Transient ischemic attack

Disease Description (Causes and Symptoms)

• Definition: Transient ischemic attack (TIA) is a condition in which blood flow to the brain temporarily decreases, causing neurological symptoms that usually completely resolve within several minutes to a maximum of 24 hours. The main mechanism is temporary blockage of blood flow caused by a thrombus or embolus; in some cases, vascular stenosis or hypotension may also contribute. A small cerebral infarction lesion may be observed on DWI MRI.
• Main causes (risk factors): Hypertension, hyperlipidemia (hypercholesterolemia), diabetes, smoking, heart disease such as atrial fibrillation, family history, etc.
• Pathophysiology summary: A thrombus or embolus originating from atherosclerosis or the heart (e.g., atrial fibrillation) blocks a cerebral blood vessel, causing temporary ischemia. When the embolus dissolves or blood flow is restored, the symptoms disappear.
• Main symptoms: Sudden weakness (paralysis) of one side of the limbs, abnormal sensation, facial asymmetry (facial paralysis), speech disturbance (aphasia), difficulty walking (claudication), dizziness, visual disturbance, vomiting, etc. Symptoms last from several minutes to several hours (within 24 hours), and the duration may vary depending on the cause (thrombosis of the cervical internal carotid artery tends to be relatively short, while cardioembolic events may persist longer).

Treatment Methods

• Initial (emergency) evaluation and tests
  • Evaluation at an emergency department or specialist clinic as soon as possible: Neurological examination and confirmation of the time symptoms began (the last known normal time).
  • Imaging: Brain MRI including diffusion-weighted imaging (DWI), or non-contrast brain CT (to rule out acute hemorrhage), and vascular evaluation (CT/CTA or MRA, and neck (carotid) ultrasound).
  • Cardiac tests: 12-lead electrocardiogram (ECG), echocardiography (transesophageal echocardiography if necessary), and cardiac monitoring (to detect atrial fibrillation).
  • Blood tests: Blood glucose, lipids, electrolytes, coagulation tests, etc.
• Medication treatment
  • Antiplatelet agents: For non-cardioembolic TIA (when there is no severe stenosis), antiplatelet agents including aspirin are recommended as first-line treatment. In some cases, short-term combination therapy with aspirin + clopidogrel may be recommended during the initial short period (e.g., up to several weeks), depending on the clinical situation.
  • Anticoagulants: If cardioembolic disease such as atrial fibrillation is confirmed, warfarin or a direct oral anticoagulant (DOAC) is administered.
  • Hyperlipidemia treatment: Statins (to reduce cardiovascular risk).
  • Blood pressure and blood glucose control: Controlling hypertension and diabetes is essential for long-term prevention of recurrence.
• Procedures/surgery
  • If there is significant symptomatic carotid (neck) stenosis (symptomatic carotid stenosis), carotid endarterectomy or stent placement may be considered (indications are determined according to the degree of stenosis).
  • Procedures or interventions may be possible for specific causes, such as a cardioembolic source (e.g., an abnormal thrombus in the left atrium).
• Lifestyle management
  • Smoking cessation, maintaining an appropriate weight, regular exercise, a low-salt and low-saturated-fat diet, and limiting alcohol consumption.
  • Adherence to medication schedules and regular checkups (blood pressure, lipids, and blood glucose).
• Precautions
  • Even if the symptoms have disappeared, emergency evaluation is necessary (the risk of progression to stroke is high during the first several days).
  • Be aware of the risk of bleeding when taking anticoagulants/antiplatelet agents, and inform medical staff in situations such as trauma or surgery.
  • Restrictions on daily activities such as driving or operating heavy machinery should be determined according to the cause of the symptoms and recovery status; consult a doctor.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare
  • A list of medications currently being taken (including prescriptions, OTC medicines, and supplements) and the times they are taken
  • Information about allergies (including drug allergies)
  • A note recording the recent time symptoms began (the exact time), how long they lasted, and how the symptoms progressed
  • Reports or CDs containing previous test results and images (CT/MRI/vascular tests)
  • Medical history: Hypertension, diabetes, heart disease (especially atrial fibrillation), surgical history, and family history
  • Lifestyle information: Smoking, alcohol consumption, exercise, and eating habits
  • Recent blood pressure records (self-measured values, if possible)
• Key items to tell the doctor in advance at the outpatient visit (prepare so that the patient can answer)
  • The exact time the symptoms first began (or the time when the patient was last known to be “normal”)
  • The type of symptoms (e.g., weakness on one side of the face or limbs, difficulty speaking, vision problems, etc.)
  • Whether the symptoms have completely recovered or whether some symptoms remain
  • Activities before and after the symptoms occurred (whether resting, exercising, etc.)
  • Whether the symptoms have occurred repeatedly and the intervals between episodes
• Examples of requests for materials to show the medical staff
  • Copies or files of previous images (CT/MRI), electrocardiograms, and blood test results

General Example Questions to Ask the Doctor

• What are the main side effects of this medication (e.g., an antiplatelet agent or anticoagulant)? How should the risk of bleeding be managed?
• How likely is it that these symptoms will progress to a stroke (permanent damage)? What is the prognosis?
• What additional tests should I undergo? What is the priority of each test?
• How should my target levels for blood pressure, cholesterol, and blood glucose be set?
• When can I resume driving or work duties (especially machinery-related or high-risk work)?

Examples of Disease-Specific Questions

• Carotid artery-related
  • What is the degree of stenosis in my carotid artery? Is it severe enough to require surgery (endarterectomy) or a stent? What are the benefits and risks of each option (surgery vs. stent vs. medication)?
• Cardiac (atrial fibrillation)-related
  • If atrial fibrillation is the cause, which anticoagulant is appropriate for me (warfarin vs. DOAC)? When should I start it (immediately after symptom onset vs. after imaging/tests)?

(※ The information above summarizes general recommendations; individual treatment plans, implementation, and medication selection may vary depending on the patient’s condition and the specialist’s judgment.)