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Transient Ischemic Attack (TIA)


Andrei V. Alexandrov

, MD, The University of Tennessee Health Science Center;

Balaji Krishnaiah

, MD, The University of Tennessee Health Science Center

Reviewed/Revised Jul 2023
Topic Resources

A transient ischemic attack (TIA) is focal brain ischemia that causes sudden, transient neurologic deficits and is not accompanied by permanent brain infarction (eg, negative results on diffusion-weighted MRI). Diagnosis is clinical. Carotid endarterectomy or stenting, antiplatelet medications, and anticoagulants decrease risk of stroke after certain types of TIA.

TIA is similar to ischemic stroke Ischemic Stroke Ischemic stroke is sudden neurologic deficits that result from focal cerebral ischemia associated with permanent brain infarction (eg, positive results on diffusion-weighted MRI). Common causes... read more Ischemic Stroke except that symptoms usually last < 1 hour; most TIAs last < 5 minutes. Infarction is very unlikely if deficits resolve within 1 hour. As shown by diffusion-weighted MRI and other studies, deficits that resolve spontaneously within 1 to 24 hours are often accompanied by infarction and are thus no longer considered TIAs.

TIAs are most common among middle-aged and older people. TIAs markedly increase risk of stroke, beginning in the first 24 hours.

Etiology of TIA

Risk factors for TIA are the same as those for ischemic stroke.

Modifiable risk factors include the following:

Unmodifiable risk factors include the following:

  • Prior stroke

  • Older age

  • Family history of stroke

  • Male sex

In subclavian steal syndrome, a subclavian artery stenosed proximal to the origin of the vertebral artery “steals” blood from the vertebral artery (in which blood flow reverses) to supply the arm during exertion, causing signs of vertebrobasilar ischemia.

Occasionally, TIAs occur in children with a severe cardiovascular disorder that produces emboli or with a very high hematocrit due to chronic hypoxemia.

Symptoms and Signs of TIA

Neurologic deficits are similar to those of strokes (see table Selected Stroke Syndromes Selected Stroke Syndromes Selected Stroke Syndromes ). Transient monocular blindness (amaurosis fugax), which usually lasts < 5 minutes, may occur when the ophthalmic artery is affected.


Symptoms of TIAs begin suddenly, usually last 2 to 30 minutes, then resolve completely. Patients may have several TIAs daily or only 2 or 3 over several years. Symptoms are usually similar in successive carotid attacks but vary somewhat in successive vertebrobasilar attacks.

Diagnosis of TIA

  • Resolution of stroke-like symptoms within 1 hour

  • Neuroimaging

  • Evaluation to identify the cause

Transient ischemic attacks are diagnosed retrospectively when sudden neurologic deficits referable to ischemia in an arterial territory resolve within 1 hour.

Isolated peripheral facial nerve palsy, loss of consciousness, or impaired consciousness does not suggest TIA. TIAs must be distinguished from other causes of similar symptoms, such as

Because an infarct, a small hemorrhage, and even a mass lesion cannot be excluded clinically, neuroimaging is required. Usually, CT is the study most likely to be immediately available. However, CT may not identify infarcts for > 24 hours. MRI usually detects evolving infarction within hours. Diffusion-weighted MRI is the most accurate imaging test to rule out an infarct in patients with presumed TIA but is not always available.

The cause of a TIA is sought as for causes of ischemic strokes Etiology Ischemic stroke is sudden neurologic deficits that result from focal cerebral ischemia associated with permanent brain infarction (eg, positive results on diffusion-weighted MRI). Common causes... read more Etiology ; evaluation includes tests for carotid stenosis, cardiac sources of emboli, atrial fibrillation Atrial Fibrillation Atrial fibrillation is a rapid, irregularly irregular atrial rhythm. Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form... read more , and hematologic abnormalities and screening for stroke risk factors. Because risk of subsequent ischemic stroke is high and immediate, evaluation proceeds rapidly, usually on an inpatient basis. It is not clear which patients, if any, can be safely discharged from the emergency department. Risk of stroke after TIA or minor stroke is highest within the first 24 to 48 hours, so if either is suspected, patients are typically admitted to the hospital for telemetry and evaluation.

Patients are at high risk of TIA if they have an ABCD2 score > 4.

The ABCD2 score is used to estimate risk of stroke after TIA and is calculated by adding the following:

  • A (age): ≥ 60 = 1

  • B (blood pressure): Systolic blood pressure ≥ 140 and/or diastolic blood pressure > 90 = 1

  • C (clinical features): Weakness = 2, speech disturbance without weakness = 1

  • D (TIA duration): ≥ 60 min = 2, 10 to 59 min = 1, < 10 minutes = 0

  • D2 (diabetes) = 1

Risk of stroke within 2 days based on the ABCD2 score is about

  • For a score of 6 to 7: 8%

  • For a score of 4 to 5: 4%

  • For a score of 0 to 3: 1%

All patients who have had a TIA require CT angiography, magnetic resonance angiography (MRA), or diffusion-weighted MRI of the carotid and cerebral circulation.

Treatment of TIA

Treatment of transient ischemic attacks is aimed at preventing strokes; antiplatelet medications and statins are used. Carotid endarterectomy or arterial angioplasty plus stenting can be useful for some patients, particularly those who have no neurologic deficits but who are at high risk of stroke (> 70% ipsilateral carotid stenosis). Anticoagulation is indicated if cardiac sources of emboli are present.

Modifying stroke risk factors, when possible, may prevent stroke.

Key Points

  • A focal neurologic deficit that resolves within 1 hour is almost always a transient ischemic attack.

  • Test as for ischemic stroke.

  • Use the same treatments used for secondary prevention of ischemic stroke (eg, antiplatelet medications, statins, sometimes carotid endarterectomy or arterial angioplasty plus stenting).

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