The symptoms of a transient ischemic attack are temporary and often resolve before the patient can be seen by a health care provider. Patient history is therefore of great importance. History from the family, witnesses, and emergency medical services, as well as the patient, should be obtained. History may include short-term alterations in [2]:

• Behavior
• Speech
• Gait
• Memory
• Movement

Symptoms can vary from individual to individual and by the area of the brain affected. Frequently symptoms include [2] [4]:

• Temporary loss of vision
• Aphasia
• Hemiparesis
• Paresthesia
• Impaired level of consciousness or disorientation
• Dizziness
• Lack of coordination or poor balance
• Temporary partial paralysis of the face and tongue

The symptoms are short-lived, usually lasting less than 15 to 60 minutes. Symptoms vary in severity.

Differential diagnoses to be excluded are [2] [3] [13]:

• Hypoglycemia
• Seizures
• Cranial tumors or lesions
• Migraine with aura
• Peripheral nerve/root disorder
• Demyelinating disease, multiple sclerosis
• Vestibular dysfunction
• Intracranial hemorrhage
• Electrolyte imbalance

• Weakness

  These scores are then added up giving a result between 0 and 7 points. 2 Calculation A Age < 60 years ≥ 60 years B Blood pressure >140 syst. or >90 diast. mmHg C Clinical features (symptoms) other complaints impaired speech without one-sided weakness [flexikon.doccheck.com]

  The weakness completely resolved at 2 hours after symptom onset, and there was no acute infarction on the initial diffusion-weighted magnetic resonance imaging (MRI) on the same day. [ncbi.nlm.nih.gov]

  […] ischemic attack s (TIAs) occur before stroke in 20 percent of patients and consist of sudden onset of one or more of the following symptoms: temporary loss of vision in one eye, unilateral numbness, temporary loss of speech or slurred speech, and localized weakness [britannica.com]

  The questions to ask are: Facial weakness – Check their face. Has their mouth drooped? Arm weakness – Can they lift both arms? Speech difficulty – Is their speech slurred? Do they understand you? Time – is critical. [betterhealth.vic.gov.au]

  During the medical history, a doctor will want to ask questions regarding the specifics of a patient's symptoms, like whether the symptoms are focal (weakness or numbness on one side of the body) or nonfocal (e.g., generalized weakness or light-headedness [verywellhealth.com]

• Falling

  Compared with neurologists, GPs considered "confusion" and "unexplained fall" more often compatible with TIA and "lower facial palsy" and "monocular blindness" less often compatible with TIA. [ncbi.nlm.nih.gov]

  […] effective rehab exercises including: Activities that retrain leg muscles to restore function and strength Stride improvement exercises to help increase your walking ability High level balance exercises in a supportive environment to decrease risk of falling [alterg.com]

  GPs were particularly doubtful about some symptoms, such as “monocular visual loss,” “confusion,” and “unexplained fall,” whereas neurologists were rather uncertain about “unsteadiness” and “diplopia.” [doi.org]

  Myoclonus may occur normally, often when a person is falling asleep. For example, as people start to doze off, they may jerk awake (as if startled), or muscles in part of the body may twitch. [merck.com]

  […] other visual problems Weakness, numbness, or tingling of the face, arm, leg or one side of the body (usually affects one side of the body, but there are exceptions) Difficulty speaking or understanding words Lightheadedness, unsteadiness of gait or falling [uvahealth.com]

• Difficulty Walking

  They happen suddenly, and include Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Difficulty walking Dizziness Loss of balance or coordination Most symptoms [nlm.nih.gov]

  walking, reduced leg strength, and decreased endurance. [alterg.com]

  Symptoms generally come on suddenly and can include: Difficulty seeing from one or both eyes Numbness or weakness in the face, arms, or legs, especially on one side Severe headache Difficulty walking Dizziness, loss of coordination and balance Difficulty [my.clevelandclinic.org]

• Coronary Atherosclerosis

  Homocysteine and coronary atherosclerosis: from folate fortification to the recent clinical trials. Eur Heart J. 2009 ; 30 :6–15. Crossref Medline Google Scholar 638. [doi.org]

• Impaired Balance

  It can for example manifest as paralysis of a limb, loss of speech and / or vision, or impaired balance. [presse.inserm.fr]

• Benign Paroxysmal Positional Vertigo

  Benign paroxysmal positional vertigo is triggered by sudden head movements (see case study). Syncope may be precipitated by emotional stimuli (eg, seeing blood) or fluid loss (eg, diarrhoea and vomiting). [pn.bmj.com]

• Diplopia

  Isolated TVS was significantly more common in TMB than in HLH and diplopia (88%, 62%, and 0%, respectively; P 2 score was significantly lower in patients with TMB compared with those with HLH and diplopia (median 2 [interquartile range 2-3] versus 3 [ [ncbi.nlm.nih.gov]

  […] cranial nerve palsy, hemiballismus Posterior cerebral artery Monocular loss of vision (amaurosis) Ophthalmic artery (a branch of the internal carotid artery) Unilateral or bilateral cranial nerve deficits (eg, nystagmus, vertigo, dysphagia, dysarthria, diplopia [msdmanuals.com]

  The most common presenting symptoms of TIA are focal neurologic deficits, which can include, but are not limited to:[5] Amaurosis fugax (painless, temporary loss of vision) One-sided facial droop One-sided motor weakness Diplopia (double vision) Problems [en.wikipedia.org]

• Blurred Vision

  Memory loss (OR 9.17, 95% CI 2.89-32.50), headache (OR 3.71, 95% CI 1.07-12.78) and blurred vision (OR 2.48, 95% CI 0.90-6.59) increased the odds of TIA mimics. [ncbi.nlm.nih.gov]

  Symptoms of TIA or stroke include: Sudden severe headache Sudden loss of or blurred vision in one or both eyes Trouble walking, talking or understanding Difficulty swallowing Weakness, tingling or numbness, typically in one side of the body Confusion [neurosurgeonsofnewjersey.com]

  TIA symptoms may include: Numbness, tingling, or weakness on one side of your body (in your face, arm, or leg) Trouble talking or understanding others Sudden confusion Change in vision (double vision, blurred vision, dimmed vision, or loss of vision) [upmc.com]

  Other signs and symptoms may include: complete paralysis of one side of the body sudden vision loss, blurred vision or double vision vertigo being sick dizziness confusion difficulty understanding what others are saying problems with balance and co-ordination [nhs.uk]

  Memory loss (OR 9.17, 95% CI 2.89–32.50), headache (OR 3.71, 95% CI 1.07–12.78) and blurred vision (OR 2.48, 95% CI 0.90–6.59) increased the odds of TIA mimics. [doi.org]

• Scotoma

  […] fingers 2 3 15 2 2 18 Numbness, half body 6 8 6 12 6 4 Numbness, hand/half mouth 4 8 7 5 6 11 Confusion‡ 4 13 3 0 2 20 Convulsion 0 7 13 0 2 20 “Jerks,” face or hand 0 3 17 0 0 22 Vertigo 2 6 12 1 7 14 Urinary incontinence 5 6 9 1 0 21 Scintillating scotoma [doi.org]

• Dizziness

  Symptoms can include: numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion or difficulty in talking or understanding speech; trouble seeing in one or both eyes; and difficulty with walking, dizziness, or loss of [ninds.nih.gov]

  They happen suddenly, and include Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Difficulty walking Dizziness Loss of balance or coordination Most symptoms [nlm.nih.gov]

  You have a severe headache or feel dizzy. Your blood pressure or blood sugar level is higher or lower than you were told it should be. You have questions or concerns about your condition or care. [drugs.com]

  Symptoms of a TIA may include one or more of the following: painless loss of vision of one or both eyes, weakness and tingling on one side of the body, difficulty speaking, or vertigo (dizziness). [opto.ca]

• Confusion

  Symptoms can include: numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion or difficulty in talking or understanding speech; trouble seeing in one or both eyes; and difficulty with walking, dizziness, or loss of [ninds.nih.gov]

  They happen suddenly, and include Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Difficulty walking Dizziness Loss of balance or coordination Most symptoms [nlm.nih.gov]

  Compared with neurologists, GPs considered "confusion" and "unexplained fall" more often compatible with TIA and "lower facial palsy" and "monocular blindness" less often compatible with TIA. [ncbi.nlm.nih.gov]

  Speech that is slurred or garbled Difficulty understanding when other people speak Weakness, numbness, or paralysis, usually in the face, arm, or leg on only one side of the body Blindness in at least one eye or blurred or double vision Severe headaches Confusion [tgh.org]

• Headache

  Our patient presented with thunderclap headache and transient ischemic attack like episode with obvious SAH on CT scan. [ncbi.nlm.nih.gov]

  However, in migraine headaches, the visual disturbances are dynamic and keep moving. Whereas with TIA the vision problems tend to remain static. Also, the migraine headaches symptoms typically come on gradually. [migraine.com]

  Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24 (suppl 1):9–160. [doi.org]

• Vertigo

  How can we differentiate peripheral vs. central causes of vertigo at the bedside? What are the best medications for patients with vertigo? and many more….. [emergencymedicinecases.com]

  BACKGROUND AND PURPOSE: Contrary to typical transient symptoms (TS), atypical TS, such as partial sensory deficit, dysarthria, vertigo/unsteadiness, unusual cortical visual deficit, and diplopia, are not usually classified as symptoms of transient ischemic [ncbi.nlm.nih.gov]

  Symptoms of a TIA may include one or more of the following: painless loss of vision of one or both eyes, weakness and tingling on one side of the body, difficulty speaking, or vertigo (dizziness). [opto.ca]

  Prevailing conditions misdiagnosed as TIA were postural hypotension, syncope, vertigo, seizures, anxiety, confusion, and complete stroke. [doi.org]

  This may include: Slurred speech Facial weakness Weakness in an arm and/or leg Headache Dizziness / vertigo Reduced level of consciousness A TIA should never be ignored and should be reported to a medical professional as soon as possible. [firstaidforfree.com]

• Slurred Speech

  […] or slurred speech, and localized weakness of… Read More [britannica.com]

  We presented a 14-year-old patient with signs suggestive of transient ischemic attack (TIA), including triple episodic weakness on the right upper limb, slurred speech, and bucking, lasting several hours in each time 2 days ago. [ncbi.nlm.nih.gov]

  This may include: Slurred speech Facial weakness Weakness in an arm and/or leg Headache Dizziness / vertigo Reduced level of consciousness A TIA should never be ignored and should be reported to a medical professional as soon as possible. [firstaidforfree.com]

  Snapshot A 55-year-old woman presents to the emergency department after developing slurred speech approximately 2 hours ago. Once she arrived, her symptoms gradually resolved. CT head without contrast and CT angiography was unremarkable. [medbullets.com]

  Symptoms and signs of a mini stroke are similar to those of a major stroke, including weakness or numbness in the face, body and limbs, slurred speech or difficulty speaking, trouble seeing out of one or both eyes, and dizziness or trouble balancing. [intermountainhealthcare.org]

The initial workup for individuals presenting with a transient ischemic attack should be aimed at excluding other metabolic or drug-induced causes for the symptoms. Tests that should be done immediately [2]:

• Blood glucose to rule out hypoglycemia
• Complete blood count
• Serum electrolyte levels
• Coagulation studies
• 12-lead electrocardiogram with rhythm strip

A complete neurologic examination is a means of determining the area of neurovascular assault. The examination should include the following [2] [3]:

• Cranial nerve testing
• Motor strength and function
• Sensory testing
• Speech and language evaluation
• Assessment of the cerebellar function, gait and balance

Physical examination should include [2] [3]:

• Vital signs: Temperature, blood pressure, heart rate and rhythm, respiratory rate and pattern, oxygen saturation.
• Overall health and appearance: Hydration status, development, skin color.
• Psychosocial issues: Attentiveness, social interaction, language and memory, cognition.

Further testing may include [2] [3]:

• Erythrocyte sedimentation rate
• Cardiac enzymes
• Lipid profile
• Screening for hypercoagulate states
• Syphilis serology
• Anti-phospholipid antibodies
• Toxicology screening
• Hemoglobin electrophoresis
• Serum protein electrophoresis
• Cerebrospinal fluid examination

Imaging studies [2] [3] [16]:

• Magnetic resonance imaging (MRI) with diffusion-weighted imaging
• Non-contrast computed tomography (CT)
• Vascular imaging: Carotid Doppler ultrasonography of the neck, computed tomography angiography (CTA), or magnetic resonance angiography (MRA)

Recommendations for evaluation and initial interventions for individuals presenting with transient ischemic attacks are [2] [5] [8]:

• Neuroimaging evaluation of the cervical vessels and intracranial vessels is within 24 hours of symptom onset. Magnetic resonance imaging with diffusion sequences are recommended. 
• Electrocardiography as soon as possible with prolonged cardiac monitoring and echocardiography in patients where no vascular etiology identified. 
• Routine blood tests: Complete blood count, electrolytes, fasting blood glucose, renal and liver studies. 
• Hospitalization of patients within 72 hours with an ABCD (2) score > 5 which indicate a high risk of recurrence [5]. 

• Hypoglycemia

  Diagnosis is then a matter of excluding other possible diagnoses such as migraines, seizures, and hypoglycemia. [symptoma.com]

  […] hemorrhage Electrolyte derangements Thus, a fingerstick blood glucose test should be performed to check for hypoglycemia, and blood should be drawn for laboratory studies. [emedicine.medscape.com]

Antithrombotic therapy, started once intracranial hemorrhage is ruled out, is recommended to prevent subsequent stroke [2]. Most frequently used medications are [1] [2] [13]:

• Aspirin (50-325 mg/day)
• Aspirin plus extended-release dipyridamole
• Clopidogrel

For cardio-embolic transient ischemic attacks long-term anticoagulation therapy is recommended using [1] [2]:

• Heparin (warfarin) titrated to maintain international normalized ratio, INR, at 2-3
• Aspirin 325 mg/day for those unable to take oral anticoagulants or with intracranial stenosis

Maintaining blood pressure below 140/90 mm Hg and total cholesterol below 200 mg/dL may prevent transient ischemic attacks, their recurrence or subsequent stroke [2].

Hospitalization may be required for early lytic therapy and other medical management and secondary prevention [18].

Hospitalization is required for [16] [17]:

• Crescendo transient ischemic attacks
• Symptoms lasting longer than 1 hour
• Internal carotid stenosis greater than 50%
• Atrial fibrillation
• Hypercoagulate status

Angioplasty or stent placement to treat transient ischemic attacks are currently being investigated, but their usefulness is not yet known [18]. Endarterectomy versus medical treatment alone has shown that surgery reduced the risk of stroke in patients with carotid stenosis, but the benefits were substantially less when surgery was delayed more than two weeks [13].

Recombinant human Interleukin-1ra (IL-1ra) administered intravenously has been shown to effectively reduce inflammation after a transient ischemic event. Though safe, its efficacy in the early hours after the ischemic episode are limited by its slow uptake. Further research is needed to find better therapeutic agents [15].

Research has shown transient ischemic attacks to be a very strong predictor of subsequent stroke and death [6]. Early identification, immediate treatment, and institution of stroke prevention techniques are imperative to preventing further morbidity and mortality [2] [3].

Transient ischemic attacks are episodes of temporary, focal cerebral dysfunction due to vascular occlusion and tissue ischemia [2] [7]. Onset is acute and abrupt and the event is of short duration, from 15 minutes to 24 hours. Resolution of symptoms is rapid as well. Transient ischemic attacks leave no residual neurological deficit [2] [8]. Differentials diagnoses include [7] migraine, epilepsy, syncope, or even neurosis. 

Transient ischemic attacks are classified and initially evaluated using the ABCD (2) score [9]. This evaluation tool is based on five criteria: Age > 60 years (1 point), blood pressure > 140/90 mm Hg (1 point), clinically unilateral weakness (2 points), speech impairment without weakness (1point), duration > 60 min (2 points) or 10 to 59 min (1 point) and diabetes (1 point) [10]. The higher the score the higher the risk for recurrence of transient ischemia and/or eminent stroke [9] [10]. 

Patients are classified as follows [9] [10]:

• High risk with a score of 6-7; stroke risk 8.1%, 
• Moderate risk with a score of 4-5; stroke risk 4.1%, 
• Low risk with score of 0-3; stroke risk 1.0%.

Transient ischemic attacks may also be classified as typical transient ischemia or nonspecific transient neurological attacks [4] [7]. Typical transient ischemic attacks are the result of temporary vascular occlusion. Nonspecific transient neurological attacks may be due to cardiac abnormalities, such as arrhythmias [7]. The non-specific form accounts for less than half of patients and studies have shown them to be at lower risk of subsequent stroke [4] [7].

The incidence of transient ischemic attacks is approximately 1 per 1000 population in the United States, accounting for 200,000-500,00 cases a year [2] [11] [12]. The reported incidence is lower in other developed countries [5] [13].

Approximately 15% of strokes occur in individuals with a history of previous transient ischemic attacks [2] [4] [13]. The incidence of transient ischemic attacks increases with age. The incidence is significantly higher in men than in women, approximately 1.5 to 1 [6].

The incidence in blacks is 1.5 times higher than that in whites [1] [6]. This may, in part, be due to an increased prevalence of diabetes and cardiovascular disease in this population group [6].

Transient ischemic attacks are the result of a temporary decrease or cessation of cerebral blood flow to a portion of the brain [4] [8]. They may be due to an acute thromboembolic event or chronic vascular stenosis. Cerebrovascular disease and atherosclerosis are the primary causes of the syndrome, and are a group of conditions that affect the blood vessels supplying the brain [14]. Symptoms vary according to the area of the brain affected.

Other possible causes include [8] [14]:

• Atherosclerosis
• Embolic cardiac disorders
• Valvular disease
• Atrial fibrillation, aortic arch disease, or atrial-septal defect
• Arterial dissection
• Arteritis and vasculitis
• Sympathomimetic drugs such as cocaine
• Tumors or hematomas
• Hypercoagulation states, clotting disorders
• Congenital heart disease
• Central nervous system infection
• Neurofibromatosis and fibromuscular dysplasia
• Marfan syndrome
• Sickle cell disease

The pathophysiology of brain ischemia is related to the action of neuro-inflammatory mediators that increase the progression of tissue damage [15]. With ischemia, increased levels of cytokines and chemokines cause the adhesion of white blood cells to the vascular endothelium [15]. This process further impairs cerebral blood flow resulting in further damage and the increased risk of subsequent stroke.

Interleukin-1 (IL-1) is a group of cytokines that regulate the immune and inflammatory responses in the body. Recent research suggests that these substances may reduce brain injury by decreasing the inflammatory progression occurring post-ischemic episode [15].

After a transient ischemic attack, reducing stroke risk has an impact on subsequent morbidity and mortality. This will require extensive public education about the symptoms of these events and the importance of immediate evaluation, no matter the duration [11].

Maintaining blood pressure below 140/90 mm Hg and total cholesterol below 200 mg/dL, weight loss and maintenance of normal body mass index may be preventive of transient ischemic attacks [17].

Transient ischemic attacks (TIA) are defined as temporary neurologic events that last less than 24 hours. They are due to short-term cerebral, spinal cord, or retinal ischemia [1] [2] and not associated with tissue infarction and subsequent damage [2] [3]. However, better imaging techniques have indicated that minimal tissue damage may occur in the shortest of episodes [1] [3].

Usual symptoms of transient ischemic attacks include hemiparesis, hemiparesthesia, dysphasia, diplopia and monocular blindness, imbalance and gait disturbances, and possible disorientation [1] [2] [4].

The incidence of subsequent stroke in individuals who have had a transient ischemic attack may be as high as 10% within 3 months and 11 to 25% in the next 5 years [2] [5] [6].

What is transient ischemic attack?

A transient ischemic attack refers to a temporary sudden decrease in blood supply to the brain resulting in short-term neurological symptoms. The cause of this disorder is a sudden decrease in blood supply to a part of the brain.

What are the symptoms?

The symptoms of transient ischemic attack include:

• Temporary loss of vision
• Difficulty speaking
• Weakness on one side of the body
• Numbness or tingling 
• Impaired level of consciousness or disorientation
• Dizziness
• Lack of coordination or poor balance

What causes transient ischemic attack?

Transient ischemic attacks are caused by interference with the blood supply to the brain. Reasons for this include:

• Atherosclerosis
• Cardiac disorders: Valvular disease, atrial fibrillation
• Inflammation of the blood vessels
• Drugs such as cocaine
• Tumors or hematomas
• Clotting disorders
• Congenital heart disease
• Central nervous system infection
• Sickle cell disease

It is believed that much of the damage and the increased risk of stroke caused by transient ischemic attacks is due to inflammation of brain tissue as a result of ischemia, decreased oxygen supply.

Who gets transient ischemic attack?

Anyone who has cerebrovascular disease or disorders is at risk for transient ischemic attacks. The risk increases with age. The incidence is higher in men than in women and in blacks than in whites.  Those at particular risk are individuals with high blood pressure, high cholesterol, diabetes, elevated body mass index (BMI), and atherosclerosis.

How is it diagnosed?

The symptoms of the disorder are of such short duration, often 1 to 60 minutes, that they may be gone before the individual can be seen by a healthcare provider. Transient ischemic attacks are diagnosed initially by the history of the event, symptoms, duration, and residual effects. Diagnosis is then a matter of excluding other possible diagnoses such as migraines, seizures, and hypoglycemia. Once it is determined that the symptoms are caused by a transient ischemic episode, the underlying cause of the decreased blood flow must be identified and that issued needs to be treated.

How is transient ischemic attack treated?

If it is determined that the transient ischemic attack is due to an embolism or clotting problem medications to decrease the formation of clots can be effective. These medications include warfarin (Coumadin) or heparin in the acute phase, and/ aspirin.
If the underlying cause is occlusion due to embolus or stenosis (clot or narrowing of blood vessel) surgical intervention may be needed. New medications are currently being researched for use in transient ischemic events. These medication reduce the inflammation caused by brain ischemia and may help to prevent subsequent strokes.

What are the complications of transient ischemic attack?

The main complication of transient ischemic attacks is cerebral vascular accidents or stroke. Research has shown that 15-25% of people who experience a transient ischemic attack will experience a stroke within 3 months to 5 years. Strokes result in permanent disability or death.

How can transient ischemic attacks be prevented?

After a transient ischemic attack, reducing stroke risk has an impact on subsequent morbidity and mortality. Maintaining blood pressure below 140/90 mm Hg and total cholesterol below 200 mg/dL, weight loss and maintenance of normal body mass index may help to preventive transient ischemic attacks and stroke.

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