Scope of Application This guideline is intended for physicians working in EDs.
Inclusion Criteria This guideline applies to adult patients aged 18 years and older presenting to the ED with a suspected TIA who have had resolution of symptoms.
Exclusion Criteria This guideline is not intended to be used for pediatric patients.
Critical Questions
In adult patients with suspected TIA, are there clinical decision rules that can identify patients at very low short-term risk for stroke who can be safely discharged from the ED?
Level B Recommendation:
In adult patients with suspected TIA, do not rely on current existing risk stratification instruments (eg, age, blood pressure, clinical features, duration of TIA and presence of diabetes [ABCD2] score) to identify TIA patients who can be safely discharged from the ED.
In adult patients with suspected TIA, what imaging can be safely delayed from the initial ED workup?
Level C Recommendations: (1) The safety of delaying neuroimaging from the initial ED workup is unknown. If noncontrast brain MRI is not readily available, it is reasonable for physicians to obtain a noncontrast head CT as part of the initial TIA workup to identify TIA mimics (eg, intracranial hemorrhage, mass lesion). However, noncontrast head CT should not be used to identify patients at high short-term risk for stroke.
(2) When feasible, physicians should obtain MRI with diffusion-weighted imaging (DWI) to identify patients at high short-term risk for stroke.
(3) When feasible, physicians should obtain cervical vascular imaging (eg, carotid ultrasonography, CTA, or MRA) to identify patients at high short-term risk for stroke.
In adult patients with suspected TIA, is carotid ultrasonography as accurate as neck CTA or MRA in identifying severe carotid stenosis?
Level C Recommendation:
In adult patients with suspected TIA, carotid ultrasonography may be used to exclude severe carotid stenosis because it has accuracy similar to that of MRA or CTA.
In adult patients with suspected TIA, can a rapid ED-based diagnostic protocol safely identify patients at short-term risk for stroke?
Level B Recommendation:
In adult patients with suspected TIA without high-risk conditions, a rapid ED-based diagnostic protocol may be used to evaluate patients at short-term risk for stroke. High-risk conditions include abnormal initial head CT result (if obtained), suspected embolic source (presence of atrial fibrillation, cardiomyopathy, or valvulopathy), known carotid stenosis, previous large stroke, and crescendo TIA.
Disclaimer Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.
