Work up of transient ischemic attack — TIA

1. Big picture

A transient ischemic attack (TIA) is not a “minor event.” It is a neurological emergency because it is often the warning sign before a disabling ischemic stroke. The exam point is simple: a patient with TIA must be worked up like an acute stroke patient until proven otherwise.

The work-up has four goals:

1. Confirm that the event was really ischemic, not a mimic.

2. Localize the vascular territory: carotid/anterior circulation vs vertebrobasilar/posterior circulation.

3. Find the cause: large artery stenosis, cardioembolism, small vessel disease, dissection, hypercoagulability, etc.

4. Start immediate secondary prevention to prevent the next stroke.

Modern guidelines emphasize urgent brain imaging, vascular imaging, cardiac evaluation, and rapid secondary prevention. AHA/ASA guidance stresses that TIA evaluation without MRI may miss higher-risk patients and that vascular imaging is required in acute TIA evaluation; ESO/AHA comparisons also emphasize completing the work-up urgently, ideally within 24–48 hours.