Suspected TIA
Transient focal neurological deficit, resolved
All Pathways
NeurologyDiagnostic
TIA Workup and Secondary Stroke Prevention
TIA Workup and Secondary Stroke Prevention: Suspected TIA → Urgent Evaluation → Calculate ABCD2 Score → Brain and Vascular Imaging → Cardiac Evaluation.
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action 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
03Action 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
04Action 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
05Action Cardiac Evaluation
Search for cardioembolic source
- ECG (look for AFib)
- Echocardiogram (TTE, consider TEE)
- Cardiac monitoring ≥24h
- Extended monitoring if cryptogenic (30 days)
06Decision Determine Etiology
TOAST classification
- Large artery atherosclerosis
- Cardioembolism (AFib, PFO, etc.)
- Small vessel disease
- Other determined cause
- Cryptogenic
07Action Atrial Fibrillation
Anticoagulation indicated
- DOAC preferred over warfarin
- Calculate CHA₂DS₂-VASc
- Assess bleeding risk (HAS-BLED)
- No need for concurrent antiplatelet usually
08Action 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
09Outcome 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
10Decision Carotid Stenosis?
Check for symptomatic stenosis
- Ipsilateral to symptoms
- ≥50% NASCET criteria = significant
- ≥70% strongly consider intervention
11Action 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
- Path rejoins step 08Shared downstream outcome
12Action 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)
13Action 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)
- Path rejoins step 08Shared downstream outcome
14Action 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
- Path rejoins step 08Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
15Action Laboratory Studies
Standard workup
- Fasting lipid panel (target LDL <70)
- HbA1c, fasting glucose
- CBC, BMP, coagulation studies
- Consider hypercoagulability workup if young
- Path rejoins step 06Shared downstream outcome
Guideline Source
2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack - AHA/ASA
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not cover pediatric stroke/TIA
- Assumes access to MRI/MRA
- Anticoagulation decisions require individual bleeding risk assessment
- DAPT duration varies by specific scenario
Contraindicated Populations
pediatric
Applicable Regions
USEUglobal
EU: ESO guidelines similar but 24h workup window preferred
US: AHA/ASA 2021 guidelines followed
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the TIA Workup and Secondary Stroke Prevention?
The TIA Workup and Secondary Stroke Prevention is a diagnostic clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack - AHA/ASA.
What guideline is the TIA Workup and Secondary Stroke Prevention based on?
This algorithm is based on 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack - AHA/ASA (DOI: 10.1161/STR.0000000000000375).
What are the limitations of the TIA Workup and Secondary Stroke Prevention?
Known limitations include: Does not cover pediatric stroke/TIA; Assumes access to MRI/MRA; Anticoagulation decisions require individual bleeding risk assessment; DAPT duration varies by specific scenario. Individual patient factors may require deviation from these recommendations.
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