Overview
Transient ischaemic attack (TIA) is defined as a transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction.
Warning Sign
TIA is a major warning sign for future stroke and requires urgent assessment and management.
Risk Factors
Lifestyle Factors
- Smoking
- Alcohol misuse
- Drug abuse (cocaine, methamphetamine)
- Physical inactivity
- Poor diet
Cardiovascular Disease
- Hypertension
- Atrial fibrillation (permanent and paroxysmal)
- Infective endocarditis
- Valvular disease
- Carotid artery disease
- Congestive heart failure
- Congenital/structural heart disease
Other Factors
- Age (risk doubles every decade after 55)
- Gender (men at younger age, women with specific risk factors)
- Hyperlipidemia
- Diabetes mellitus
- Sickle cell disease
- Antiphospholipid syndrome
- Chronic kidney disease
- Obstructive sleep apnoea (OSA)
Clinical Features
Suspicion Criteria
Suspect a TIA if the person presents with sudden onset, focal neurological deficit which has completely resolved within 24 hours of onset and cannot be explained by another condition.
Important Note
Most TIAs are thought to resolve within 1 or 2 hours but can persist for up to 24 hours.
Focal Neurological Deficits
- Unilateral weakness or sensory loss
- Dysphasia
- Ataxia, vertigo, or incoordination
- Syncope
- Sudden transient loss of vision in one eye (amaurosis fugax)
- Homonymous hemianopia
- Cranial nerve defects
Differential Diagnosis
Many conditions (stroke mimics) can present with similar clinical features to stroke and TIA:
Toxic/Metabolic
- Hypoglycaemia
- Drug and alcohol toxicity
Neurological
- Seizure
- Migraine with aura
- Demyelination
- Bell's palsy
- Spinal epidural haematoma
Other Conditions
- Syncope
- Peripheral vestibular disturbance
- Trauma
- CNS infections
- Encephalopathies
- Space occupying lesions
- Vasculitis
- Somatoform or conversion disorder
Initial Management
Suspected TIA within Last Week
- Give aspirin 300 mg immediately (with PPI cover where appropriate) unless:
- Bleeding disorder or anticoagulant use
- Already taking low-dose aspirin regularly
- Aspirin contraindicated
- Arrange urgent assessment by specialist stroke physician
- Refer immediately to be seen within 24 hours of symptom onset
- Do not use scoring systems (e.g., ABCD2) to assess risk or inform urgency
- Do not offer CT brain unless clinical suspicion of alternative diagnosis
Admission Considerations
Discuss need for admission with stroke specialist if:
- More than one suspected TIA (crescendo TIA)
- Suspected cardioembolic source or severe carotid stenosis
- Unable to attend urgent review or lacks reliable observer at home
Suspected TIA More Than Week Ago
- Refer for specialist assessment within 7 days
- Assess for atrial fibrillation and other arrhythmias
Patient Education
Give all people with suspected TIA and their family/carers information on recognition of stroke and TIA. Advise them to call 999 immediately if symptoms occur. Advise not to drive until seen by specialist.
DVLA Guidance
- Single diagnosed TIA: No driving for 1 month (need not notify DVLA)
- Multiple TIAs: No driving and must notify DVLA
- Multiple TIAs over short period: No driving for 3 months
- Driving may resume after 3 months if no further TIAs
Specialist Investigation and Management
Imaging
- Consider MRI (including diffusion-weighted and blood-sensitive sequences) to determine territory of ischemia or detect hemorrhage/alternative pathologies
- Everyone considered candidate for carotid endarterectomy should have urgent carotid imaging
Carotid Endarterectomy
- People with stable neurological symptoms from acute non-disabling stroke or TIA
- Symptomatic carotid stenosis of 50-99% according to NASCET criteria
- Should be assessed and referred urgently for carotid endarterectomy
Prognosis
High Stroke Risk
TIAs are associated with a high risk of stroke in the following month and up to 1 year afterwards.
Risk of Stroke Following TIA
| Timeframe |
Risk of Stroke |
| Within 2 days |
3.9–5% |
| Within 7 days |
5.5–8% |
| Within 30 days |
7.5–12% |
| Within 90 days |
9.2–17% |
Risk Reduction
A patient's 90-day risk can be significantly lowered with rapid investigation and aggressive management.
Long-term Management and Prevention
Secondary Prevention
- Antiplatelet therapy (aspirin, clopidogrel, or combination therapy)
- Anticoagulation if atrial fibrillation or other embolic source identified
- Blood pressure management
- Statin therapy
- Diabetes management if applicable
- Lifestyle modifications (smoking cessation, diet, exercise)
Follow-up
- Regular follow-up with stroke specialist
- Monitoring for new symptoms
- Management of risk factors
- Patient education on stroke recognition