Transient Ischaemic Attack (TIA)
Current UK guidance: Suspected transient ischaemic attack — immediate actions
- Suspected TIA is a time-sensitive clinical diagnosis: exclude hypoglycaemia, distinguish persistent stroke deficits and mimics, and arrange immediate specialist referral to be assessed within 24 hours of symptom onset.
- NICE recommends aspirin 300 mg daily immediately for suspected TIA unless contraindicated, while awaiting specialist assessment; subsequent antithrombotic treatment depends on diagnosis and mechanism.
- Do not use ABCD2 or other risk scores to decide whether TIA assessment may be delayed. The absence of symptoms at examination does not rule out clinically important cerebrovascular disease.
Reference: NICE NG128 (checked 2026-10-30). This is a targeted evidence-linked teaching update; the historic article below still requires full clinical reconciliation. Follow local protocols and the current BNF for prescribing.
Related Subjects:
|Neurological History taking
|Causes of Stroke
|Ischaemic Stroke
|Hypertension
|Small Vessel Disease
|Hypertension
| Transient Global Amnesia (TGA)
| Exploding head syndrome
🌟 Introduction
- 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
