Transient Ischaemic Attack and Carotid Disease

The answer first

A TIA is a brief episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction on tissue-based definition. ^[10] The clinical job is not to reassure because the deficit resolved. The job is to prevent the next event in the hours and days when risk is highest. ^{[1] [5]}

For high-risk TIA or minor non-cardioembolic ischaemic stroke, short dual antiplatelet therapy with aspirin plus clopidogrel reduces early recurrence when started promptly and stopped after a short course. ^{[2] [3]} Urgent specialised assessment, same-admission or same-day vascular imaging, and rapid treatment of carotid stenosis and risk factors cut stroke rates in the EXPRESS model of care. ^{[5] [6]}

For symptomatic extracranial carotid stenosis of high grade, carotid endarterectomy reduces recurrent ipsilateral stroke when performed with acceptable perioperative risk; stenting is an alternative in selected anatomy and risk profiles. ^{[9] [4]}

References11ShowHide

1. [1]Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack Lancet, 2007.PMID 17258668
2. [2]Wang Y, Wang Y, Zhao X, Liu L, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack N Engl J Med, 2013.PMID 23803136
3. [3]Johnston SC, Easton JD, Farrant M, Barsan W, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA N Engl J Med, 2018.PMID 29766750
4. [4]Brott TG, Hobson RW 2nd, Howard G, Roubin GS, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis N Engl J Med, 2010.PMID 20505173
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7. [7]Fonseca AC, Merwick Á, Dennis M, Ferrari J, et al. European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack Eur Stroke J, 2021.PMID 34414306
8. [8]Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association Stroke, 2021.PMID 34024117
9. [9]Barnett HJM, Taylor DW, Haynes RB, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis N Engl J Med, 1991.PMID 1852179
10. [10]Easton JD, Saver JL, Albers GW, Alberts MJ, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists Stroke, 2009.PMID 19423857
11. [11]Amarenco P Risk of Stroke after Transient Ischemic Attack or Minor Stroke N Engl J Med, 2016.PMID 27464211