Transient Ischemic Attack: Management

Original Editor - Mary Akinwola

Top Contributors - Mary Akinwola  

Overview[edit | edit source]

Transient ischemic attack is clinically defined as an acute episode of temporary neurologic dysfunction resulting from a focal cerebral ischemia and is not associated with sudden tissue ischemia[1]. Although the classical definition of TIA included symptoms lasting and resolving in 24 hours, the American Stroke Association certifies a new definition based on tissue rather than time. It focuses on focal ischemia rather than acute infarction[2]. Therefore, because of the peculiarities of TIA, it is often neglected because symptoms tend to dissipate[3].

TIAs are often early warning signs for ischemic stroke, so, in addition to the management of symptoms, there is a need for interventions to prevent permanent stroke and the accompanying disability[4][5].

Physiotherapy[edit | edit source]

Following an acute management of TIA, physiotherapy is important in the management of symptoms accompanying TIA. Early initiation of stroke rehabilitation has better functional outcome. Also, more intensive and longer rehabilitation has a positive effect on functional outcome [6]. A clinical protocol was recommended to provide physiotherapists with a general guide for management of TIA [7]. With this protocol, the progression of treatment should be individualized and based on the patient's needs .

Precaution and Contraindications[edit | edit source]

During management, it is important to closely monitor the symptoms that will indicate a repeat stroke. if the following signs are observed during treatment, the patient should be taken to the ER for acute care.

  1. Change in alertness
  2. Confusion or memory loss
  3. Slurred speech
  4. Decreased bowel and bladder control
  5. Difficulty walking
  6. Unilateral numbness or tingling.

It is also important to monitor the pre and post exercise hemodynamics, specifically, blood pressure and heart rate. To prevent re occurrence, risk factors should be screened for.

PHASE I[edit | edit source]

This is the immediate phase of care which spans Week 1-Week 4 following the event.

The goals of this phase include:

  • Monitoring hemodynamics throughout physiotherapy sessions
  • Increase cardiovascular exercise to five times a week
  • Addressing modifiable risk factors by commencing a weight loss program to manage obesity for example
  • Addressing coordination or balance deficits

Physiotherapy Interventions such as :

  1. Neurological Facilitation Techniques such as joint loading, tapping if residual deficits are noticed
  2. Resisted PNF
  3. Perturbations during balance training
  4. Static and Dynamic balance training
  5. Closed-chain strengthening exercises
  6. Gait training

Phase II[edit | edit source]

This intermediate phase of the protocol spans Week 5-Week8

Goals include:

  • Monitor heart rate and blood pressure throughout physiotherapy sessions
  • Continue weight loss program
  • Brisk walking for 2.5 hours/week
  • Muscular endurance exercises at least 2 days/week
  • Full return to household activities

Interventions include:

  1. Kinesiotaping
  2. Balance training
  3. Closed-chain strengthening exercises
  4. Stationary bike to increase cardiovascular and muscular endurance
  5. Functional strengthening exercises for the upper and lower extremities
  6. Gait training

Phase III[edit | edit source]

This is the Advanced phase which starts from week 9 and above


  • Full return to community and recreational activities
  • Continue strengthening muscles

Physiotherapy interventions include;

  • Kinesiotaping
  • Manual therapy as needed to address biomechanical restrictions
  • Functional exercises
  • Plyometrics as appropriate
  • Cardiovascular exercises

Conclusion[edit | edit source]

Transient Ischemic Attack (TIA) is a transient episode caused by neurological ischemia. It is a high warning sign for stroke. Early stroke rehabilitation is important for better functional outcomes. Beyond lifestyle changes, longer period of rehabilitation is recommended for good outcomes.

References[edit | edit source]

  1. Mc Sharry J, Baxter A, Wallace LM, Kenton A, Turner A, French DP. Delay in seeking medical help following Transient Ischemic Attack (TIA) or "mini-stroke": a qualitative study. PLoS One. 2014;9(8):e104434. Published 2014 Aug 19. doi:10.1371/journal.pone.0104434
  2. Jagoda A, Chan YF. Transient ischemic attack overview: defining the challenges for improving outcomes. Ann Emerg Med. 2008;52(2):S3-S6. doi:10.1016/j.annemergmed.2008.04.030
  3. Eliasziw M, Kennedy J, Hill MD, Buchan AM, Barnett HJ; North American Symptomatic Carotid Endarterectomy Trial Group. Early risk of stroke after a transient ischemic attack in patients with internal carotid artery disease. CMAJ. 2004;170(7):1105-1109. doi:10.1503/cmaj.1030460
  4. Gladstone DJ, Kapral MK, Fang J, Laupacis A, Tu JV. Management and outcomes of transient ischemic attacks in Ontario. CMAJ. 2004;170(7):1099-1104. doi:10.1503/cmaj.1031349
  5. Loh VW, Soon DT, Yeo LL. Outpatient management of transient ischaemic attack. Singapore Med J. 2016;57(12):658-663. doi:10.11622/smedj.2016180
  6. Venketasubramanian N, Pwee KH, Chen CP; Singapore Ministry of Health Clinical Practice Guidelines Workgroup on Stroke and Transient Ischaemic Attacks. Singapore ministry of health clinical practice guidelines on stroke and transient ischemic attacks. Int J Stroke. 2011;6(3):251-258. doi:10.1111/j.1747-4949.2011.00602.x
  7. AlterG.Transient Ischemic Attack (TIA) Protocol.