Transient Ischemic Attack (TIA)

Transient Ischemic Attack (TIA) is a topic covered in the 5-Minute Clinical Consult.

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  • A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction
  • Most important predictor of stroke: 15% of patients with stroke report previous TIA.
  • Synonym(s): ministroke


  • 200,000 to 500,000 new TIA cases reported each year
    • 83 cases per 100,000 people/year in the United States
    • 400 to 800 cases per 100,000 persons aged 50 to 59 years
  • Prevalence of TIA in general population: ~2.3%
  • Predominant age: Risk increases >60 years; highest in 7th and 8th decades
  • Predominant sex: male > female (3:1)
  • Predominant race/ethnicity: African Americans > Hispanics > Caucasians. The difference in African Americans is exaggerated at younger ages.

Etiology and Pathophysiology

Temporary reduction/cessation of cerebral blood flow adversely affecting neuronal function

  • Carotid/vertebral atherosclerotic disease
    • Artery-to-artery thromboembolism
    • Low-flow ischemia
  • Small, deep vessel disease associated with hypertension (HTN)
    • Lacunar infarcts
  • Cardiac diseases
    • 1–6% of patients with MI develop stroke.
  • Embolism secondary to the following:
    • Valvular (mitral valve) pathology
    • Mural hypokinesias/akinesias with thrombosis (acute anterior MI/congestive cardiomyopathies)
    • Cardiac arrhythmia (atrial fibrillation accounts for 5–20% incidence)
  • Hypercoagulable states
    • Antiphospholipid antibodies
    • Increased estrogen (e.g., oral contraceptives)
    • Pregnancy and parturition
  • Arteritis
    • Noninfectious necrotizing vasculitis
    • Drugs
    • Irradiation
    • Local trauma
  • Sympathomimetic drugs (e.g., cocaine)
  • Other causes: spontaneous and posttraumatic (e.g., chiropractic manipulation) arterial dissection
  • Fibromuscular dysplasia

Inheritance is polygenic, with tendency to clustering of risk factors within families.

Risk Factors

  • HTN
  • Cardiac diseases (atrial fibrillation, MI, valvular disease)
  • Diabetes
  • Hyperlipidemia
  • Atherosclerotic disease (carotid/vertebral stenosis)
  • Cigarette smoking
  • Thrombophilias

General Prevention

  • Lifestyle changes: smoking cessation, diet modification, weight loss, regular aerobic exercise, and limited alcohol intake
  • Strict control of medical risk factors: diabetes (glycemic control), HTN (thiazide and/or ACE/ARB), hyperlipidemia (statins), anticoagulation when high risk of cardioembolism (e.g., atrial fibrillation, mechanical valves)
  • Causation is key to preventing recurrence (1).
  • 10–20% of patients with TIA have CVA within 90 days; up to 80% of this risk is preventable (2).
  • 25–50% of those occur within the first 48 hours.
Geriatric Considerations
  • Older patients have a higher mortality rate than younger patients—highest in 7th and 8th decades.
  • Atrial fibrillation is a frequent cause among the elderly.
Pediatric Considerations
  • Congenital heart disease is a common cause among pediatric patients.
  • Other causes include the following:
    • Metabolic: homocystinuria, Fabry disease
    • Central nervous system infection
    • Clotting disorders
    • Genetic: Marfan syndrome, moyamoya, or sickle cell disease
Pregnancy Considerations
  • Preeclampsia, eclampsia, and HELLP syndrome
  • TTP and hemolytic uremic syndrome
  • Postpartum angiopathy
  • Cerebral venous thrombosis
  • Hypercoagulable states related to pregnancy

Commonly Associated Conditions

  • Atrial fibrillation
  • Uncontrolled HTN
  • Carotid stenosis
  • TIA mimics
    • Some disease processes mimic TIA presentation.
    • Seizures, migraines, metabolic disturbances, syncope
    • Gradual onset with nonspecific symptoms (headache, memory loss)

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