SCOPE: Acute evaluation and secondary prevention after transient ischemic attack in adults. Covers risk stratification (ABCD2), urgent workup (MRI with DWI, vascular imaging, cardiac evaluation), dual antiplatelet therapy initiation, and rapid secondary prevention. TIA is a medical emergency — 90-day stroke risk is 10-15% without intervention, highest in first 48h. Excludes completed ischemic stroke (see Acute Ischemic Stroke template), hemorrhagic stroke, and TIA mimics.
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
Within 24h (ideally <6h). DWI-positive in 30-50% of clinical TIA — these patients are at HIGHEST stroke risk and may be reclassified as minor stroke
DWI restriction = acute ischemia (even if symptoms resolved, this upgrades risk and may change to minor stroke diagnosis); FLAIR changes; prior infarcts
Pacemaker, metallic implants, severe claustrophobia
CT head without contrast (CPT 70450)
STAT
STAT
-
-
Immediate (if MRI unavailable or contraindicated); excludes hemorrhage and mass
No hemorrhage; no mass; may show old infarcts
Pregnancy (relative)
CTA head and neck (CPT 70496, 70498) (OR MRA head and neck)
STAT
STAT
URGENT
-
With initial imaging or within 24h. Evaluates extracranial AND intracranial vessels
325 mg :: PO :: load :: 325 mg PO loading dose immediately upon TIA diagnosis (give in ED). Do NOT delay antiplatelet therapy
Active GI bleed; true aspirin allergy; thrombocytopenia <50K
GI symptoms; bleeding
STAT
STAT
STAT
-
Clopidogrel (loading dose for DAPT)
PO
-
300 mg :: PO :: load :: 300 mg PO loading dose (give with aspirin for DAPT). DAPT is standard for high-risk TIA (ABCD2 ≥4) or minor stroke per CHANCE and POINT trials
81 mg :: - :: daily :: Aspirin 81 mg daily + Clopidogrel 75 mg daily x 21 days (CHANCE protocol) or x 90 days (POINT protocol — higher bleeding risk with longer duration). Then transition to single antiplatelet (typically clopidogrel 75 mg or aspirin 81 mg monotherapy)
81 mg :: PO :: daily :: Aspirin 81 mg daily + Ticagrelor 90 mg BID x 30 days (THALES trial; for minor stroke NIHSS ≤5). Then single antiplatelet
Intracranial hemorrhage history; high bleeding risk; hepatic impairment
Bleeding; dyspnea (common side effect); avoid strong CYP3A4 inhibitors
-
STAT
STAT
-
High-intensity statin
PO
-
80 mg :: PO :: daily :: Atorvastatin 80 mg PO daily (or Rosuvastatin 20-40 mg). Start immediately regardless of baseline LDL
Active liver disease; pregnancy
LFTs at 12 weeks; lipid panel at 4-12 weeks; CK if myalgia
STAT
STAT
STAT
-
Blood pressure management (acute)
-
-
25% :: - :: - :: If SBP >220 or DBP >120 in ED: lower gently (15-25% in first 24h). If lower BP levels: permissive hypertension in first 24-48h unless end-organ damage. Avoid precipitous drops
Carotid stenosis with hemodynamic TIA: do NOT aggressively lower BP (may worsen symptoms)
5 mg :: - :: BID :: Start DOAC within 1-3 days for TIA (can start earlier than stroke). Preferred: Apixaban 5 mg BID (2.5 mg BID if criteria met). Alternative: Rivaroxaban 20 mg daily; Dabigatran 150 mg BID. Discontinue antiplatelet when anticoagulant started (do NOT combine long-term unless specific indication)
Active bleeding; mechanical valve (use warfarin); severe renal impairment
Renal function q6-12 months; bleeding signs
-
ROUTINE
ROUTINE
-
Carotid endarterectomy (CEA)
Surgery
-
50% :: - :: - :: For symptomatic carotid stenosis ≥50% (NASCET criteria); ideally performed within 2 weeks of TIA (maximum benefit). NNT = 6 for 70-99% stenosis; NNT = 22 for 50-69% stenosis
Near-occlusion (controversial); life expectancy <5 years; severe cardiac comorbidity
Post-op: BP monitoring; neuro checks q1h x 24h; wound hematoma; cranial nerve injury
-
URGENT
URGENT
-
Carotid artery stenting (CAS)
Endovascular
-
N/A :: Endovascular :: per protocol :: Alternative to CEA if: high surgical risk, prior neck radiation, prior CEA with restenosis, surgically inaccessible. Requires DAPT (aspirin + clopidogrel) post-stenting
Severe aortic arch tortuosity; fresh thrombus
Post-procedure: BP management; neuro checks; DAPT compliance; restenosis surveillance
-
ROUTINE
ROUTINE
-
PFO closure
Procedure
-
N/A :: Procedure :: per protocol :: For cryptogenic TIA/stroke age 18-60 with PFO and right-to-left shunt. Reduces recurrent stroke vs medical therapy alone (CLOSE, RESPECT, REDUCE trials). Requires 3-6 months DAPT then aspirin indefinitely
Anatomic constraints; active infection
Echo at 6-12 months; aspirin long-term
-
-
ROUTINE
-
Ezetimibe
PO
-
10 mg :: PO :: daily :: 10 mg PO daily; add if LDL not at goal on max statin
LFTs; lipid panel
-
-
ROUTINE
ROUTINE
-
PCSK9 inhibitor (evolocumab or alirocumab)
SC
-
140 mg :: SC :: monthly :: Evolocumab 140 mg SC q2 weeks or 420 mg monthly; if LDL not at goal on statin + ezetimibe
Lipid panel q4-12 weeks; injection site
-
-
-
ROUTINE
-
Diabetes management (optimize)
PO/SC
-
7% :: - :: - :: Target HbA1c <7% (individualized); GLP-1 agonists and SGLT2 inhibitors have cardiovascular benefit
ABCD2 ≥4; crescendo TIA (recurrent within 24h); large vessel stenosis identified; atrial fibrillation detected; DWI-positive on MRI; incomplete workup that cannot be completed within 24h as outpatient
Rapid TIA clinic / 24-48h outpatient workup
ABCD2 <4; symptoms fully resolved; no large vessel disease on imaging; no AF on ECG; MRI/CTA completed and negative; reliable follow-up; medications started
Discharge from ED (with next-day follow-up)
Low risk (ABCD2 0-3); all imaging completed and normal (MRI DWI negative, CTA normal, ECG sinus); medications started; reliable patient; follow-up within 24-48h guaranteed
Admit to ICU
Rarely needed; consider if hemodynamic TIA with critical stenosis; malignant hypertension; crescendo TIA progressing to stroke
Transfer to stroke center
If vascular imaging, MRI, or neurology consultation not available within 24h
Clinical features: Speech impairment without weakness
1
Duration ≥60 min
2
Duration 10-59 min
1
Diabetes
1
Total possible
7
Score
2-Day Stroke Risk
90-Day Stroke Risk
Recommendation
0-3 (Low)
1.0%
3.1%
Rapid outpatient workup within 24-48h; may discharge from ED if workup complete
4-5 (Moderate)
4.1%
9.8%
Admit or ensure <24h follow-up; start DAPT
6-7 (High)
8.1%
17.8%
Admit; aggressive workup and treatment
Note: ABCD2 is imperfect as a stand-alone tool. DWI-positive MRI, large vessel stenosis, and AF detection independently predict stroke risk regardless of ABCD2 score.