In 2016, ACEP published “Clinical Policy: Critical Issues in the Evaluation of Adult Patients with Suspected Transient Ischemic Attack (TIA) in the Emergency Department” in the Annals of EM. Here is a brief refresher.

Transient ischemic attack (TIA) is a part of a spectrum of ischemia affecting the central nervous system.

  • “Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.” – The American Heart and Stroke Associations
  • Most TIAs are thought to last fewer than 1-2 hours.
  • Currently there is no specific acute intervention for patients with TIA; the goal is to reduce the potential for future strokes.


TL;DR Summary (more detail below)

In addition to working in collaboration with your neurology colleagues, the next time you treat a patient suspected of having a TIA, follow these ACEP clinical recommendations:

  • Do not discharge the patient.
  • Do not delay neuroimaging.
  • Consider ED observation for patients without high-risk conditions* to evaluate those at short-term risk for stroke.


Are there clinical decision rules that can identify patients at very low short-term risk for stroke who can be safely discharge from the ED?


In adult patients with a suspected TIA, what imaging can be safely delayed from the initial ED workup?

  • The safety of delaying neuroimaging from the initial ED workup is unknown. If noncon brain MRI is not readily available, it is reasonable for physicians to obtain a noncontrast head CT as part of the initial TIA workup to identify TIA mimics (ICH, mass lesion). However, NCHCT should not be used to identify patients at high short-term risk for stroke.
  • Level C recommendation


Is carotid ultrasonography as accurate as neck CTA or MRA?

  • Carotid US may be used to exclude severe carotid stenosis because it has accuracy similar to that of MRA or CTA.
  • Level C recommendation


Can a rapid ED-based diagnostic protocol (ex, ED observation unit) safely identify patients at short term risk for stroke?

  • In adult patients with suspected TIA without high-risk conditions*, a rapid ED-based diagnostic protocol may be used to evaluate patients at short-term risk for stroke.   
  • High risk conditions: abnormal initial CT, suspected embolic source, carotid stenosis, previous large CVA, or crescendo TIA
  • Level B recommendation


An example of a rapid ED-based diagnostic protocol


You can download and read the entire clinical policy here:


May 2024