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Transient Ischaemic Attack (TIA)
National Clinical Guideline for Stroke 2023 Edition.
NICE Guideline [NG128] Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Last updated: Apr 2022
Refer within 24 hours to acute stroke unit / specialist
Do NOT use the ABCD2 score to stratify risk of TIA / inform urgency of referral / guide treatment
Specialist Care (Stroke Unit)
If the patient takes anticoagulant / has a bleeding disorder → urgent non-contrast head CT to exclude intracranial haemorrhage
Otherwise, NICE recommends NOT to routinely offer CT brain unless there is clinical suspicion of an alternative diagnosis that CT could detect. Unlike in suspected stroke, where non-contrast head CT is done in ALL patients.
Consider the following imaging in all patients with TIA (after specialist assessment):
MRI head (on the same day) to determine the territory of ischaemia or detect haemorrhage
Carotid imaging (if considered a candidate for carotid endarterectomy)
The following investigations are not explicitly mentioned in NICE / NCGS guidelines but are endorsed by international guidelines and done in practice: [Ref]
Cardiac monitoring (telemetry and ECG +/- Holter) – recommended in ALL patients (to detect underlying AF or other arrhythmias)
Echocardiography – in selected patients (if cardiac source is suspected)
Standard laboratory studies (FBC, U&E, HbA1c, lipid profile etc.)
Management
There are 3 aspects of TIA management:
1. Antithrombotic Therapy
Every patient with TIA needs some form of antithrombotic therapy to prevent further cerebrovascular events, but the choice depends on whether the patient has atrial fibrillation or not.
TIA with no Atrial Fibrillation
Antiplatelets are the choice of antithrombotic therapy in the absence of AF (i.e., for thrombotic TIA)
There are 2 regimens recommended, depending on the patient’s bleeding risk.
Bleeding risk
Antiplatelet regimen
Low bleeding risk (most cases)
Phase 1: on the same day offer a loading dose of DAPT (aspirin 300 mg + clopidogrel 300 mg)
Phase 2: maintenance dose DAPT for 21 days (aspirin 75 mg + clopidogrel 75 mg)
Phase 3: after 21 days of DAPT, switch to clopidogrel 75 mgmonotherapy lifelong
Alternative to clopidogrel is ticagrelor (loading dose: 180 mg, maintenance dose: 90 mg BD)
High bleeding risk
Phase 1: on the same day offer a loading dose of clopidogrel 300 mg
Phase 2: maintenance dose of clopidogrel 75 mg monotherapy lifelong
Note that DAPT is used in TIA but not in ischaemic stroke. This is due to the higher risk of haemorrhagic transformation in ischaemic stroke, which outweighs the potential benefits of DAPT.
TIA with Atrial Fibrillation
Offer a head CT to exclude intracerebral haemorrhage, then offer anticoagulation
1st line for most patients: DOAC (e.g. apixaban)
1st line in valvular AF: warfarin
Note the timing to start anticoagulation in TIA is different from that in ischaemic stroke:
In ischaemic stroke with AF (i.e., embolic stroke), anticoagulation is only started after 5-14 days, with only aspirin 300mg being given during those 5-14 days
In TIA with AF (i.e., embolic TIA), anticoagulation can be started immediately, once intracerebral haemorrhage has been excluded
This difference in timing reflects the balance of benefits and bleeding risk in the presence of established infarction (stroke) vs TIA. Anticoagulants carry a much higher risk of intracerebral haemorrhage than antiplatelets.
In ischemic stroke with AF, there is a significant risk of hemorrhagic transformation in the infarcted brain tissue if anticoagulation is started immediately. Therefore, anticoagulation is typically delayed for about 5-14 days, while aspirin 300 mg is given in this period to prevent early recurrent ischemia.
In TIA with AF, there is no established infarcted tissue and thus essentially no risk of hemorrhagic transformation. Once intracerebral haemorrhage is excluded by imaging, anticoagulation can be started immediately to provide early secondary stroke prevention.
But ultimately, for both ischaemic stroke and TIA patients with AF, long-termanticoagulation (not antiplatelet therapy) is required for effective stroke prevention.
Do NOT routinely offer carotid intervention to all patients with TIA.
Indications for carotid intervention depend on the severity of stenosis (reported with the NASCET method):
Stenosis severity
Management
Severe stenosis (50-99%)
Perform carotid endarterectomy (on the problematic side only) within 7 days
If unfit for surgery → consider carotid angioplasty and stenting
Mild / moderate stenosis (<50%)
NO intervention is necessary
DVLA Guidelines
TIA and Driving
After a stroke / TIA → always stop driving immediately. Further action depends on the license type:
Class I vehicle (car / motorcycle)
Stop driving for at least 1 month
No need to inform the DVLAroutinely (unless there is residual neurological / cognitive deficit after 1 month or there was any seizure or brain surgery was performed)
