Diagnosis and Management of TIA

Stanford Neurologists Play Key Role In Redefinition Of TIA, Determining Prognosis And Optimal Management

In a 2002 article in the New England Journal of Medicine, Stanford Neurologist Greg Albers, MD, and other cerebrovascular experts called for a revision in the definition of TIA — from time-based (the resolution of symptoms in 24 hours) — to the presence or absence of brain infarction, a tissue-based definition, on neuroimaging. In 2009, the American Stroke Association released a guideline endorsing this change in the definition of TIA.

Image showing DWI positivie lesion Image shows a DWI positive lesion in a patient with transient left sided weakness.

The benefits of the new TIA definition have been demonstrated in a series of recent publications in Lancet Neurology, Stroke, and Neurology that were co-authored by Stanford Stroke Center neurologists. These studies have documented that that identifying a small area of brain injury on the MRI is much more powerful than clinical data alone to predicting early stroke risk; in fact early stroke risk is about 15 times higher in patients with TIA symptoms who have a small area of tissue injury on the MRI compared to those who have a normal MRI.

High risk patients should be admitted to the hospital for close observation so that tPA can be administered rapidly if a stoke occurs, and to facilitate urgent completion of a full diagnostic evaluation. Low risk TIA patients can be managed safely and cost-effectively in an outpatient TIA clinic. A recent Stanford study, TWO ACES, documented that this novel TIA strategy resulted in extremely low stroke rates and high patient satisfaction.

Images demonstrate a PWI positive lesion (arrows) in a patient with transient right sided weakness/numbness.

The Stanford TIA program is currently evaluating a new technology, perfusion weighted imaging (PWI), as a method of confirming an ischemic “footprint” that can verify a transient neurological episode was caused by ischemia, rather than a non-ischemic condition. In a preliminary study, Stanford Stroke Center neurologists demonstrated that about 30% of patients with symptoms suggestive of a TIA have a positive PWI scan.


Stanford has collaborated with the National Stroke Association, the American Heart Association and the American College of Chest Physicians to produce several guideline statements aimed at refining the diagnosis and management of TIA:

National Stroke Association Recommendations for TIA

Guidelines for the Prevention of Stroke in Patients with TIA

Definition and Evaluation of Transient Ischemic Attack

Antithrombotic and thrombolytic therapy for ischemic stroke