• Exclude hypoglycaemia
• Offer aspirin 300mg immediately uncless contraindicated
• Refer within 24 hours to acute stroke unit / specialist

 

Do not use ABCD2 score to stratify risk of TIA / inform urgency of referral / guide treatment

If the patient takes anticoagulant / has a bleeding disorder → urgent non-contrast head CT to exclude haemorrhage

• Otherwise NICE recommends NOT to offer CT brain unless there is clinical suspicion of an alternative diagnosis that CT could detect

After specialist assessment, consider:

• MRI (on the same day) to determine territory of ischaemia or detect haemorrhage
• Urgent carotid imaging (if considered a candidate for carotid endarterectomy)

Antiplatelet is the choice of antithrombotic therapy if the TIA is not thought to be secondary to atrial fibrillation. 

There are 2 main regimens, depending on the bleeding risk.

Bleeding risk	Antiplatelet regimen
Low bleeding risk (most cases)	Phase 1: on the same day offer a loading dose of DAPT (aspirin 300mg + clopidogrel 300mg) Phase 2: maintenance dose DAPT for 21 days (aspirin 75mg + clopidogrel 75mg) Phase 3: after 21 days of DAPT, switch to clopidogrel 75mg monotherapy lifelong Alternative to clopidogrel is ticargrelor (loading dose: 180mg, maintenance dose: 90mg BD)
High bleeding risk	Phase 1: on the same day offer a loading dose of clopidogrel 300mg Phase 2: maintenance dose of clopidogrel 75mg monotherapy lifelong

 

All patients should receive:

• Lifestyle advice
• High-intensity stain 
• BP lowering therapy

Do NOT offer carotid intervention routinely to all patients with TIA.

Indications for carotid intervention depending on the severity of stenosis, reported with NASCETNorth American Symptomatic Carotid Endarterectomy Trial method:

• If severe stenosis (50-99%) → perform carotid endarterectomy within 7 days
  • If unfit for surgery → consider carotid angioplasty and stenting

If there is mild / moderate stenosis (<50%) → no intervention