Carotid Doppler ultrasound: Detects narrowing using blood flow velocity and may identify plaque features reflecting risk. Limited by calcification and arterial anatomy.

CT angiography (CTA) and contrast MR angiography (MRA): More accurate than carotid Doppler ultrasound, and can evaluate intracranial arterial stenosis. Beware that contrast agents carry risks for patients with renal impairment.

• Electrocardiography (ECG): Arrhythmias (particularly AF) and myocardial infarction (may indicate ventricular aneurysm)
  
• Echocardiography: Valvular heart disease, for example mitral valve disease (association with AF), enlarged left atrium (also associated with atrial fibrillation) and intracardiac thrombus. Use of a contrast agent (micro-bubbles) may show a patent foramen ovale.
  
• Cardiac rhythm monitoring: Asymptomatic AF may be detected using cardiac rhythm monitoring, for example ward-based monitoring or 24 h tape.

Management

Early assessment: The risk of stroke is highest very early after TIA; therefore, patients with suspected TIA require easy and rapid access to specialist review and investigation. For moderate and high-risk patients (e.g. ABCD2 score of 4 or above), this is typically within 24 h. For low-risk patients, it may be reasonable for review to occur within 7 days.

Medical management (see Chapter 14): According to two studies (SOS-TIA and EXPRESS), medical management alone can reduce 30 day stroke risk by 80% following TIA. Patients with AF (including paroxysmal AF) have a significant risk of stroke after TIA of about 4–18% per annum, depending on the presence of other risk factors such as age, hypertension, congestive cardiac failure and diabetes.

• Antiplatelet agents: With proven benefit include Aspirin, dipyridamole (Modified release dipyridamole reduces risk of stroke following TIA, over and above only in combination with aspirin. Immediate release preparations appear to be ineffective) and clopidogrel.

Initial treatment: Aspirin 300 mg daily, aspirin 75 mg + dipyridamole modified release 200 mg bd or clopidogrel 75 mg daily are reasonable. In high-risk patients, a combination of aspirin 75 mg and clopidogrel 75 mg daily, after loading with 300 mg of each drug, may be beneficial.

Subsequent treatment (e.g. after 14 days): A combination of aspirin and modified release dipyridamole is more effective than aspirin alone (ESPRIT and ESPS2 trials). Clopidogrel appears to be equivalent to aspirin and dipyridamole in combination (PROFESS trial).

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