A transient ischemic attack (TIA), often called a “mini-stroke,” occurs when there is a temporary blockage of blood flow to the brain, spinal cord, or retina. This temporary reduction in blood supply, known as ischemia, causes sudden, stroke-like symptoms that fully resolve, typically within minutes to a few hours, and by definition within 24 hours. A TIA is a serious medical emergency and should not be dismissed. It serves as a strong warning sign that a full, disabling stroke may be imminent, with the risk being highest in the days immediately following the event.
Immediate Emergency Response
The most important action following the onset of symptoms, even if they disappear quickly, is to immediately call emergency services. There is no way to distinguish between a TIA and a full stroke while symptoms are occurring, and rapid assessment is necessary to prevent long-term damage. While awaiting transport, note the exact time the symptoms began and resolved, as this information is important for the medical team.
Even if you feel completely recovered, emergency medical transport is necessary for prompt evaluation at a stroke-equipped hospital. The highest risk of a full stroke is concentrated in the first 48 hours after a TIA, making time a factor in initiating preventative treatment. Seeking immediate care allows doctors to begin the diagnostic workup required to determine the underlying cause of the blockage.
Hospital Evaluation and Diagnostic Testing
Upon arrival at the emergency department, a rapid diagnostic evaluation begins to identify the cause of the TIA and assess the immediate stroke risk. Initial tests include a fingerstick blood glucose check to rule out low blood sugar, which can mimic stroke symptoms. Blood samples are also drawn for laboratory tests to check for infection, clotting abnormalities, and high cholesterol.
Brain imaging is a cornerstone of the evaluation, typically starting with a non-contrast computed tomography (CT) scan to quickly exclude a brain bleed. The preferred imaging method is a magnetic resonance imaging (MRI) scan, particularly with diffusion-weighted imaging (DWI). MRI can detect areas of acute ischemia or permanent tissue injury that may be missed on a CT scan. This advanced imaging should be performed as soon as possible, ideally within 24 hours of the symptoms’ onset.
Non-invasive vascular imaging is performed to investigate the blood vessels. This may include a carotid ultrasound to check for narrowing in the carotid arteries of the neck. Alternatively, CT angiography (CTA) or MR angiography (MRA) is used to visualize arteries in the neck and brain for blockages. Cardiac assessment is also performed, usually with a 12-lead electrocardiogram (ECG), to look for rhythm disturbances like atrial fibrillation (AF).
If the initial ECG does not find an irregular rhythm, longer-term cardiac monitoring, such as Holter monitoring, may be initiated to detect intermittent AF. An echocardiogram uses sound waves to create images of the heart and is performed to look for structural heart issues or blood clots. The results from all these tests are used to identify the mechanism behind the TIA, guiding the subsequent treatment plan.
Establishing a Treatment Plan
The primary goal of the post-TIA treatment plan is to reduce the risk of a future stroke, achieved through a personalized approach based on diagnostic findings. This plan involves pharmaceutical interventions aimed at preventing blood clots from forming or traveling to the brain. Most patients are prescribed antiplatelet drugs, such as aspirin or clopidogrel, which make blood platelets less sticky and reduce the likelihood of clot formation.
If the TIA is caused by a heart rhythm disorder like atrial fibrillation, a different class of medication called anticoagulants is used. These drugs, often referred to as blood thinners, inhibit the clotting process and are more effective than antiplatelets for heart-related clots. Common examples include warfarin and direct oral anticoagulants, such as apixaban or rivaroxaban.
Treatment also includes managing underlying conditions that contributed to the TIA. This involves prescribing medications to control high blood pressure, with a target goal typically below 140/90 mmHg. Statins are also prescribed to lower cholesterol levels, regardless of the baseline measurement. Statins help stabilize plaques in the arteries, making them less likely to rupture and cause a blockage.
For patients with severe narrowing (stenosis) in their carotid artery, a procedural intervention may be necessary to clear the blockage. Carotid endarterectomy involves surgically removing the plaque from the artery wall. Less invasive options, like carotid angioplasty and stenting, use a balloon to open the artery and a small mesh tube to keep it open.
Long-Term Prevention Strategies
Long-term stroke prevention after a TIA requires sustained commitment to managing chronic health factors and adopting lifestyle changes. Strict adherence to all prescribed medications—including antiplatelets, anticoagulants, and drugs for blood pressure and cholesterol control—is paramount to maintaining reduced stroke risk. Patients should never stop or alter these medications without first consulting their healthcare provider.
Dietary modification is an important component of this long-term strategy, emphasizing heart-healthy eating patterns like the Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet. These plans focus on reducing sodium intake, increasing consumption of fruits, vegetables, and whole grains, and limiting saturated and trans fats. Maintaining a moderate body weight also helps manage blood pressure and cholesterol levels.
Regular physical activity minimizes stroke risk by contributing to better blood pressure and weight management. Adults should aim for at least 150 minutes of moderate-intensity aerobic exercise each week, such as brisk walking or cycling. Smoking cessation is one of the most impactful changes a patient can make, as tobacco use significantly increases the risk of a recurrent vascular event.