TIA Workup and Secondary Stroke Prevention

Algorithm Steps

1. ▶

   Start

   Suspected TIA

   Transient focal neurological deficit, resolved

   1. ●

      Action

      Urgent Evaluation

      Complete workup within 24-48 hours

      • Risk of stroke highest in first 48h
      • ED observation unit or TIA clinic
      • ESO recommends 24h workup
      • AHA allows up to 48h
      1. ●

         Action

         Calculate ABCD2 Score

         Risk stratification tool

         • A: Age ≥60 (+1)
         • B: BP ≥140/90 (+1)
         • C: Clinical features: unilateral weakness (+2), speech impairment (+1)
         • D: Duration ≥60 min (+2) or 10-59 min (+1)
         • D: Diabetes (+1)
         • Score 0-3: low, 4-5: moderate, 6-7: high risk
         1. ●

            Action

            Brain and Vascular Imaging

            MRI preferred over CT

            • MRI with DWI (detects 30-50% have infarct)
            • MRA or CTA of head and neck
            • Carotid ultrasound if MRA/CTA unavailable
            • CT/CTA if MRI contraindicated
            1. ●

               Action

               Cardiac Evaluation

               Search for cardioembolic source

               • ECG (look for AFib)
               • Echocardiogram (TTE, consider TEE)
               • Cardiac monitoring ≥24h
               • Extended monitoring if cryptogenic (30 days)
               1. ◆

                  Decision

                  Determine Etiology

                  TOAST classification

                  • Large artery atherosclerosis
                  • Cardioembolism (AFib, PFO, etc.)
                  • Small vessel disease
                  • Other determined cause
                  • Cryptogenic
                  1. ●

                     Action

                     Atrial Fibrillation

                     Anticoagulation indicated

                     • DOAC preferred over warfarin
                     • Calculate CHA₂DS₂-VASc
                     • Assess bleeding risk (HAS-BLED)
                     • No need for concurrent antiplatelet usually
                     1. ●

                        Action

                        Risk Factor Management

                        Long-term secondary prevention

                        • BP target <130/80 mmHg
                        • High-intensity statin (LDL <70 mg/dL)
                        • Glycemic control (HbA1c <7%)
                        • Smoking cessation
                        • Mediterranean diet, exercise
                        1. ✓

                           Outcome

                           Secondary Prevention Initiated

                           Follow-up and monitoring

                           • Neurology follow-up in 1-2 weeks
                           • Primary care for risk factor management
                           • Stroke education, warning signs
                           • Driving restrictions per local laws
                  2. ◆

                     Decision

                     Carotid Stenosis?

                     Check for symptomatic stenosis

                     • Ipsilateral to symptoms
                     • ≥50% NASCET criteria = significant
                     • ≥70% strongly consider intervention
                     1. ●

                        Action

                        Carotid Revascularization

                        CEA or CAS if indicated

                        • CEA within 2 weeks if symptomatic 70-99%
                        • Consider for 50-69% based on risk factors
                        • CAS alternative if high surgical risk
                        • Dual antiplatelet before and after CAS
                     2. ●

                        Action

                        Non-Cardioembolic TIA

                        Antiplatelet therapy

                        • DAPT (aspirin + clopidogrel) for 21-30 days
                        • Start within 24h of symptom onset
                        • Then single antiplatelet long-term
                        • High-intensity statin (LDL target <70)
                        1. ●

                           Action

                           DAPT Protocol (POINT/CHANCE)

                           Short-term dual antiplatelet

                           • Aspirin 325 mg load + clopidogrel 300 mg load
                           • Then ASA 81 mg + clopidogrel 75 mg daily
                           • Duration: 21 days (CHANCE) to 90 days (POINT)
                           • Most benefit in first 21 days
                           • After DAPT: single agent (clopidogrel or ASA)
                           1. ●

                              Action

                              Intracranial Stenosis

                              If 70-99% symptomatic stenosis

                              • DAPT (ASA + clopidogrel) up to 90 days
                              • Aggressive medical management preferred
                              • Stenting NOT recommended (SAMMPRIS)
                              • Consider in failure of medical therapy only
            2. ●

               Action

               Laboratory Studies

               Standard workup

               • Fasting lipid panel (target LDL <70)
               • HbA1c, fasting glucose
               • CBC, BMP, coagulation studies
               • Consider hypercoagulability workup if young