Ctrl

K

Table of contents

Expand All Topics

Transient ischemic attack

Background

Overview

Definition
A TIA is a brief episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, with clinical symptoms typically lasting less than 1 hour but can persist for up to 24 hours, and without evidence of acute infarction.
1
Pathophysiology
The pathophysiology of TIA involves a temporary disruption in blood flow to a specific area of the brain, often due to emboli or thrombi. This leads to ischemia in the affected area, causing transient neurological symptoms. Common conditions causing a TIA include cerebrovascular disorders such as large artery atherosclerosis, carotid or vertebral artery stenosis, and cervical artery dissection; cardiovascular disorders such as AF, valvular heart disease, and infective endocarditis; hypercoagulable conditions such as antiphospholipid antibody syndrome, cancer, hyperhomocysteinemia, and sickle cell disease; and inflammatory vascular conditions such as FMD, giant cell arteritis, and primary angiitis of the CNS.
2
3
Epidemiology
The incidence of TIA in the US is estimated at 0.7-1.19 per 1,000 person-years.
4
5
Risk factors
Risk factors for TIA include advanced age, male gender, hypertension, diabetes mellitus, obesity, dyslipidemia, tobacco smoking, high sodium intake, high stress, CVDs, and a family history of cerebrovascular accidents.
2
Disease course
The clinical course of a TIA is characterized by sudden onset of symptoms that resolve within 24 hours. Symptoms can include motor weakness, dysphasia, altered consciousness, syncope, dizziness, amnesia, confusion, hemianopia, monocular visual loss, isolated diplopia, bilateral visual disturbance, vertigo, ataxia, sensory symptoms, and gait difficulties.
6
Prognosis and risk of recurrence
Patients with TIA have an increased risk of subsequent stroke, with a 10-20% risk within the first 90 days after the event, and an increased risk of cardiovascular events for the following 5 years.
7

Guidelines

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 of Cardiology (ESC 2024), 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 ...
Show more

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.
D
Create free account

Diagnostic investigations

Timing for initial assessment: as per AHA/ASA 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.
B
Create free account

More topics in this section

  • Brain imaging

  • Cervical imaging

  • ECG

Medical management

Antithrombotic therapy, before imaging: as per ESO 2021 guidelines, consider initiating de novo antiplatelet monotherapy in patients with a suspected TIA if a wait of > 24 hours to planned imaging is foreseen and a delay is judged to increase the risk of further ischemic events, above the risk of starting antiplatelet medication.
C
Create free account

More topics in this section

  • Antithrombotic therapy (intracranial atherosclerotic disease)

  • Antithrombotic therapy (non-cardioembolic TIA)

  • Management of hypertension (BP targets)

  • Management of hypertension (antihypertensive therapy)

  • Management of hypertension (induced hypertension)

  • Management of dyslipidemia

  • Management of diabetes

  • Management of obesity

  • Management of obstructive sleep apnea

Nonpharmacologic interventions

Dietary modifications
As per AHA/ASA 2021 guidelines:
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.
C
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.
C
Create free account

More topics in this section

  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Substance use cessation

Therapeutic procedures

Ischemic preconditioning: as per ESO 2022 guidelines, 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.
C
Create free account

More topics in this section

  • Intracranial angioplasty/stenting

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.
D
Create free account

Specific circumstances

Patients with carotid artery stenosis, medical therapy: as per AHA/ASA 2021 guidelines, 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.
A
Create free account

More topics in this section

  • 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 valvular heart disease (antithrombotic therapy)

  • Patients with valvular heart disease (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

Preventative measures

Secondary prevention, health system-based interventions: as per AHA/ASA 2021 guidelines, 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.
B
Show 2 more
Create free account

More topics in this section

  • Secondary prevention (behavioral changes)

Quality improvement

Health equity: as per AHA/ASA 2021 guidelines, 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.
B
Show 3 more
Create free account