Transient Ischemic Attack

What is the treatment for a transient ischemic attack (TIA)?

TIA Therapy
Treatment for a transient ischemic attack is aimed at preventing a second stroke. Since there is no way of determining the severity of future episodes, and no guarantee that the symptoms will resolve, prevention of a future TIA or CVA is crucial.
Treatment guidelines address a variety of targeted goals.
Antiplatelet therapy

• If the patient was not taking aspirin when the TIA occurred, it usually is started at a dose of 325mg per day.
• If the patient was taking aspirin, another antiplatelet drug called dipyridamole may be added. Aggrenox is a combination of aspirin and dipyridamole. Headache is often a side effect.
• If the patient cannot tolerate aspirin because of allergy or stomach upset clopidogrel (Plavix) may be used.

High blood pressure therapy

• Even if the patient does not have hypertension or high blood pressure, there may be benefit in taking anti-hypertensive medications.  
• Two classes of drugs are recommended to be started at the same time, a diuretic and an ACE inhibitor.
• The goal for normal blood pressure is 120/80.

Cholesterol lowering therapy

• Guidelines recommend that a statin drug be started, even if cholesterol levels are normal. Simvastatin (Zocor) is the most commonly recommended medication, but new guidelines limit the amount prescribed per day because of the risk of liver side effects.

Risk modification
Smoking, excessive alcohol, obesity and lack of physical activity are considered risks for future stroke. The following recommendations are now suggested:

• Smoking: Counseling, smoking cessation aids like nicotine gum or medications like varenicline (Chantix) should be considered. Environmental smoke should be avoided.
• Alcohol: Intake should be limited to two or fewer drinks a day for men and one or less for women.
• Obesity: Overweight people should try to lose weight using a combination of diet, exercise and counseling. The goal is a BMI of 18.5-24.9 and a waist line of 35 inches or less for women and 40 inches or less for men.
• Exercise: 30 minutes of moderate exercise daily is recommended for those who are able. For patients with disabilities, a tailored exercise program to their capabilities should be arranged. 

What is the prognosis for transient ischemic attack (TIA)?

A transient ischemic attack should be considered a major warning sign of an impending future stroke. Up to 10% of people will experience a stroke within three months of TIA. Since there is no way of predicting that stroke-like symptoms will resolve, the patient and family need to be educated should symptoms occur, they need to access medical care emergently activating the emergency medical services system and calling 911.
If a stroke occurs, there is a very short period of time where thrombolytic (clot dissolving) drugs, (for example, alteplase [TPA]), can be used to reverse a stroke. In most hospitals, the drug can only be given within 4 1/2 hours of onset of stroke symptoms. In that time frame, the patient needs to get to the hospital, the diagnosis needs to be made, laboratory tests and head CT scans need to be performed, neurologic consultation needs to occur, and the drug administered. The longer the delay, there is a higher the risk that the drug won't work and that complications such as bleeding into the brain will occur.
Specialized interventional radiologists can inject TPA directly into the clot that has blocked the blood vessel in the brain. This can extend the time frame to six hours, but currently this treatment is not widely available.
TIAs should be considered the equivalent of angina of the brain. In heart disease, angina is the heart pain that warns of potential heart attack. When heart muscle is damaged, it cannot be replaced or repaired. Similarly, brain tissue is at risk when there is decreased blood supply and it, too, cannot be replaced.