“Mini-stroke”: Transient Ischemic Attack (TIA)

A transient ischemic attack (TIA) is a temporary disturbance of blood supply to the brain that causes acute, focal neurological symptoms. TIA has traditionally been referred to as a “mini-stroke,” but it is now considered a serious warning sign that a major stroke may occur. The risk of stroke is particularly high within the first 48 hours after a TIA, and the condition always requires urgent evaluation and follow-up¹.

Causes and pathophysiology

A transient ischemic attack (TIA) occurs due to a temporary reduction or blockage of blood flow to a specific area of the brain. This is most often caused by small blood clots (thrombi or emboli) that temporarily block a blood vessel but then dissolve or pass through, restoring blood flow quickly. Common causes include atherosclerosis in the carotid arteries or cerebral vessels, as well as emboli originating from the heart (e.g., in atrial fibrillation) or larger vessels. Small vessels within the brain may also become blocked due to local changes (so-called lacunar infarcts).

From a pathophysiological perspective, TIA and ischemic stroke exist on a continuum, with the main difference being the duration and the absence or presence of permanent brain tissue damage. In TIA, blood flow is restored before a lasting infarction occurs, while in stroke, the damage is permanent¹.

Risk factors

The most important risk factors for TIA are the same as for stroke and other cardiovascular diseases:

• High blood pressure (hypertension) – the most significant risk factor at both individual and population levels

• Diabetes

• Advanced age

• Smoking

• Overweight

• Excessive alcohol consumption

• Unhealthy diet

• Psychosocial stress

• Physical inactivity

Previous TIA or stroke significantly increases the risk of future events. There are also rarer causes, such as arterial dissection, vasculitis, and certain congenital conditions¹.

Epidemiology

The true incidence of TIA is difficult to establish, as symptoms often resolve before patients seek medical care, and many cases are mistaken for other conditions. Internationally, the incidence is around 0.4 per 1,000 people per year, though numbers vary. In the United States, an estimated 500,000 new TIAs occur each year, and about 2% of the adult population has experienced a TIA during their lifetime. The risk increases with age – from extremely rare in the young to more than 1,500 per 100,000 in those over 85 years. Men are slightly more often affected than women¹.

Symptoms and clinical presentation

TIA causes sudden, focal neurological symptoms that must always be treated as possible stroke until proven otherwise. Typical symptoms depend on which blood vessel and corresponding brain area are affected:

• Sudden weakness or paralysis of the arm, leg, or face (often on one side)

• Speech difficulties (aphasia), either in comprehension or expression

• Vision loss in one eye or double vision

• Numbness or sensory loss

• Coordination problems or unsteadiness

Symptoms usually last less than one hour, often just a few minutes. They should always be regarded as serious, even if they resolve spontaneously. Because symptoms often disappear before examination, it is crucial to obtain a thorough history from relatives or witnesses¹.

Diagnosis

The diagnosis of TIA is primarily based on patient history. The patient (or witnesses) describes a sudden onset of neurological symptoms that resolve within one hour, without lasting functional impairment. Because many other conditions can present with similar symptoms (“TIA mimics”), it is important to exclude migraine, epilepsy, transient hypoglycemia, and functional neurological disorders.

All patients with suspected TIA should undergo urgent evaluation with brain and vascular imaging (CT/MRI), blood tests, and ECG to assess underlying causes and risk. Assessment of the carotid arteries (ultrasound, CT angiography) and the heart (echocardiography) is often required.

The ABCD2 score is used to estimate the risk of stroke in the days following a TIA. Points are assigned based on age, blood pressure, symptom type, duration, and the presence of diabetes. A higher score indicates increased risk and the need for hospitalization¹.

Treatment and medical management

TIA is a medical emergency and requires immediate management to prevent progression to stroke. Interventions are similar to those for ischemic stroke, but the aim is to prevent permanent infarction. The main principles include:

• Rapid diagnostics and risk stratification

• Antiplatelet therapy (blood thinners)

• Management of underlying conditions (e.g., blood pressure control, cholesterol-lowering treatment)

• Treatment of cardiac arrhythmias (e.g., atrial fibrillation)

• Carotid surgery may be considered in cases of significant stenosis

• Early initiation of lifestyle interventions (smoking cessation, weight reduction, physical activity)

• Hospital admission for observation is recommended in high-risk cases¹

Prognosis and course

TIA does not cause permanent brain damage in itself but serves as a serious warning sign. Without rapid evaluation and treatment, the risk of stroke is particularly high in the first 48 hours. Proper management significantly reduces this risk, and most patients do not experience permanent impairment. Prognosis depends on the underlying cause, comorbidities, and adherence to preventive measures. Recurrent TIAs increase the risk of both functional decline and dementia in the long term¹.

Differential diagnoses

The diagnosis of TIA can be challenging because several other conditions cause acute, transient neurological symptoms resembling TIA. These conditions are referred to as “mimics” and account for about half of all cases investigated for possible TIA. To establish an accurate diagnosis, it is essential to differentiate TIA from other causes using history, clinical examination, laboratory tests, and imaging.

The most important differential diagnoses include:

• Vestibular disorders (e.g., benign paroxysmal positional vertigo, vestibular migraine)

• Epileptic seizures (particularly focal seizures with subsequent paresis or confusion)

• Migraine with aura (especially with visual or sensory symptoms)

• Bell’s palsy (facial palsy without central involvement)

• Drug side effects or withdrawal

• Dementia and transient confusional states

• Electrolyte disturbances (e.g., low sodium or calcium)

• Acute infections

• Alcohol withdrawal or intoxication

• Stroke (ischemic or hemorrhagic – differentiation based on symptom duration and presence of permanent deficits)

• Meningitis (often accompanied by fever and neck stiffness)

• Multiple sclerosis

• Syncope (brief loss of consciousness, but without focal deficits)²

Accurate differentiation is crucial for guiding treatment decisions and prognosis.

Physiotherapy and secondary prevention

The role of the physiotherapist after TIA is twofold: to help assess and restore function in those with residual symptoms, and to provide targeted education and guidance on lifestyle changes to prevent recurrent TIA or stroke.

Research shows that individuals with TIA often have lower levels of physical activity than healthy controls, and insufficient activity is a significant risk factor for recurrence and cardiovascular disease in general¹¹. Especially important are:

• Education on the importance of physical activity, diet, smoking cessation, and control of blood pressure and blood glucose

• Functional assessment (balance, strength, gait, coordination) and development of an individualized exercise program

• Fall prevention and assessment of the need for assistive devices

• Collaboration with other healthcare professionals in complex cases

Clinical assessment

1. History

• Onset and duration of symptoms (often < 1 hour, always < 24 hours; specify timing and duration)

• Symptoms during the episode (e.g., unilateral weakness, numbness, double vision, unsteadiness, aphasia)

• Are symptoms completely resolved now?

• Previous TIA or stroke?

• Risk factors (hypertension, atrial fibrillation, diabetes, smoking, hyperlipidemia, physical inactivity)

• Medications and follow-up after TIA

2. Clinical observation and orientation

• Consciousness, alertness, ability to respond coherently

• Facial asymmetry, drooling, drooping mouth corner

• Spontaneous movements, posture, gait

3. Neurological screening

• Cranial nerves (brief): eye movements, visual fields, facial nerve (smile, raise eyebrows), tongue motor function

• Motor: arm and leg lifts (with and without resistance), pronator drift, finger tapping, foot tapping

• Sensation: light touch and pin-prick (basic screening)

• Coordination: finger-to-nose, heel-to-shin

• Balance tests: standing with feet together (Romberg), gait, tandem gait, sit-to-stand

4. Function and activity

• Gait function and endurance (short walking distance, 6 m test)

• Stair test, sit-to-stand

• Use of assistive devices or need for support

5. Summary and assessment

• Residual symptoms

• Fall risk

• Need for further referral or evaluation

• Current training level and functional capacity

Further measures (if needed):

• Referral to stroke clinic or neurologist

• Advice on physical activity and risk factors

• Fall prevention if residual symptoms are present

• Information and support for relatives

Lifestyle interventions

Systematic reviews show that interventions specifically targeting increased physical activity are most effective, and physiotherapists – with their expertise in movement and rehabilitation – play a key role in these programs¹¹. It is also recommended that TIA patients be offered structured rehabilitation similar to cardiac rehabilitation, with close follow-up and guidance over six weeks. Example: three sessions per week, 1.5 hours each, focusing on physical training, risk factor management, and lifestyle counseling¹³. A medical evaluation should always be performed before starting.

Education on warning signs and when to seek emergency medical care, as well as support to implement lasting lifestyle changes, are central elements of physiotherapy in TIA management.

Summary and key points

Transient ischemic attack (TIA) and minor ischemic stroke should be managed in the same way. Accurate diagnosis is essential, as about half of patients investigated for TIA have an alternative explanation. Atrial fibrillation is a common cause, and all patients must undergo urgent imaging to exclude mimicking conditions. Rapid evaluation of underlying cause is necessary to initiate effective secondary prevention. There is strong evidence that TIA patients benefit from structured rehabilitation programs similar to cardiac rehabilitation, with emphasis on increased physical activity, coping strategies, and lifestyle changes¹,²,¹¹,¹³.

References

1. Coutts SB. Diagnosis and management of transient ischemic attack. Continuum: Lifelong Learning in Neurology. 2017;23(1):82. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898963/ [accessed 05.07.2025]

2. Panuganti KK, Tadi P, Lui F. Transient ischemic attack. In: StatPearls [Internet]. 2019 Mar 21. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459143/ [accessed 05.07.2025]

3. Estol CJ. Dr C. Miller Fisher and the history of carotid artery disease. Stroke. 1996;27(3):559–66.

4. Coupland AP, Thapar A, Qureshi MI, Jenkins H, Davies AH. The definition of stroke. J R Soc Med. 2017;110(1):9–12. Available from: https://journals.sagepub.com/doi/full/10.1177/0141076816680121 [accessed 05.07.2025]

5. Truelsen T, Begg S, Mathers C. World Health Organization: The global burden of cerebrovascular disease. Global Burden of Disease 2000.

6. Giles MF, Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2007;6(12):1063–72.

7. Kleindorfer D, Panagos P, Pancioli A, et al. Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke. 2005;36(4):720–3.

8. Bots ML, van der Wilk EC, Koudstaal PJ, Hofman A, Grobbee DE. Transient neurological attacks in the general population: prevalence, risk factors, and clinical relevance. Stroke. 1997;28(4):768–73.

9. Sheehan OC, Merwick A, Kelly LA, et al. Diagnostic usefulness of the ABCD2 score to distinguish TIA and minor stroke from noncerebrovascular events. Stroke. 2009;40:3449–54.

10. The 4th European Congress of the ER-WCPT / Physiotherapy. 2016:eS67–eS282. Physio role in TIA. Available from: https://www.physiotherapyjournal.com/article/S0031-9406(16)30153-5/pdf [accessed 05.07.2025]

11. Hendrickx W, Vlietstra L, Valkenet K, et al. General lifestyle interventions on their own seem insufficient to improve physical activity after stroke or TIA: a systematic review. BMC Neurol. 2020;20(1):1–3.

12. M Dedge. Rehab after TIA. YouTube. Available from: https://www.youtube.com/watch?v=p3EN1uLvbDw [accessed 05.07.2025]

13. Eureka Alert. Indiana University researcher, hospital, study potential rehab following 'mini stroke'. Available from: https://www.eurekalert.org/pub_releases/2010-02/iu-iur022310.php [accessed 05.07.2025]