A prompt evaluation of your symptoms is vital in diagnosing the cause of your TIA and deciding on a method of treatment. To help determine the cause of your TIA and to assess your risk of a stroke, your doctor may rely on the following:
Physical exam and tests. Your doctor will perform a physical exam and a neurological exam. The doctor will test your vision, eye movements, speech and language, strength, reflexes, and sensory system. Your doctor may use a stethoscope to listen to the carotid artery in your neck. A whooshing sound (bruit) may indicate atherosclerosis. Or your doctor may use an ophthalmoscope to look for cholesterol fragments or platelet fragments (emboli) in the tiny blood vessels of the retina at the back of your eye.
Your doctor may check for risk factors of a stroke, including high blood pressure, high cholesterol levels, diabetes and in some cases high levels of the amino acid homocysteine.
- Carotid ultrasonography. If your doctor suspects that the carotid artery may be the cause of your TIA, a carotid ultrasound may be considered. A wand-like device (transducer) sends high-frequency sound waves into your neck. After the sound waves pass through your tissue and back, your doctor can analyze images on a screen to look for narrowing or clotting in the carotid arteries.
- Computerized tomography (CT) or computerized tomography angiography (CTA) scanning. CT scanning of your head uses X-ray beams to assemble a composite 3D look at your brain or evaluate the arteries in your neck and brain. CTA scanning uses X-rays similar to a standard CT scan but may also involve injection of a contrast material into a blood vessel. Unlike a carotid ultrasound, a CTA scan can evaluate blood vessels in the neck and head.
- Magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA). These procedures, which use a strong magnetic field, can generate a composite 3D view of your brain. MRA uses technology similar to MRI to evaluate the arteries in your neck and brain but may include an injection of a contrast material into a blood vessel.
Echocardiography. Your doctor may choose to perform a traditional echocardiography called transthoracic echocardiogram (TTE). A TTE involves moving an instrument called a transducer across your chest. The transducer emits sound waves that bounce off different parts of your heart, creating an ultrasound image.
Or your doctor may choose to perform another type of echocardiography called a transesophageal echocardiogram (TEE). During a TEE, a flexible probe with a transducer built into it is placed in your esophagus — the tube that connects the back of your mouth to your stomach. Because your esophagus is directly behind your heart, clearer, detailed ultrasound images can be created. This allows a better view of some things, such as blood clots, that might not be seen clearly in a traditional echocardiography exam.
Arteriography. This procedure gives a view of arteries in your brain not normally seen in X-ray imaging. A radiologist inserts a thin, flexible tube (catheter) through a small incision, usually in your groin.
The catheter is manipulated through your major arteries and into your carotid or vertebral artery. Then the radiologist injects a dye through the catheter to provide X-ray images of the arteries in your brain. This procedure may be used in selected cases.
Once your doctor has determined the cause of your transient ischemic attack, the goal of treatment is to correct the abnormality and prevent a stroke. Depending on the cause of your TIA, your doctor may prescribe medication to reduce the tendency for blood to clot or may recommend surgery or a balloon procedure (angioplasty).
Doctors use several medications to decrease the likelihood of a stroke after a transient ischemic attack. The medication selected depends on the location, cause, severity and type of TIA. Your doctor may prescribe:
Anti-platelet drugs. These medications make your platelets, one of the circulating blood cell types, less likely to stick together. When blood vessels are injured, sticky platelets begin to form clots, a process completed by clotting proteins in blood plasma.
The most frequently used anti-platelet medication is aspirin. Aspirin is also the least expensive treatment with the fewest potential side effects. An alternative to aspirin is the anti-platelet drug clopidogrel (Plavix).
Your doctor might prescribe aspirin and clopidogrel to be taken together for about a month after the TIA. Research shows that taking these two drugs together in certain situations reduces the risk of a future stroke more than taking aspirin alone. There may be certain situations when the duration of taking both medications together may be extended, such as when the cause of the TIA is a narrowing of a blood vessel located in the head.
Your doctor may consider prescribing Aggrenox, a combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce blood clotting. The way dipyridamole works is slightly different from aspirin.
Anticoagulants. These drugs include heparin and warfarin (Coumadin, Jantoven). They affect clotting-system proteins instead of platelet function. Heparin is used for a short time and is rarely used in the management of TIAs.
These drugs require careful monitoring. If atrial fibrillation is present, your doctor may prescribe a direct oral anticoagulant such as apixaban (Eliquis), rivaroxaban (Xarelto), edoxaban (Savaysa) or dabigatran (Pradaxa).
If you have a moderately or severely narrowed neck (carotid) artery, your doctor may suggest carotid endarterectomy (end-ahr-tur-EK-tuh-me). This preventive surgery clears carotid arteries of fatty deposits (atherosclerotic plaques) before another TIA or stroke can occur. An incision is made to open the artery, the plaques are removed, and the artery is closed.
In selected cases, a procedure called carotid angioplasty, or stenting, is an option. This procedure involves using a balloon-like device to open a clogged artery and placing a small wire tube (stent) into the artery to keep it open.
Preparing for your appointment
A TIA often is diagnosed in an emergency situation, but if you're concerned about your risk of having a stroke, you can prepare to discuss the subject with your doctor at your next appointment.
What you can do
If you want to discuss your risk of a stroke with your doctor, write down and be ready to discuss:
- Your risk factors for a stroke, such as family history of strokes
- Your medical history, including a list of all medications, as well as any vitamins or supplements, you're taking
- Key personal information, such as lifestyle habits and major stressors
- Whether you think you've had a TIA and what symptoms you experienced
- Questions you might have
What to expect from your doctor
Your doctor may recommend that you have several tests to check your risk factors. Your doctor should tell you how to prepare for the tests, such as fasting before having your blood drawn to check your cholesterol and blood sugar levels.