Diagnosis:
- Sudden neurological focal deficit of vascular origin lasting <24 hrs (usually lasts <1 hr), with normal diffusion weighted MRI (DWI).
- PWI: may show decreased perfusion.
Investigations to Consider:
Blood tests:
- FBC, Coagulation screen, Blood Glucose, Blood chemistry panel,
- Fasting: Cholesterol, Lipids, glucose
- ESR: vasculitides, giant cell arteritis.
- Consider Homocystein, vasculitic screen, thrombophilia screen
Extracranial vascular evaluation:
- CTA, MRA
- Or carotid ultrasound if carotid territory (too low sensitivity in posterior ciruclation TIA)
Intracranial vascular evaluation:
- CTA, MRA: good screening tests, particularly CTA
- Cathetera angiography: confirmatory test for intracranial stenosis
Cardiac evaluation:
- ECG: Exclude AF
- Transthoracic echocardiogram
- Transoesophageal Echocardiogram TOE, especially if other tests don’t reveal the mechanism.
- Consider implantable cardiac monitor or prolonged external monitor (>or=60 days) if clinically definite TIA
Consider:
- DWI MRI: high signal indicates high risk of stroke
Treatment:
- Emergent or urgent evaluation & treatment. [EXPRESS]
- If admitting to the hospital, admit the patient to the stroke unit
Antiplatelets: Choose one
- Aspirin +/-dipyridamole
- Clopidogre
- Cilostazol
- Don’t use aspirin +clopidogrel, use single antiplatelt agent investigations confirm intracranial atherosclerotic disease with stenosis
Anticoagulation: if cardioembolic stroke (see cardioembolic stroke)
Manage risk factors for stoke & atheroma:
- Hypertension control
- Statin
- Others: smoking, diabetes mellitus, diet, exercise
Revascularization if meets crteria for extracranial symptomatic carotid stenosis: by carotid artery stenting or carotid endarterectomy