PassFinals
Neurology

Transient ischaemic attack

A transient focal neurological syndrome caused by cerebral, spinal or retinal ischaemia without acute infarction; symptoms may resolve quickly, but the event is a medical warning that requires immediate aspirin and specialist assessment within 24 hours.

In a nutshell

A TIA is a transient focal neurological syndrome without acute infarction, but it is not benign: give aspirin 300 mg immediately (see BNF) unless contraindicated, arrange specialist assessment within 24 hours and start mechanism-led secondary prevention.

Classic presentation

Sudden facial or limb weakness, dysphasia, transient monocular visual loss or posterior-circulation symptoms that have completely resolved by assessment.

Key points

  • TIA is tissue-defined; do not use a fixed 24-hour rule as the diagnosis.
  • Give aspirin 300 mg immediately (see BNF) unless contraindicated and arrange specialist assessment within 24 hours.
  • Do not use ABCD2 to decide urgency or treatment.
  • A deficit that persists is managed as suspected stroke, not a reassuring TIA.
  • Consider MRI after specialist assessment when defining ischaemic territory, excluding haemorrhage or resolving diagnostic uncertainty will change management.
  • Within 24 hours of TIA or minor stroke, selected low-bleeding-risk patients may receive short-course aspirin plus clopidogrel or ticagrelor under the specialist stroke pathway (see BNF); long-term dual therapy is not routine.
  • Look for atrial fibrillation and symptomatic carotid stenosis because anticoagulation or revascularisation may prevent the next stroke.

First-line investigation

Urgent specialist neurovascular assessment with glucose, ECG and targeted brain, carotid and cardiac imaging according to the clinical question.

Management

Treat the warning event as an emergency

  • Give aspirin 300 mg immediately (see BNF) unless contraindicated, document the last-known-well time and give explicit 999 safety-netting.1,2,6

Obtain urgent specialist assessment

  • Arrange specialist neurovascular assessment and investigation to be completed within 24 hours; do not use ABCD2 to downgrade urgency.1,3,2
  • Use clinical history, examination, glucose and ECG to separate TIA from stroke and common mimics.1,2

Identify the vascular mechanism

  • Use MRI selectively after specialist assessment, and arrange carotid imaging within 24 hours when carotid intervention may be appropriate.1,2,5
  • Monitor for atrial fibrillation and use prolonged rhythm monitoring or echocardiography when the result could change anticoagulation or another prevention decision.2,5

Escalate recurrent symptoms and high-risk mechanisms

  • Call 999 for recurrent or persistent focal symptoms, and escalate urgently to stroke and vascular teams for symptomatic carotid disease, AF, crescendo events or diagnostic uncertainty.1,2,4

Prevent recurrence

  • Use short-course dual antiplatelet therapy only when the specialist pathway confirms eligibility; then continue mechanism-appropriate monotherapy or anticoagulation and treat vascular risk factors.2,5,7,8

Exam traps

  • ABCD2 should not be used to ration urgent TIA assessment.
  • A resolved neurological deficit is still an emergency; a persistent deficit is suspected stroke.
  • Do not delay immediate aspirin for routine imaging when TIA is suspected and there is no contraindication.
  • Posterior-circulation TIA may present with diplopia, dysarthria, ataxia or visual symptoms without classic FAST findings.
  • Do not use long-term aspirin plus clopidogrel without another indication; antiplatelet versus anticoagulant treatment depends on mechanism.

Illustrations

Anterior vs posterior circulation TIA symptomsDiagram mapping carotid territory symptoms (weakness, dysphasia, amaurosis fugax) against vertebrobasilar symptoms (diplopia, vertigo, ataxia).PassFinals · original
TIA vs stroke timelineTimeline diagram showing a transient occlusion with resolving symptoms and no infarction, contrasted against a persistent occlusion progressing to infarct.PassFinals · original

Key sources

  1. NICE NG128: Stroke and transient ischaemic attack in over 16s, recommendations (NG128, current recommendations; last reviewed March 2026)
  2. National Clinical Guideline for Stroke 2023: Acute care (Intercollegiate Stroke Working Party, 2023, acute care chapter)
  3. NICE NG128: Rationale and impact for TIA assessment and risk scoring (NG128 rationale and impact; risk scores and urgent assessment)
  4. NHS: Stroke symptoms (NHS condition information)
  5. National Clinical Guideline for Stroke 2023: Long-term management and secondary prevention (Intercollegiate Stroke Working Party, 2023, secondary prevention chapter)
  6. BNF: Aspirin (BNF medicine monograph)
  7. BNF: Clopidogrel (BNF medicine monograph)
  8. BNF: Atorvastatin (BNF medicine monograph)
  9. NHS: Stroke treatment (NHS condition information)
  10. NICE NG128: Update information (NG128 update information, including TIA and clopidogrel review)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.