Transient Ischaemic Attack (TIA)

Presentation

• Sudden onset neurological deficit resolving within 24 hours (often <1 hour)

• Common symptoms include facial droop, slurred speech, vision loss (amaurosis fugax), limb weakness, paraesthesia, imbalance, speech disturbance

Investigations

• ABCD2 score for stroke risk stratification (Age ≥60, BP ≥140/90, Clinical features of TIA, Duration of symptoms, Diabetes)

  • Add 1 point for history of hypertension

  • Higher scores indicate increased stroke risk

• Blood tests: FBC, UEC, LFT, lipid profile, fasting glucose/HbA1c

• Cardiac evaluation: ECG to exclude arrhythmias (e.g. AF), transthoracic echo (or TOE if suspicion of cardiac embolic source)

• Imaging:

  • Urgent CT/MRI brain to exclude haemorrhage or established infarction

  • Carotid duplex ultrasound for anterior circulation TIAs (especially if carotid territory)

Management

• Urgent imaging (CT/MRI)

  • If ABCD2 score >3, atrial fibrillation, carotid symptoms, or crescendo TIA (≥2 events in 1 week) → refer immediately or within 24 hours

  • If score ≤3 or symptom onset >1 week → manage in GP setting with imaging within 48 hours

• Carotid management

  • Symptomatic stenosis >70% → refer for endarterectomy within 2 weeks of the event

  • Asymptomatic stenosis → specialist review within 1 week

• Early antiplatelet therapy

  • Aspirin 300mg stat, then 100mg daily

  • Alternatively, clopidogrel monotherapy (75mg daily) or aspirin plus dipyridamole if aspirin contraindicated

  • Consider short-term dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for up to 21 days if TIA or minor stroke and no high bleeding risk

• Anticoagulation

  • Indicated if CHA2DS2-VASc ≥2 in atrial fibrillation

  • Warfarin for valvular AF, mural thrombus, or mechanical valves

  • DOACs for non-valvular AF

  • Delay anticoagulation if large infarct present (to reduce risk of haemorrhagic transformation)

• Statins

  • High-potency statin (e.g. atorvastatin 40mg or 80mg daily) regardless of baseline cholesterol levels

• Blood pressure control

  • Target <140/90 in most patients

  • ACE inhibitors or thiazide diuretics commonly used, even if BP not significantly elevated, unless symptomatic hypotension occurs

• Lifestyle (SNAP)

  • Smoking cessation, nutrition (healthy diet), reduce alcohol intake (<2 standard drinks/day), increase physical activity

  • Aim for healthy BMI and regular exercise

Post-TIA Care

• Rapid referral to TIA clinic or stroke prevention service if moderate-high risk features

• Ongoing risk-factor modification (hypertension, hyperlipidaemia, diabetes, smoking)

• Consider screening for carotid stenosis if not done earlier

• Arrange timely follow-up and reinforcement of compliance with secondary prevention measures

Differential Diagnosis

• Migraine aura (can mimic TIA)

• Hypoglycaemia

• Focal seizure with Todd’s paresis

Notes

• TIA is a warning sign: up to 10–15% risk of stroke within 90 days, with half occurring in the first 48 hours

• Urgent carotid intervention and antiplatelet therapy can significantly reduce stroke risk

• Monitor for recurrent episodes or crescendo TIAs (increased stroke risk)

• Educate patients about recognising stroke-like symptoms (FAST) and seeking immediate care if they recur