Transient ischemic attack

Last updated: November 20, 2023

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Summarytoggle arrow icon

Transient ischemic attack (TIA) is a temporary, focal cerebral ischemic event that results in reversible neurological symptoms but is not associated with a visible acute infarct on neuroimaging. Cardiogenic embolism (e.g., from atrial fibrillation) and atherosclerosis (e.g., carotid artery stenosis) are the most commonly identified etiologies. Symptoms depend on the affected territory and may mimic an acute stroke; however, symptoms are transient. Because patients with TIA have an increased stroke risk, early diagnosis and initiation of secondary preventive therapies for subsequent stroke are vital. Management typically includes urgent neuroimaging, antithrombotic therapy (e.g., antiplatelet therapy), and prompt determination of the underlying cause (e.g., using echocardiography and neurovascular studies) to guide targeted preventative measures, such as the management of underlying atrial fibrillation or carotid artery stenosis.

See also “Ischemic stroke,” “Overview of stroke,” and “Carotid artery stenosis.”

Definitiontoggle arrow icon

TIA refers to temporary, focal cerebral ischemia that results in reversible neurological deficits without acute infarction (i.e., imaging findings show no signs of infarction). [2][3]

Epidemiologytoggle arrow icon

Etiologytoggle arrow icon

Clinical featurestoggle arrow icon

Perform a full physical examination to assess for neurological deficits and look for evidence of specific causes.

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Managementtoggle arrow icon

TIA is a self-limiting event that is most often diagnosed retrospectively and requires no specific treatment. The primary management goal is stroke prevention.

Approach [2][3][10]

Treat patients with ongoing neurological deficits or acute infarct seen on imaging as having an acute stroke; see “Initial management of acute stroke.”

Disposition [3][11]

Disposition is decided based on clinical judgment, as there is no evidence-based consensus. [11][12][13]

  • Neurology consultation is recommended for:
    • Patients with complex or high-risk TIAs requiring admission
    • All patients in follow-up to help tailor long-term stroke prevention
  • Use clinical scoring systems as a guide only (see “Risk stratification”). [3]
  • Features that support admission include: [11][12]
    • Multiple TIA episodes or TIA while on therapeutic anticoagulation
    • Evidence of a potential embolic source
    • Inability to complete outpatient workup within 2 days
  • If discharged from the emergency department:

Risk scoring systems and imaging findings do not replace clinical judgment in determining overall stroke risk and disposition.

Diagnosticstoggle arrow icon

Laboratory studies [2][3][10]

Neuroimaging [2][3][10]

Neurovascular studies in TIA [2][3][10]

Cardiac evaluation [2][3][10]

Risk stratificationtoggle arrow icon

General considerations

  • Estimating the patient's risk of a future stroke after a TIA helps guide management decisions (e.g., further diagnostic workup, treatment, and disposition).
  • Individual risk depends on a combination of clinical and diagnostic parameters.
  • Risk score reliability remains limited and a complete clinical risk assessment is recommended.

Clinical scoring systems

  • The ABCD2 risk assessment score is most frequently used to assess short-term stroke risk. [11][19][20][21]
  • The Canadian TIA score can be used to assess the 7-day risk of stroke. [22]
ABCD2 score [23]
Criteria Points

≥ 60 years


Blood pressure

SBP ≥ 140 mm Hg OR DBP ≥ 90 mm Hg


Clinical features

Speech impairment only


Unilateral weakness


Duration of symptoms

10–59 minutes


≥ 60 minutes


Diabetes mellitus




  • Score 0 to 3: low two-day stroke risk (1%)
  • Score 4 to 5: moderate two-day stroke risk (4%)
  • Score 6 to 7: high two-day stroke risk (8%)

The ABCDE2 score is only a general guide; it cannot reliably identify low-risk patients who can be discharged from ambulatory settings in isolation. [11]

High-risk imaging findings

Treatmenttoggle arrow icon

Antithrombotic therapy for TIA [2][10][14][25]

Noncardioembolic TIA

Antiplatelets are generally preferred over oral anticoagulation. [2]

Avoid triple therapy (i.e., combined DAPT and anticoagulation) or prolonged DAPT (i.e., > 90 days) in patients with noncardioembolic TIA, because of the risk of hemorrhage. [2]

Cardioembolic TIA

The choice of agents and dosage is based on the etiology and clinical manifestation, e.g.:

Large artery disease

The choice of agents and dosage is based on the etiology and clinical severity, e.g.:

Hypercoagulable states

Can manifest as cardioembolic or noncardioembolic TIA. The choice of agents and dosage is based on the etiology and clinical manifestation, e.g.:

Consider antiphospholipid syndrome as a cause of TIA in young female patients with no ASCVD risk factors. [28]

Patients already on antithrombotic therapy

  • Currently on antiplatelet monotherapy
    • Consider switching to DAPT in consultation with neurology. [2]
    • Patients with indications for anticoagulation (e.g., Afib): Consider switching to or adding anticoagulation. [14]
  • Chronic anticoagulation
    • Ensure therapeutic dosing of oral anticoagulants.
    • Consult a specialist (e.g., neurology, cardiology) to determine if the addition of antiplatelet monotherapy is indicated.

Surgical or intravascular intervention [2]

Long-term stroke prevention

Acute management checklisttoggle arrow icon

A brain MRI is preferred for TIA evaluation but a head CT (without IV contrast) must be performed first and immediately if there is concern for hemorrhage or acute infarction requiring reperfusion therapy.

If there is evidence of an acute infarct on imaging, start immediate management for an acute ischemic stroke.

Prognosistoggle arrow icon

  • Increased risk of future ischemic stroke [5]
    • Within 2 days: ∼ 3–10%
    • Within 90 days: ∼ 9–17%

Referencestoggle arrow icon

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  2. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease.. Stroke. 2009; 40 (6): p.2276-93.doi: 10.1161/STROKEAHA.108.192218 . | Open in Read by QxMD
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  28. $Contributor Disclosures - Transient ischemic attack. All of the relevant financial relationships listed for the following individuals have been mitigated: Jan Schlebes (medical editor, is a shareholder in Fresenius SE & Co KGaA). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.

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