Transient Ischaemic Attacks (TIAs) are a medical emergency 🚨 - they carry a high risk of disabling or fatal stroke within days.
Rapid diagnosis and treatment can reduce stroke risk by up to 80%.
Most TIAs resolve within 1 hour (classic definition allows <24h), but urgent assessment is essential.

🧠 Definition

A TIA is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction on imaging.
Diagnosis is primarily clinical, supported by history and rapid imaging.

🩺 Clinical Features

Carotid Territory: Dysphasia, hemiplegia, hemisensory loss, hemianopia, monocular blindness (amaurosis fugax).
Vertebrobasilar Territory: Diplopia, dysarthria, ataxia, vertigo, hemiplegia, hemisensory loss, Horner’s syndrome.
Atypical / Unlikely TIA: Gradual onset, spreading paraesthesia, confusion, blackout, isolated vertigo, seizure activity.

🩻 Establishing the Diagnosis

Take a clear history: onset, duration, and resolution of symptoms.
Note posture at onset, preceding triggers (e.g., exertion, dehydration, infection).
Enquire about migraine, seizures, or similar prior events.
Check for vascular risk factors: hypertension, AF, diabetes, smoking, hyperlipidaemia.

🔎 Differential Diagnosis

Condition	Typical Features
Stroke	Persistent neurological deficit, infarction on imaging.
Migraine with Aura	Positive spreading symptoms, headache follows.
Seizure	Involuntary movements, loss of awareness, post-ictal confusion.
Syncope	Transient loss of consciousness, often with prodrome.
Transient Global Amnesia	Isolated memory loss, no motor deficit.

⚡ Immediate Management

If symptoms are ongoing → treat as stroke and transfer to ED/Hyperacute Stroke Unit (HASU).
If stable and TIA suspected:
- Aspirin 300 mg immediately (unless contraindicated, or patient already anticoagulated) 💊
- Start high-intensity statin (Atorvastatin 80 mg) unless contraindicated.
- Arrange urgent TIA clinic review within 24 hours (NICE NG128).
- Advise no driving until reviewed by specialist 🚗❌.

🧪 Investigations

Blood tests: FBC, U&E, glucose, lipids, ESR (consider GCA if visual symptoms).
ECG: Check for AF or recent MI.
Holter Monitoring: For paroxysmal AF if initial ECG normal.
Brain Imaging: MRI with DWI within 24h (preferred), CT if MRI unavailable.
Vascular Imaging: Carotid Doppler, CTA or MRA to assess for carotid stenosis.

🏥 Role of the TIA Clinic

Function	Details
Confirm/exclude TIA	Differentiates from mimics such as migraine or seizure.
Identify AF	Initiate anticoagulation where appropriate.
Identify carotid stenosis	Refer for urgent carotid endarterectomy if significant stenosis.
Address vascular risk	Start secondary prevention (antiplatelet/anticoagulation, statin, BP control, smoking cessation).

💊 Medical Management

Atherothrombotic TIA: Long-term single antiplatelet therapy (e.g., Clopidogrel 75 mg daily). Aspirin + Dipyridamole if Clopidogrel unsuitable.
Cardioembolic TIA (AF, valve disease): Anticoagulate with DOAC (e.g., Apixaban, Rivaroxaban, Dabigatran, Edoxaban) or Warfarin.
Blood Pressure: Target <140/90 mmHg (<130/80 if diabetic).
Lipids: High-intensity statin regardless of baseline cholesterol.
Lifestyle: Stop smoking 🚭, weight reduction, healthy diet, regular exercise 🏃‍♂️.

🔪 Surgical Management

Carotid Endarterectomy: Within 2 weeks of TIA for symptomatic carotid stenosis.
- 70–99% stenosis → Strongly recommended.
- 50–69% stenosis → Consider if low surgical risk.
- <50% stenosis or complete occlusion → Not beneficial.

📊 Prognosis

Risk of stroke after TIA is highest in the first few days: ~5% at 2 days, ~10% at 90 days.
Early intervention (antiplatelet, statin, BP control, surgery if indicated) drastically reduces this risk.

📚 References

NICE NG128: Stroke and TIA in over 16s (2019)
Johnston SC, Rothwell PM, et al. Lancet. 2007.
Josephson SA, Sidney S, et al. Stroke. 2008.

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Transient Ischaemic Attack (TIA)

🌟 Introduction