Transient Ischemic Attack and Minor Stroke Management

Authors: M. Škorňa 1,2;  J. Neumann 3;  S. Peška 1;  R. Mikulík 2,4
Authors‘ workplace: Neurologická klinika LF MU a FN Brno 1;  ICRC – Mezinárodní centrum klinického výzkumu, FN u sv. Anny v Brně 2;  Iktové centrum, Neurologické oddělení, Krajská zdravotní a. s., Nemocnice Chomutov 3;  I. neurologická klinika LF MU a FN u sv. Anny v Brně 4
Published in: Cesk Slov Neurol N 2016; 79/112(2): 178-187
Category: Review Article
doi: 10.14735/amcsnn2016178


Transient ischemic attack (TIA) and minor stroke are acute cerebrovascular diseases that are usually non-disabling. However, if not followed adequately, they may lead to potentially fatal stroke recurrence. The aim of this review is to summarize the main challenges of the current clinical practice (in the Czech Republic) and suggest a rational algorithm for TIA/minor stroke management. This review informs about the new TIA definition based on the fact that up to 50% of TIA patients have a brain infarction on MRI (magnetic resonance imaging), about risk stratification and its use in patients management, about the importance of imaging studies and about the available treatment options. Risk stratification for TIA is underused in the Czech Republic and this affects risk-benefit ratios for the available management plans. In particular, follow-up of high-risk patients need urgent attention - patients with speech and/or motor symptoms lasting ≥ 5 min, with ABCD2 score ≥ 4, with atrial fibrillation, and patients with an infarction on DWI MRI or CT (computed tomography), and with an occlusion or significant ≥ 50% stenosis of a precerebral/cerebral large vessel. The review highlights the importance of an immediate medical intervention with early endarterectomy and provides an overview of new therapeutic options, e.g. dual antiplatelet therapy, the benefit of which has recently been documented for the first time.

Key words:
transient ischemic attack – minor stroke – risk stratification

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.


1. Neumann J, Mikulík R, Václavík D, et al. Standard pro diagnostiku a léčbu pacientů po tranzitorní ischemické atace. Dostupné z URL: data/ k/ W/ A/ phpkWAE7u.doc.

2. Mohr JP. Historical perspective. Neurology 2004;62(Suppl 6):S3– 6.

3. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the american heart association/ american stroke association stroke council; council on cardiovascular surgery and anesthesia; council on cardiovascular radiology and intervention; council on cardiovascular nursing; and the interdisciplinary council on peripheral vascular disease. The american academy of neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009;40(6):2276– 93. doi: 10.1161/ STROKEAHA.108.192218.

4. Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD2 score performance in tissue- vs time-defined tia: a multicenter study. Neurology 2011;77(13):1222– 8. doi: 10.1212/ WNL.0b013e3182309f91.

5. Transient ischemic attack of the brain. Available from URL: http:/ / icd/ entity/ 1050192520.

6. Fischer U, Baumgartner A, Arnold M, et al. What is a minor stroke? Stroke 2010;41(4):661– 6. doi: 10.1161/ STROKEAHA.109.572883.

7. Coutts SB, Modi J, Patel SK, et al. What causes disability after transient ischemic attack and minor stroke?: results from the ct and mri in the triage of tia and minor cerebrovascular events to identify high risk patients (CATCH) study. Stroke 2012;43(11):3018– 22. doi: 10.1161/ STROKEAHA.112.665141.

8. Luengo-Fernandez R, Gray AM, Bull L, et al. Quality of life after tia and stroke: Ten-year results of the oxford vascular study. Neurology 2013;81(18):1588– 95. doi: 10.1212/ WNL.0b013e3182a9f45f.

9. Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack –  proposal for a new definition. N Engl J Med 2002;347(21):1713– 6.

10. Johnston SC, Gress DR, Browner WS, et al. Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284(22):2901– 6.

11. Kleindorfer D, Panagos P, Pancioli A, et al. Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke 2005;36(4):720– 3.

12. Brown RD, Petty GW, O‘Fallon WM, et al. Incidence of transient ischemic attack in Rochester, Minnesota, 1985– 1989. Stroke 1998;29(10):2109– 13.

13. Cancelli I, Janes F, Gigli GL, et al. Incidence of transient ischemic attack and early stroke risk: validation of the ABCD2 score in an Italian population-based study. Stroke 2011;42(10):2751– 7. doi: 10.1161/ STROKEAHA.110.612705.

14. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007;370(9596):1432– 42.

15. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 69(9558):283– 92.

16. Coutts SB, Sylaja PN, Choi YB, et al. The ASPIRE approach for TIA risk stratification. Can J Neurol Sci 2011;38(1):78– 81.

17. Coutts SB, Modi J, Patel SK, et al. CT/ CT angiography and MRI findings predict recurrent stroke after transient ischemic attack and minor stroke: results of the prospective CATCH study. Stroke 2012;43(4):1013– 7. doi: 10.1161/ STROKEAHA.111.637421.

18. Haacke EM, DelProposto ZS, Chaturvedi S, et al. Imaging cerebral amyloid angiopathy with susceptibility-weighted imaging. AJNR Am J Neuroradiol 2007;28(2):316– 7.

19. Guo LF, Wang G, Zhu XY, et al. Comparison of ESWAN, SWI-SPGR, and 2D T2*-weighted gre sequence for depicting cerebral microbleeds. Clin Neuroradiol 2013;23(2):121– 7. doi: 10.1007/ s00062-012-0185-7.

20. Merino JG, Warach S. Imaging of acute stroke. Nat Rev Neurol 2010;6(10):560– 71. doi: 10.1038/ nrneurol.2010.129.

21. Ebinger M, Galinovic I, Rozanski M, et al. Fluid-attenuated inversion recovery evolution within 12 hours from stroke onset: a reliable tissue clock? Stroke 2010;41(2):250– 5. doi: 10.1161/ STROKEAHA.109.568410.

22. Nael K, Khan R, Johnson K, et al. Acute MR stroke protocol in six minutes. MAGNETOM Flash 2013;5:44– 50.

23. Izenberg A, Aviv RI, Demaerschalk BM, et al. Crescendo transient aura attacks: A transient ischemic attack mimic caused by focal subarachnoid hemorrhage. Stroke 2009;40(12):3725– 9. doi: 10.1161/ STROKEAHA.109.557009.

24. Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the american heart association/ american stroke association. Stroke 2012;43(6):1711– 37. doi: 10.1161/ STR.0b013e3182587839.

25. Mitchell P, Wilkinson ID, Hoggard N, et al. Detection of subarachnoid haemorrhage with magnetic resonance imaging. J Neurol Neurosurg Psychiatry 2001;70(2):205– 11.

26. Moreau F, Modi J, Almekhlafi M, et al. Early magnetic resonance imaging in transient ischemic attack and minor stroke: do it or lose it. Stroke 2013;44(3):671– 74. doi: 10.1161/ STROKEAHA.111.680033.

27. Reif M, Mikulík R. Zobrazovací vyšetření u mozkového infarktu. Neurol Prax 2006;6:317– 20.

28. Asdaghi N, Hill MD, Coulter JI, et al. Perfusion MR predicts outcome in high-risk transient ischemic attack/ minor stroke: a derivation-validation study. Stroke 2013;44(9):2486– 92. doi: 10.1161/ STROKEAHA.111.000208.

29. Gladstone DJ, Kapral MK, Fang J, et al. Management and outcomes of transient ischemic attacks in Ontario. CMAJ 2004;170(7):1099– 104.

30. Buskens E, Nederkoorn PJ, Buijs-Van Der Woude T, et al. Imaging of carotid arteries in symptomatic patients: cost-effectiveness of diagnostic strategies. Radiology 2004;233(1):101– 12.

31. Josephson SA, Bryant SO, Mak HK, et al. Evaluation of carotid stenosis using CT angiography in the initial evaluation of stroke and TIA. Neurology 2004;63(3):457– 60.

32. Wardlaw JM, Chappell FM, Stevenson M, et al. Accurate, practical and cost-effective assessment of carotid stenosis in the UK. Health Technol Assess 2006;10(30):iii– iv,ix– x,1– 182.

33. Silvestrini M, Vernieri F, Pasqualetti P, et al. Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA 2000;283(16):2122– 7.

34. Markus HS, MacKinnon A. Asymptomatic embolization detected by doppler ultrasound predicts stroke risk in symptomatic carotid artery stenosis. Stroke 2005;36(5):971– 5.

35. Molloy J, Markus HS. Asymptomatic embolization predicts stroke and TIA risk in patients with carotid artery stenosis. Stroke 1999;30(7):1440– 3.

36. Siebler M, Nachtmann A, Sitzer M, et al. Cerebral microembolism and the risk of ischemia in asymptomatic high-grade internal carotid artery stenosis. Stroke 1995;26(11):2184– 6.

37. Purroy F, Montaner J, Delgado P, et al. Usefulness of urgent combined carotid/ transcranial ultrasound testing in early prognosis of TIA patients. Med Clin (Barc) 2006;126(17):647– 50.

38. Coutts SB, Hill MD, Eliasziw M, et al. Final 2 year results of the vascular imaging of acute stroke for identifying predictors of clinical outcome and recurrent ischemic events (VISION) study. BMC Cardiovasc Disord 2011;11(4):18. doi: 10.1186/ 1471-2261-11-18.

39. Horton M, Modi J, Patel SK, et al. Refinement of imaging predictors of recurrent events following transient ischemic attack and minor stroke. PLoS One 2013;8(6):e65752.

40. Coutts SB, O‘Reilly C, Hill MD, et al. Computed tomography and computed tomography angiography findings predict functional impairment in patients with minor stroke and transient ischaemic attack. Int J Stroke 2009;4(6):448– 53. doi: 10.1111/ j.1747-4949.2009.00346.x.

41. Merwick A, Albers GW, Amarenco P, et al. Addition of brain and carotid imaging to the ABCD² score to identify patients at early risk of stroke after transient ischaemic attack: a multicentre observational study. Lancet Neurol 2010;9(11):1060– 9. doi: 10.1016/ S1474-4422(10)70240-4.

42. Herzig R, Školoudík D, Šaňák D. Management ischemické cévní mozkové příhody a tranzitorní ischemické ataky –  doporučení european stroke organisation (ESO) 2008 –  zestručněná česká verze. Cesk Slov Neurol N 2008;71/ 104(3):364– 71.

43. Kalita Z. Farmakologická sekundární prevence nekardioemboligenního mozkového infarktu/ tranzitorní ischemické ataky –  současnost a budoucnost. Cesk Slov Neurol N 2011;74/ 107(3):261– 72.

44. Malloy RJ, Kanaan AO, Silva MA, et al. Evaluation of antiplatelet agents for secondary prevention of stroke using mixed treatment comparison meta-analysis. Clin Ther 2013;35(10):1490– 500. doi: 10.1016/ j.clinthera.2013.09.004.

45. Chaturvedi S. Acetylsalicylic acid + extended-release dipyridamole combination therapy for secondary stroke prevention. Clin Ther 2008;30(7):1196– 205.

46. Sacco RL, Diener HC, Yusuf S, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med 2008;359(12):1238– 51. doi: 10.1056/ NEJMoa0805002.

47. Creager MA. Results of the CAPRIE trial: efficacy and safety of clopidogrel. Clopidogrel versus aspirin in patients at risk of ischaemic events. Vasc Med 1998;3(3):257– 60.

48. Schipperheijn JJ. Results of the match trial on stroke prevention. Neth Heart J 2004;12(7/ 8):371– 2.

49. Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomized, double-blind, placebo-controlled trial. Lancet 2004;364(9431):331– 7.

50. Benavente OR, Hart RG, McClure LA, et al. Effects of clopidogrel added to aspirin in patients with recent lacunar stroke. N Engl J Med 2012;367(9):817– 25. doi: 10.1056/ NEJMoa1204133.

51. Bhatt DL, Fox KA, Hacke W, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006;354(16):1706– 17.

52. Markus HS, Droste DW, Kaps M, et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the clopidogrel and aspirin for reduction of emboli in symptomatic carotid stenosis (CARESS) trial. Circulation 2005;111(17):2233– 40.

53. Wang X, Lin WH, Zhao YD, et al. The effectiveness of dual antiplatelet treatment in acute ischemic stroke patients with intracranial arterial stenosis: a subgroup analysis of clair study. Int J Stroke 2013;8(8):663– 8. doi: 10.1111/ j.1747-4949.2012.00828.x.

54. Wang Y, Johnston SC. Clopidogrel with aspirin in minor stroke or transient ischemic attack. N Engl J Med 2013;369(1):1376– 7. doi: 10.1161/ CIRCULATIONAHA.114.014791.

55. Johnston SC, Easton JD, Farrant M, et al. Platelet-oriented inhibition in new TIA and minor ischemic stroke (POINT) trial: rationale and design. Int J Stroke 2013;8(6):479– 83. doi: 10.1111/ ijs.12129.

56. Cairns JA. Which oral anticoagulant for which atrial fibrillation patient: recent clinical trials and evidence-based choices. Can J Cardiol 2013;29(10):1165– 72. doi: 10.1016/ j.cjca.2013.05.010.

57. Heidbuchel H, Verhamme P, Alings M, et al. European heart rhythm association practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15(5):625– 51. doi: 10.1093/ europace/ eut083.

58. Mandzia JL, Hill MD. Acute stroke management in patients with known or suspected atrial fibrillation. Can J Cardiol 2013;29(Suppl 7):S45– 53. doi: 10.1016/ j.cjca.2013.04.031.

59. Butcher K, Kate M, Gioia L, et al. Safety and feasibility of acute dabigatran therapy in minor ischemic stroke patients without atrial fibrillation. International Stroke Conference; 2014 Feb 12– 14; San Diego, California, USA.

60. Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370(26):2478– 86. doi: 10.1056/ NEJMoa1313600.

61. Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl JMed 2014;370(26):2467– 77. doi: 10.1056/ NEJMoa1311376.

62. Wichterle D, Bulková V. Monitorace léčby fibrilace síní. Postgrad Med 2010;12(5):529– 33.

63. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ ACCF/ AHA/ AANN/ AANS/ ACR/ ASNR/ CNS/ SAIP/ SCAI/ SIR/ SNIS/ SVM/ SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the american college of cardiology foundation/ american heart association task force on practice guidelines, and the american stroke association, american association of neuroscience nurses, american association of neurological surgeons, american college of radiology, american society of neuroradiology, congress of neurological surgeons, society of atherosclerosis imaging and prevention, society for cardiovascular angiography and interventions, society of interventional radiology, society of neurointerventional surgery, society for vascular medicine, and society for vascular surgery. Circulation 2011;124(4):e54– 130. doi: 10.1161/ CIR.0b013e31820d8c98.

64. Rothwell PM, Eliasziw M, Gutnikov SA, et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004;363(9413):915– 24.

65. Derdeyn CP, Chimowitz MI, Lynn MJ, et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomized trial. Lancet 2014;383(9914):333– 41. doi: 10.1016/ S0140-6736(13)62038-3.

66. Emberson J. Impact of treatment delay, age and stroke severity on the effects of intravenous thrombolysis with alteplase in acute ischemic stroke: an individual-patient-data meta-analysis. International Stroke Conference; 2014 Feb 12– 14; San Diego, California, USA.

67. Dubuc V, Mandzia J, Hill M, et al. Thormbolysis for minor ischemic stroke with proven acute symptomatic occlusion using TNK-tPA (TEMPO-1). International Stroke Conference; 2014 Feb 12– 14; San Diego, California, USA.

68. Amarenco P, Benavente O, Goldstein LB, et al. Results of the stroke prevention by aggressive reduction in cholesterol levels (SPARCL) trial by stroke subtypes. Stroke 2009;40(4):1405– 9. doi: 10.1161/ STROKEAHA.108.534107.

69. Huisa BN, Stemer AB, Zivin JA. Atorvastatin in stroke: a review of SPARCL and subgroup analysis. Vasc Health Risk Manag 2010;6:229– 36.

70. Goldstein LB, Amarenco P, Szarek M, et al. Hemorrhagic stroke in the stroke prevention by aggressive reduction in cholesterol levels study. Neurology 2008;70(2):2364– 70.

71. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/ american stroke association. Stroke 2011;42(1):227– 76. doi: 10.1161/ STR.0b013e3181f7d043.

Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 2

2016 Issue 2

Most read in this issue
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account