting
  • Medical managementAntiplatelets, 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

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