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TIA Workup and Secondary Stroke Prevention

TIA Workup and Secondary Stroke Prevention: Suspected TIA in an adult → Symptoms still present, fluctuating or recurring? → Symptoms present or fluctuat...

Pathway Overview

27 steps

Algorithm Steps

27 total

  1. 01Start

    Suspected TIA in an adult

    Sudden focal neurological deficit (weakness, numbness, speech or vision loss). First ask: has it fully resolved?

  2. 02Decision

    Symptoms still present, fluctuating or recurring?

    Examine now. Symptoms present or fluctuating at assessment are treated as a stroke, not a TIA.

  3. If Yes
    1. 03Action

      Symptoms present or fluctuating: treat as acute stroke now

      Time-critical. Assess for thrombolysis or thrombectomy.

      • Call the stroke team (code stroke); outside hospital, call 000
      • Check capillary glucose; immediate brain CT or MRI with CTA
      • No aspirin or other antithrombotic before brain imaging
      • Continue on the acute ischaemic stroke pathway
    2. 04Outcome

      Managed on the acute stroke pathway

      Return to the secondary prevention steps below after acute treatment decisions.

    If No
    1. 05Action

      Symptoms resolved: same-day assessment (ED or TIA clinic)

      Every suspected TIA is urgent, whatever the ABCD2 score. Do tests now; if not available at once, within 48 h.

      • Capillary glucose now: hypoglycaemia can mimic TIA
      • 12-lead ECG now: look for AF
      • Highest risk: crescendo TIAs, AF, taking an anticoagulant, or carotid territory symptoms: stroke specialist review now
      • Age 50 or more with transient vision loss, new headache or jaw claudication: ESR and CRP now (giant cell arteritis needs same-day steroids)
      • Consider mimics: migraine aura, focal seizure or Todd's paresis, syncope, BPPV, transient global amnesia
    2. 06Action

      Blood tests at the first visit

      Results guide the antithrombotic choice and dose.

      • FBC; UEC with creatinine clearance (Cockcroft-Gault) for DOAC dosing
      • INR and APTT (essential if taking an anticoagulant)
      • Glucose, HbA1c and lipid profile (fasting not needed)
      • Young patient or no cause found: targeted tests on specialist advice (e.g. antiphospholipid antibodies); confirmed antiphospholipid syndrome: warfarin, not a DOAC (haematology advice)
    3. 07Action

      ABCD2 score: use it to choose DAPT, not to delay tests

      A low score does not exclude AF or carotid stenosis (about 1 in 4 'low-risk' patients has one). Score 4 or more = high-risk TIA.

      • Age 60 years or more: 1
      • BP 140/90 mmHg or more at first assessment: 1
      • Clinical: unilateral weakness 2; speech disturbance without weakness 1
      • Duration: 60 min or more 2; 10 to 59 min 1
      • Diabetes: 1
      • Total 0 to 7: 0 to 3 low, 4 to 5 moderate, 6 to 7 high risk
    4. 08Action

      Brain and vessel imaging now (maximum 48 h)

      Brain CT or MRI must exclude haemorrhage before any antithrombotic is given.

      • Brain: MRI with DWI preferred (about 1 in 3 shows an infarct); CT if MRI is not quickly available
      • Vessels: CTA or MRA from aortic arch to vertex
      • No CTA or MRA: carotid Doppler for anterior circulation symptoms (it does not assess the posterior circulation)
      • Carotid imaging must not be delayed more than 2 days
    5. 09Decision

      Haemorrhage on brain imaging?

      Includes intracerebral haemorrhage, subdural haematoma and convexity subarachnoid blood (amyloid spells).

    6. If Yes
      1. 10Outcome

        Haemorrhage found: not a TIA; no antithrombotic

        Give no antiplatelet or anticoagulant. Reverse any anticoagulant. Manage on the intracerebral haemorrhage pathway with neurology or neurosurgery.

      If No
      1. 11Warning

        No haemorrhage: before any antithrombotic, check these

        After IV thrombolysis: no antiplatelet or anticoagulant until 24-h brain imaging excludes haemorrhage. Aspirin allergy or aspirin-induced asthma: use clopidogrel alone. Otherwise start antithrombotic therapy now; do not wait for the full work-up. Pregnancy: no DOAC, warfarin or statin; obstetric medicine and stroke specialist advice (LMWH if anticoagulation is needed).

        • Active bleeding or previous intracerebral haemorrhage: stroke specialist advice before any antithrombotic
        • Fever, new murmur, IV drug use or prosthetic valve: suspect infective endocarditis; 3 sets of blood cultures and echo; no new antiplatelet or anticoagulant without specialist advice
        • Already taking an anticoagulant: check adherence, dose and INR; specialist advice; do not add an antiplatelet routinely
      2. 12Decision

        Atrial fibrillation (known, on ECG or on monitoring)?

        Paroxysmal, persistent or permanent AF all count.

      3. If Yes
        1. 13Warning

          AF with mechanical valve or moderate-severe mitral stenosis: warfarin, no DOAC

          DOACs caused more strokes and bleeds with mechanical valves (RE-ALIGN). Check the echo and history before choosing. Confirmed antiphospholipid syndrome: also warfarin, not a DOAC (haematology advice).

          • Mechanical valve: warfarin; INR target by valve (mechanical mitral 2.5 to 3.5)
          • Ask about rheumatic heart disease (higher rates in Aboriginal and Torres Strait Islander, Maori and Pacific peoples)
          • Creatinine clearance too low for any DOAC: warfarin (INR 2.0 to 3.0)
        2. 14Action

          AF: start an oral anticoagulant, not an antiplatelet

          TIA without infarct: start as soon as imaging excludes haemorrhage (after IV thrombolysis: not within 24 h). DOAC preferred over warfarin (except valve conditions above).

          • DOAC (apixaban, dabigatran or rivaroxaban): dose by age, weight and creatinine clearance per product information
          • Check interactions (e.g. strong CYP3A4 or P-gp inhibitors or inducers, some antiepileptics)
          • Infarct on MRI: minor-moderate stroke start within 48 h; major stroke day 6 to 7 (ELAN)
          • No added antiplatelet unless a clear indication (e.g. recent coronary stent)
          • Treat modifiable bleeding risks (BP, alcohol, NSAIDs); a bleeding score is not a reason to withhold
          • Anticoagulant truly contraindicated: specialist advice (left atrial appendage occlusion); aspirin is not a substitute
        3. 15Outcome

          Antithrombotic started today: complete the cardiac and cause work-up

          Treatment does not wait for the full work-up. Cardiac tests and cause-specific steps follow.

        If No
        1. 16Decision

          No AF: high-risk TIA (ABCD2 4 or more) or minor stroke, seen early?

          Minor stroke = NIHSS 3 or less (a TIA with a small infarct on MRI counts). Best started within 24 h of onset. Up to 72 h, or NIHSS 4 to 5 within 24 h, is reasonable when a 50% or more stenosis explains the event and no IV thrombolysis was given (AHA 2026).

        2. If Yes
          1. 17Action

            High-risk TIA or minor stroke: aspirin plus clopidogrel for 21 days

            Adults. Not if: need for anticoagulation, previous intracerebral haemorrhage, active bleeding, or thrombolysis in the past 24 h.

            • Load once: aspirin 300 mg plus clopidogrel 300 mg to 600 mg orally
            • Then daily: aspirin 100 mg to 150 mg plus clopidogrel 75 mg orally
            • Stop one agent at day 21; continue a single antiplatelet long term
            • Up to 90 days only for 70 to 99% intracranial stenosis (see below)
            • Gastric protection if needed: pantoprazole (fewer CYP2C19 interactions with clopidogrel)
            • Never continue DAPT long term (more bleeding, no benefit)
          2. Path rejoins step 15Shared downstream outcome
          If No
          1. 18Action

            Low-risk TIA, late presentation or DAPT not suitable: single antiplatelet

            Adults. Start as soon as imaging excludes haemorrhage (after IV thrombolysis: only after 24-h imaging) and continue long term.

            • Aspirin 300 mg load, then 100 mg to 150 mg daily
            • Or clopidogrel 75 mg daily (300 mg load if rapid onset is needed)
            • Or aspirin 25 mg plus dipyridamole modified release 200 mg, twice daily
          2. Path rejoins step 15Shared downstream outcome
    7. Work-up continues
    8. 19Action

      All patients without haemorrhage: cardiac tests for a source of emboli

      Runs alongside treatment. Complete during admission or at the TIA clinic.

      • Cardiac monitoring for at least 24 h
      • Echocardiogram if a cardiac source is possible; TOE is more sensitive for left atrial, valve and aortic arch disease
      • No cause found: prolonged monitoring (30-day monitor or implantable loop recorder)
      • AF found at any time: stop the antiplatelet and start an anticoagulant (see AF step)
    9. 20Action

      All patients: long-term risk factor treatment

      Start before discharge or at the TIA clinic visit. Then check for a specific cause below.

      • BP: start or intensify if above 140/90 mmHg; target below 130/80 mmHg for most
      • High-potency statin (atorvastatin 80 mg, or rosuvastatin 40 mg except in Asian patients or CrCl below 30 mL/min) if atherosclerosis is possible; LDL target below 1.8 mmol/L; add ezetimibe 10 mg if needed
      • Diabetes: individualised HbA1c target, often below 7% (53 mmol/mol)
      • Stop smoking; alcohol no more than 10 standard drinks a week and 4 on any day
      • Mediterranean-style diet, regular physical activity, weight loss if overweight
      • Women: avoid starting HRT; prefer non-oestrogen contraception
    10. 21Decision

      Cause found on imaging and cardiac tests?

      Go to each step that applies, then to the follow-up step at the end. No specific cause (e.g. small vessel disease): go straight to follow-up.

    11. Carotid stenosis 50-99%
    12. 22Action

      Symptomatic carotid stenosis 50 to 99%: vascular surgery referral now

      Stenosis ipsilateral to symptoms (NASCET method). Benefit is greatest with early surgery.

      • 70 to 99%: carotid endarterectomy, ideally within 2 weeks (centre stroke or death rate below 6%)
      • 50 to 69%: endarterectomy for selected patients (centre rate below 3%)
      • Endarterectomy preferred over stenting; stenting if unfavourable anatomy, restenosis or prior neck radiotherapy
      • Continue antiplatelet, statin and BP treatment; stenting needs aspirin plus clopidogrel (proceduralist plan)
      • Below 50%, occluded or asymptomatic: no revascularisation; best medical therapy
    13. Intracranial stenosis 70-99%
    14. 23Action

      Symptomatic intracranial stenosis 70 to 99%: DAPT up to 90 days

      Event in the past 30 days. Intensive medical therapy; stenting is not first line.

      • Aspirin plus clopidogrel 75 mg daily for up to 90 days, then a single antiplatelet
      • Target systolic BP below 140 mmHg and LDL below 1.8 mmol/L
      • Angioplasty or stenting: not first line (SAMMPRIS); specialist decision after failed medical therapy
      • Warfarin gives no benefit over aspirin and more bleeding (WASID)
    15. Dissection
    16. 24Action

      Cervical artery dissection: antiplatelet or anticoagulant for at least 3 months

      Neither is clearly better (CADISS, TREAT-CAD). Individual choice with the stroke team.

      • Intracranial dissection: neurology or neurosurgery advice before any anticoagulant
      • Repeat vessel imaging to guide duration
    17. PFO
    18. 25Action

      PFO, age 18 to 60, no other cause: joint neurology and cardiology review

      PFO closure reduces recurrence after non-lacunar ischaemic stroke with high-risk PFO features. Evidence for TIA alone is weaker.

      • Exclude other causes first, including occult AF (prolonged monitoring)
      • Continue antiplatelet therapy; anticoagulate only for another indication (e.g. DVT)
    19. Cryptogenic
    20. 26Action

      No cause found (cryptogenic or ESUS): look for occult AF

      Continue the antiplatelet. Do not start empirical anticoagulation (no benefit in trials).

      • Prolonged rhythm monitoring: 30-day monitor or implantable loop recorder
      • AF found: switch to an anticoagulant
      • Age 60 or under: bubble echo for PFO
    21. No specific cause
    22. 27Outcome

      All patients: follow-up and safety-netting

      Call 000 at once if symptoms return. No driving for 2 weeks (private licence) or 4 weeks (commercial licence) after a TIA (Austroads).

      • GP review of BP, lipids and adherence; stroke or TIA clinic follow-up
      • Stop DAPT at day 21 (day 90 for intracranial stenosis)
      • Written information on TIA and stroke warning signs

Guideline Source

2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack - AHA/ASA (Kleindorfer et al., Stroke 2021;52:e364-e467); with the Australian and New Zealand Living Clinical Guidelines for Stroke Management (Chapters 2 and 4) and the 2026 AHA/ASA acute ischaemic stroke guideline (section 4.8, DAPT)

DOI: 10.1161/STR.0000000000000375View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only. Symptoms still present or fluctuating = acute stroke pathway, not this pathway.
  • No antithrombotic until brain imaging excludes haemorrhage. DOAC dose depends on age, weight and creatinine clearance: use the product information.
  • Intracranial stenosis, dissection and PFO decisions need stroke specialist input; stenting and PFO closure are specialist decisions.
  • Does not cover intracerebral haemorrhage, cerebral venous sinus thrombosis or children.

Contraindicated Populations

Children (under 18 years)Pregnancy: obstetric medicine and stroke specialist advice (no DOAC, warfarin or statin)

Applicable Regions

AUNZUSEUglobal

AU: Australian and New Zealand Living Clinical Guidelines for Stroke Management (Stroke Foundation) Chapters 2 and 4. Driving after TIA: Austroads Assessing Fitness to Drive, no driving for 2 weeks (private) or 4 weeks (commercial). Ticagrelor for stroke or TIA is off-label in Australia.

EU: Follow ESO or national guidance where it differs; antithrombotic principles are the same.

NZ: Same living guideline as Australia. Check NZTA medical aspects of fitness to drive for local driving rules.

US: AHA/ASA 2021 secondary prevention guideline; 2026 AHA/ASA acute ischaemic stroke guideline for early DAPT (section 4.8).

Version 2Next review: 2027-09-30

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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 (Kleindorfer et al., Stroke 2021;52:e364-e467); with the Australian and New Zealand Living Clinical Guidelines for Stroke Management (Chapters 2 and 4) and the 2026 AHA/ASA acute ischaemic stroke guideline (section 4.8, DAPT).

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 (Kleindorfer et al., Stroke 2021;52:e364-e467); with the Australian and New Zealand Living Clinical Guidelines for Stroke Management (Chapters 2 and 4) and the 2026 AHA/ASA acute ischaemic stroke guideline (section 4.8, DAPT) (DOI: 10.1161/STR.0000000000000375).

What are the limitations of the TIA Workup and Secondary Stroke Prevention?

Known limitations include: Adults only. Symptoms still present or fluctuating = acute stroke pathway, not this pathway.; No antithrombotic until brain imaging excludes haemorrhage. DOAC dose depends on age, weight and creatinine clearance: use the product information.; Intracranial stenosis, dissection and PFO decisions need stroke specialist input; stenting and PFO closure are specialist decisions.; Does not cover intracerebral haemorrhage, cerebral venous sinus thrombosis or children.. Individual patient factors may require deviation from these recommendations.

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