High-risk TIA — ABCD2, DAPT and the carotid window

Definition. Tissue-based (AHA/ASA 2009): a transient episode of neurological dysfunction from focal brain, spinal cord or retinal ischaemia without acute infarction. DWI-positive lesion = stroke, not TIA.^[1] Finger-prick glucose first to exclude hypoglycaemia. Fully resolved deficit is not a thrombolysis candidate.

ABCD2 (Johnston 2007): Age ≥60 (1) + BP ≥140/90 (1) + Clinical unilateral weakness (2) + Duration 10–59 min (1) + Diabetes (1) = 6 → high early stroke risk (8.1% at 2 days for score 6–7).^[2] ABCD2 is a risk tool, not a reason to delay carotid imaging or specialist assessment — urgent assessment with neuroimaging and carotid imaging within 24 hours remains the standard.^[1]

Workup. ECG (AF), non-contrast CT (exclude haemorrhage/mass), urgent carotid imaging (duplex/CTA/MRA) within 24 h, lipids, MRI DWI when available.^[1]

Secondary prevention (non-cardioembolic high-risk TIA)

• Aspirin 300 mg stat.
• Dual antiplatelet therapy aspirin + clopidogrel for 21 days then monotherapy (CHANCE; POINT benefit early, bleeding accrues with longer dual therapy).^[4][5]
• High-intensity statin; BP control; smoking cessation.
• If AF → anticoagulation (DOAC), not antiplatelet long-term.
• Symptomatic severe carotid stenosis (≥70% NASCET): CEA within 2 weeks — benefit is highly time-dependent.^[7]

Disposition: high-risk features favour admission or same-day specialist pathway — urgent assessment and treatment cut the 90-day recurrent-stroke risk from 10.3% to 2.1% (EXPRESS); never discharge without a plan for carotid imaging and secondary prevention.^[3]