A patient comes in with sudden slurred speech and right arm weakness that resolved in 15 minutes. Now they look fine. The rookie temptation? “They’re better now, no need to worry.” Wrong. Transient Ischemic Attacks (TIAs) are neurological emergencies — warning shots for stroke. The ED is the frontline to prevent disaster.
What Is a TIA?
- A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia.
- By definition: no acute infarction on imaging and symptoms resolve within 24 hrs (usually minutes).
- Think of TIA as “angina of the brain.”
Why TIAs Matter
- Stroke risk after TIA:
- 5% within 48 hrs
- 10–15% within 90 days
- Up to half of strokes after TIA are preventable with urgent ED action.
Step 1: Rapid Assessment
- ABCs, vitals, glucose.
- Full neuro exam (even if normal now).
- Look for focal deficits, carotid bruits, irregular pulse (AFib).
Step 2: Imaging
- CT head non-contrast: rule out bleed or mimic.
- CTA head/neck: check for carotid stenosis, large vessel occlusion.
- MRI brain (DWI): detects small infarcts missed on CT.
- Don’t delay secondary prevention if imaging negative.
Step 3: Labs & ECG
- CBC, electrolytes, renal, glucose, lipids, HbA1c.
- ECG for atrial fibrillation.
- Consider telemetry/echo for cardioembolic source.
Step 4: Risk Stratification
- ABCD² score:
- Age ≥60 (1)
- BP ≥140/90 (1)
- Clinical features: unilateral weakness (2), speech impairment (1)
- Duration: ≥60 min (2), 10–59 min (1)
- Diabetes (1)
- Score ≥4 = higher risk → admission usually warranted.
Step 5: Treatment in the ED
- Antiplatelets:
- Aspirin 300 mg immediately (if no bleed on CT).
- If minor stroke/TIA and low bleed risk → dual therapy (ASA + clopidogrel) for 21 days (per POINT/CHANCE trials).
- Statin: high-intensity statin (e.g., atorvastatin 80 mg).
- BP control: avoid aggressive lowering acutely unless >220/120.
- Glucose control: avoid extremes.
- Anticoagulation: if AFib confirmed, start once hemorrhage excluded.
Step 6: Disposition
- Admit if:
- Ongoing/recurrent symptoms.
- ABCD² ≥4.
- Large vessel disease on imaging.
- Unreliable follow-up.
- Discharge with expedited outpatient stroke clinic if very low risk and rapid follow-up available.
Common Rookie Mistakes
- Dismissing TIA because symptoms resolved.
- Forgetting to order vascular imaging.
- Discharging without antiplatelet therapy.
- Not considering AFib or cardioembolic causes.
- Ignoring stroke mimics (migraine, seizure, hypoglycemia).
Rookie Pearls
- “TIA is a stroke warning, not a benign event.”
- ABCD² score is useful but not absolute — use clinical judgment.
- Always give antiplatelet + statin unless contraindicated.
- Admit if uncertain — safer than sending home a high-risk patient.
- Document onset time, duration, and full neuro exam even if normal now.
Take-Home Message
For rookies:
- TIA = high-risk stroke warning.
- Rapid imaging, risk stratification, and secondary prevention are essential.
- Aspirin + statin + risk assessment in the ED saves lives.
Never blow off a TIA — it’s your chance to prevent a devastating stroke.
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