Recommendations
Urgent
Suspect a transient ischaemic attack (TIA) in a patient who presents with sudden-onset, focal neurological deficit that resolves spontaneously and cannot be explained by another condition such as hypoglycaemia.[9] Most patients with TIA usually have complete resolution of symptoms and signs within 1 hour.[2] Until the neurological symptoms and signs have resolved completely you cannot assume the event is a TIA, and you should proceed with investigations and management for a working diagnosis of stroke.[9] See Ischaemic stroke and Haemorrhagic stroke.
Focal neurological deficit may result in:[2]
Unilateral weakness or paralysis in the face, arm, or leg
Dysphasia
Vision problems – specifically monocular blindness, diplopia, or homonymous hemianopia
Difficulty with coordination and gait
Vertigo or loss of balance, especially with the above signs.
Suspect a stroke if sudden-onset, focal neurological deficit is ongoing and cannot be explained by another condition.[9]
Urgently test blood glucose to exclude hypoglycaemia as the cause of the sudden-onset neurological symptoms.[9] If present, treat hypoglycaemia urgently, and then reassess the patient.
Use a validated tool to aid diagnosis in patients with suspected TIA.[9][40]
In the accident and emergency department: use the Recognition of Stroke in the Emergency Room (ROSIER) scale to rapidly establish a diagnosis of TIA or stroke.[9]
In the community: use the Face Arm Speech Test (FAST) to screen people with sudden onset of neurological symptoms for TIA or stroke.[9][40]
If you see the patient while they are having ongoing neurological symptoms or soon after, use the National Institutes of Health Stroke Scale (NIHSS) to help identify the need for urgent treatment (thrombolysis). [ NIH Stroke Score Opens in new window ] See Ischaemic stroke and Haemorrhagic stroke.
Be aware that in the case of TIA, by the time the patient is seen, their NIHSS score may have reverted to normal.
Admit any patient with suspected stroke directly to a hyperacute (or acute, depending on availability) stroke unit within 4 hours of presentation.[9][40] See Ischaemic stroke and Haemorrhagic stroke.
Give a loading dose of aspirin immediately (if not contraindicated) to any patient with suspected TIA and refer them immediately to a TIA clinic (or suitable alternative) for specialist assessment and investigation to be seen within 24 hours of onset of symptoms.[9][40] Give clopidogrel as an alternative to aspirin in patients who are allergic or intolerant to aspirin.
Do not use scoring systems, such as ABCD2, to inform the urgency of referral or subsequent treatment options.[40] Consider all people with suspected TIA to be at high risk of having a stroke.[9][41]
Request an urgent computed tomography scan of the head in patients taking an anticoagulant or with a bleeding disorder to exclude haemorrhage.[40]
Remember that symptoms and signs are an important part of the clinical diagnosis of TIA.
Key Recommendations
TIA is a medical emergency requiring immediate diagnosis and appropriate treatment because the risk of recurrent stroke is up to 10% in the first 7 days following a TIA.[42]
Take a history asking about the type, duration, and intensity of symptoms.
A TIA has a sudden onset and may last anything from a few minutes to 24 hours. However, most patients with TIA usually have complete resolution of symptoms and signs within 1 hour.[2] Until the neurological symptoms and signs have resolved completely you cannot assume the event is a TIA and you should proceed with investigations and management for a working diagnosis of stroke.[9] See Ischaemic stroke and Haemorrhagic stroke.
As part of the initial evaluation, send bloods for:
Full blood count and platelet count[2]
Prothrombin time, INR, partial thromboplastin time[2]
Fasting lipid profile[2]
Serum electrolytes.[2]
Do not use computed tomography (CT) head scanning in patients with suspected TIA unless you suspect an alternative diagnosis that CT could detect or they are using anticoagulants.[9][40] Patients with suspected TIA should otherwise be assessed by a stroke specialist clinician before a decision on brain imaging is made.[40]
Suspect a TIA in a patient with sudden-onset, focal neurological deficit that cannot be explained by another condition such as hypoglycaemia.[9] Until the neurological symptoms and signs have resolved completely you cannot assume the event is a TIA and should proceed with investigations and management for a working diagnosis of stroke.[9] See Ischaemic stroke and Haemorrhagic stroke.
Be aware that focal neurological deficit may result in:[2]
Unilateral weakness or paralysis in the face, arm, or leg
Dysphasia
Vision problems – specifically monocular blindness, diplopia, or homonymous hemianopia
Difficulty with coordination and gait
Vertigo or loss of balance, especially with the above signs.
Use signs and symptoms to ascertain the arterial territory involved:[43]
Anterior circulation (carotid territory) ischaemia[43]
Dysphasia (usually indicates left-sided cerebral hemisphere ischaemia)
Transient monocular visual loss (amaurosis fugax)
Posterior circulation (vertebrobasilar territory) ischaemia[43][44]
Isolated homonymous hemianopia
Diplopia
Vertigo (although not usually in isolation)
Bilateral limb weakness.
See Ischaemic stroke and Haemorrhagic stroke.
Screening: in the emergency department
Use the Recognition of Stroke in the Emergency Room (ROSIER) scale in those with suspected TIA or stroke to establish the diagnosis rapidly.[9]
Score -1 point for each feature (clinical history):
Loss of consciousness or syncope
Seizure activity.
Score +1 point for each feature (neurological history):
Asymmetrical face weakness
Asymmetrical arm weakness
Asymmetrical leg weakness
Speech disturbance
Visual field defect.
A score >0: TIA or stroke likely; a score ≤0: TIA or stroke unlikely (but not excluded).
Admit any patient with suspected stroke directly to a hyperacute (or acute, depending on availability) stroke unit within 4 hours of presentation.[9][40] See Ischaemic stroke and Haemorrhagic stroke.
Screening: in the community
Use a validated tool such as the Face Arm Speech Test (FAST) to screen people with sudden onset of neurological symptoms for a diagnosis of TIA or stroke.[9][40]
Score 1 point for each feature:
Face weakness
Arm (or leg) weakness
Speech disturbance.
Suspect a TIA or stroke if score >0.
Practical tip
Be aware that a person may have ongoing focal neurological deficits despite a negative FAST. Manage these patients as having had an acute stroke rather than a TIA.
Refer to hospital any patient with suspected stroke for admission to a hyperacute (or acute, depending on availability) stroke unit within 4 hours of presentation.[9][40] See Ischaemic stroke and Haemorrhagic stroke.
Evidence: FAST and ROSIER screening tools to identify TIA or stroke
Despite very limited evidence, guidelines recommend using validated screening tools to expedite access to specialist care for patients with stroke or TIA in the pre-hospital setting. There are fewer guideline recommendations on the use of these tools in the emergency department setting.[40][45][46]
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Pre-hospital setting
The 2023 National Clinical Guideline for Stroke for the UK and Ireland recommends the Face Arms Speech Time (FAST) test in the pre-hospital phase but states that further evidence is required before Recognition of Stroke in the Emergency Room (ROSIER) can be recommended to screen for non-FAST symptoms in the pre-hospital phase.[40]
The recommendation for use of FAST is based on working party consensus and the results of a single diagnostic accuracy study comparing ambulance paramedics using FAST versus primary care doctor versus emergency department (ED) referrals for 487 people with suspected stroke to a stroke unit.[47]
The study found ambulance paramedics' stroke diagnosis using FAST gave a positive predictive value (PPV; i.e., the proportion with a positive test who in reality actually have the condition or characteristic) of 78% (95% CI 72% to 84%).[47]
FAST may not identify some people with symptoms of stroke (e.g., sudden-onset visual disturbance, lateralising cerebellar dysfunction).
Community-based clinicians should continue to treat a person as having a suspected stroke if they are suspicious of the diagnosis despite a negative FAST test.[40]
The UK National Institute for Health and Care Excellence (NICE) 2022 stroke guideline also recommends using a validated tool, such as FAST, outside hospital, citing evidence from the same diagnostic accuracy study.[9][47]
A 2017 European Academy of Neurology and European Stroke Organisation consensus statement for pre-hospital management of stroke makes no recommendation for a specific scale, but instead states:
To use a simple pre-hospital stroke scale (no specific one recommended), despite the lack of evidence. In their view, benefit would outweigh possible harm and minimal resource use.
To be aware that the scales (currently available at the time of this guidance) are not sensitive enough to detect posterior circulation stroke.
Emergency department setting
NICE recommends using a validated tool, such as ROSIER, in the ED.[9]
This recommendation is underpinned by a validation study for the ROSIER tool, including 343 patients with suspected stroke in the ED in the development phase and 173 in the validation phase.[48]
In this study, ROSIER showed a PPV of 90% (95% CI 85% to 95%) when used by ED clinicians.[48]
The National Clinical Guideline for Stroke for the UK and Ireland makes no specific recommendation on the use of ROSIER to screen for stroke in the hospital ED setting.[40]
Take a focused history. Ask about:
Sudden-onset, focal neurological deficits which may include:[2]
Unilateral weakness or paralysis in the face, arm, or leg
Dysphasia
Vision problems – specifically monocular blindness, diplopia, or homonymous hemianopia
Difficulty with coordination and gait
Vertigo or loss of balance, especially with the above signs.
Duration and intensity of symptoms
Whether the event has happened before
Any recent surgery, especially on the heart or carotids
Any previous stroke or coronary heart disease
Any key risk factors for TIA such as:
Practical tip
If possible, ask family members and other witnesses about the patient’s symptoms. Fleeting symptoms may be more obvious to an observer than to the patient.
Practical tip
Confusion, syncope, lightheadedness, and an altered consciousness level are usually not associated with TIA.
Carry out a general neurological examination to determine the severity of the patient’s neurological deficits.[2]
If you see the patient while they are having ongoing neurological symptoms or soon after, use the National Institutes of Health Stroke Scale (NIHSS) to help identify the need for urgent treatment (thrombolysis). [ NIH Stroke Score Opens in new window ] See Ischaemic stroke and Haemorrhagic stroke.
Be aware that in the case of TIA, by the time the patient is seen, their NIHSS score may have reverted to normal.
Check for evidence of cardiac arrhythmias (e.g., atrial fibrillation) or valvular pathology.
Auscultate the heart.
Arrhythmias, murmurs, and pulmonary oedema are associated with cardiac comorbidities, which predispose patients to stroke and TIA.
Give a loading dose of aspirin, unless contraindicated, to any person with suspected TIA.[9][40]
Give a proton-pump inhibitor to anyone with dyspepsia associated with aspirin use.[9]
Give clopidogrel as an alternative to aspirin in patients who are allergic or intolerant to aspirin.
Refer the patient immediately for specialist assessment and investigation to a TIA clinic (or suitable alternative) to be seen within 24 hours of onset of symptoms following your initial assessment. [9] Assessment should be conducted by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit.[40] See Specialist investigations in the TIA clinic under Investigations below
It is important to urgently confirm or refute the diagnosis of suspected TIA with specialist opinion because there are no reliable diagnostic tools.[9]
Do not use scoring systems, such as ABCD2, to inform the urgency of referral or subsequent treatment options.[40] Consider all people with suspected TIA to be at high risk of having a stroke.[9][41]
Evidence: Risk prediction scores in suspected TIA
Risk prediction scores are poor for assessing risk of future stroke in people with suspected TIA.
In a 2019 evidence update the UK National Institute of Health and Care Excellence (NICE) looked at validated risk stratification tools/scoring systems for people over 16 years old with suspected TIA.[52] NICE included two individual patient data (IPD) meta-analyses and five additional prospective cohorts.
The first IPD meta-analysis (published 2010) contained relevant data in its validation cohort (2 studies, n=1232).[53]
These cohorts were used for validation of ABCD2, ABCD3, and ABCD3-I.
The second IPD meta-analysis (published 2016) was a validation study with data from 16 cohort studies (n=2176).[54]
These cohorts were used for validation of ABCD2, ABCD2-I, and ABCD3-I.
The analysis only included people who had an MRI within 7 days of TIA onset and before any future stroke, meaning there was a risk of selection bias when assessing ABCD2 (which does not require imaging).
All of the additional prospective studies assessed ABCD2.
Most of the data was from an indirect population of patients with confirmed TIA, not suspected TIA as per the NICE review protocol.
Overall there was a high risk of incorrect risk stratification for future stroke with all of the scores.
NICE calculated the C statistic to assess discrimination.
The C statistic is a measure of the ability of a score to distinguish between people who do and people do not have the condition/outcome of interest.
Perfect discrimination C statistic = 1.0
Discrimination no better than chance C statistic = 0.5.
ABCD2 was the most commonly used risk score. Its C statistic for the discrimination of stroke risk at 2, 3, or 7 days ranged from 0.56 to 0.76 (quality as assessed by GRADE moderate to very low).
The ABCD2-I and ABCD3-I scores, which add imaging of the carotid artery and/or brain, performed slightly better with a C statistic of 0.71 to 0.84 (GRADE low) for future risk of stroke. These scores, however, may not be practical if imaging facilities are not available.
None of the studies looked at how the scores performed in predicting future risk of stroke at 24 hours, functional outcomes at 90 days or 1 year, mortality at 7 days, or quality of life.
From the IPD meta-analyses, ABCD3 and ABCD2-I were shown to have poor calibration (i.e., the predicted probabilities poorly agreed with the observed risk [GRADE low]). The results for ABCD3-I were inconsistent (GRADE very low).
These recommendations remained unchanged in a 2022 update to the NICE guideline.
The 2023 National Clinical Guideline for Stroke for the UK and Ireland also advises against the use of assessment tools such as the ABCD2 score to stratify risk of TIA, inform urgency of referral, or inform subsequent treatment options.[40] The guideline notes these scores do not discriminate sufficiently between low- and high-risk patients in both short-term and long-term follow-up, citing a prospective multi-centre study of patients in Norway (published 2021).[55]
Blood tests
As part of the initial evaluation, send a blood sample for:
To exclude hypoglycaemia as the cause of sudden-onset neurological symptoms
Full blood count and platelet count[2]
To exclude other causes of sudden-onset neurological symptoms (e.g., infection)
Prothrombin time, INR, partial thromboplastin time[2]
To exclude coagulopathy
Usually ordered in patients with TIA when neurological deficit persists at the time of presentation, in case thrombolytic therapy is being considered
Fasting lipid profile[2]
As a baseline measure and to evaluate for treatable atherosclerotic risk factors
Serum electrolytes[2]
To exclude electrolyte disturbance as the cause of sudden-onset neurological symptoms.
ECG
Request an ECG in all patients with suspected TIA to evaluate for atrial fibrillation and other arrhythmias and to rule out myocardial ischaemia.[40]
Perform prolonged ECG monitoring (at least 24 hours).
Consider prolonged sequential or continuous ECG monitoring with an external patch, wearable recorder, or implantable loop recorder in those in whom no other cause of stroke has been found, particularly if they have a pattern of cerebral ischaemia on brain imaging suggestive of cardioembolism.
CT head
Request an urgent computed tomography (CT) scan of the head in patients taking an anticoagulant or with a bleeding disorder to exclude haemorrhage.[40]
Do not use CT head scanning in patients with suspected TIA unless you suspect an alternative diagnosis that CT could detect or they are using anticoagulants.[9][40]
Patients with suspected TIA should otherwise be assessed by a stroke specialist clinician before a decision on brain imaging is made.[40]
Practical tip
Remember that symptoms and signs are an important part of the clinical diagnosis of TIA. Be aware that by the time you see the patient their TIA symptoms and signs have usually resolved, hence the importance of taking a good history.[43]
Specialist investigations in the TIA clinic
In patients with suspected TIA, a specialist undertaking assessment in the TIA clinic might consider urgent magnetic resonance imaging including diffusion-weighted and blood-sensitive sequences (performed on the same day as the assessment).[9]
MRI should be the principal brain imaging modality for detecting the presence and/or distribution of brain ischaemia.[40]
For patients with suspected TIA in whom brain imaging cannot be undertaken within 7 days of symptoms, MRI (using a blood-sensitive sequence such as susceptibility weighted imaging [SWI] or T2*-weighted imaging) should be the preferred means of excluding haemorrhage.[40]
Patients with confirmed anterior circulation TIA who the specialist considers as candidates for carotid endarterectomy should undergo urgent carotid imaging within 24 hours.[27]
Carotid imaging reports should clearly state which criteria (European Carotid Surgery Trial [ECST] or North American Symptomatic Carotid Endarterectomy Trial [NASCET]) were used when measuring the extent of carotid stenosis. Patients with TIA who have symptomatic carotid stenosis of 50% to 99% according to the NASCET criteria need to be assessed and referred urgently for carotid endarterectomy to a service following current national standards.[9]
In patients with cryptogenic TIA, contrast transthoracic echocardiography (TTE) is recommended to rule out patent foramen ovale (PFO). If contrast TTE is negative, contrast transoesophageal echocardiography (TOE) is used in selected patients instead.[56]
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