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Transient ischemic attack

Key sources
The following summarized guidelines for the evaluation and management of transient ischemic attack are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2023), the European Stroke Organisation (ESO 2022; 2021; 2019), the Society for Cardiovascular Angiography and Interventions (SCAI 2022), the American Heart Association (AHA/ASA 2021), the European Society of Cardiology (ESC/EACTS 2021), the American Society of Hematology (ASH 2020), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American College of Physicians (ACP/AAFP 2017), the American College of Emergency Physicians (ACEP 2016), the Canadian Cardiovascular Society (CCS 2014), and the Society for Cardiovascular Angiography and Interventions (SCAI/SNIS/SVM/AANS/ASNR/CNS/AANN/SVS/AHA/ACR/SAIP/ACC/ASA/SIR 2011).
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Guidelines

1.Classification and risk stratification

Risk prediction tools: as per ESO 2021 guidelines, avoid using prediction tools alone to identify high-risk patients/make triage and treatment decisions in patients with a suspected TIA.
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2.Diagnostic investigations

Timing for initial assessment: as per AHA 2021 guidelines, obtain diagnostic evaluation for gaining insights into the etiology and planning optimal strategies for preventing recurrent stroke, completed or underway within 48 hours of the onset of stroke symptoms, in patients with a TIA.
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  • Brain imaging

  • Cervical imaging

  • ECG

3.Medical management

Antithrombotic therapy, intracranial atherosclerotic disease, ESO
Consider initiating dual antiplatelet therapy over monotherapy in patients with a TIA related to intracranial stenosis due to intracranial atherosclerotic disease.
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Do not initiate oral anticoagulation over aspirin, unless there is another formal indication for it, in patients with a TIA due to high-grade stenosis related to intracranial atherosclerotic disease.
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  • Antithrombotic therapy (before imaging)

  • Management of hypertension (antihypertensive therapy)

  • Management of hypertension (BP targets)

  • Management of hypertension (induced hypertension)

  • Management of dyslipidemia

  • Management of diabetes

  • Management of obesity

  • Management of obstructive sleep apnea

  • Antithrombotic therapy (non-cardioembolic TIA)

4.Nonpharmacologic interventions

Dietary modifications
Consider advising to follow a Mediterranean-type diet, typically with an emphasis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce the risk of recurrent stroke in patients with a TIA.
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Consider advising to reduce the sodium intake by at least 1 g/day sodium (2.5 g/day salt) to reduce the risk of CVD events, including stroke, in patients with a TIA and hypertension.
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  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Substance use cessation

5.Therapeutic procedures

Ischemic preconditioning: considering performing ischemic preconditioning as an adjuvant to best medical treatment in patients with a TIA related to high-grade stenosis due to intracranial atherosclerotic disease. Consider enrolling patients in a dedicated RCT whenever possible.
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  • Intracranial angioplasty/stenting

6.Surgical interventions

Indications for surgery: as per ESO 2022 guidelines, do not perform neurosurgical procedures in patients with a TIA related to high-grade stenosis due to intracranial atherosclerotic disease.
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7.Specific circumstances

Patients with carotid artery stenosis, medical therapy: initiate intensive medical therapy with antiplatelet therapy, lipid-lowering therapy, and antihypertensive therapy to reduce the risk of stroke in patients with a TIA and carotid artery stenosis.
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  • Patients with carotid artery stenosis (timing of revascularization)

  • Patients with carotid artery stenosis (carotid endarterectomy)

  • Patients with carotid artery stenosis (carotid artery stenting)

  • Patients with carotid artery stenosis (transcarotid artery revascularization)

  • Patients with carotid artery stenosis (bypass surgery)

  • Patients with vertebral artery stenosis

  • Patients with carotid or vertebral artery dissection

  • Patients with vertebrobasilar dolichoectasia

  • Patients with FMD

  • Patients with carotid web

  • Patients with aortic arch atherosclerosis

  • Patients with Moyamoya disease

  • Patients with AF (anticoagulant therapy)

  • Patients with AF (antiplatelet therapy)

  • Patients with AF (LAA closure)

  • Patients with intracardiac thrombi

  • Patients with VHD (antithrombotic therapy)

  • Patients with VHD (valvular surgery)

  • Patients with congenital heart disease

  • Patients with patent foramen ovale

  • Patients with cardiomyopathy

  • Patients with cardiac tumors

  • Patients with inherited thrombophilias

  • Patients with antiphospholipid syndrome

  • Patients with hyperhomocysteinemia

  • Patients with sickle cell disease

  • Patients with autoimmune vasculitis

  • Patients with infectious vasculitis

  • Patients with Fabry disease

8.Preventative measures

Secondary prevention, health system-based interventions: implement voluntary hospital-based or outpatient-focused quality monitoring and improvement programs to improve short-term and long-term adherence to nationally accepted, evidence-based guidelines for secondary stroke prevention in patients with ischemic stroke or TIA.
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  • Secondary prevention (behavioral changes)

9.Quality improvement

Health equity: assess and address social determinants of health (literacy level, language proficiency, medication affordability, food insecurity, housing, and transportation barriers) when managing stroke risk factors to reduce healthcare disparities.
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