Webinar Report: Transient Ischaemic Attack – Insights from the Latest ESO Webinar

The latest 23^rd ESO Educational Webinar on 24 June 2025 focused on TIA with insightful presentations from Dr Linxin Li (UK) and Dr Vojtech Novotny (Norway), moderated by Dr Xabier Urra (Spain) and Dr Maria Peycheva (Bulgaria) followed by a discussion based on questions from the audience.

Dr Vojtech Novotny, after giving a short introduction on the evolving definition of TIA presented 4 cases to illustrate the challenge of TIA diagnosis. Case 1 was an elderly male patient with typical vertebrobasilar symptoms and DWI negative MRI managed as a TIA. Case 2 was an elderly female with isolated transient vertebrobasilar symptoms but with DWI positive MRI in the brainstem. Case 3 was a young male patient with a history of migraine who had migraine aura-like symptoms but infarction on MRI related to PFO- which could be regarded as a “chameleon TIA”. Case 4 was an elderly male patient with isolated recurrent diplopia and headache together with elevated ESR and CRP, who was diagnosed with biopsy proven giant cell arteritis (GCA).

After this practical introduction, Dr Linxin Li gave a comprehensive overview of the definition, diagnosis, management and prognosis of TIA. She mentioned the new tissue-based versus previous clinical based definition and the potential impact on epidemiological studies. Because acute MRI is not readily available in many healthcare settings, the clinical based definition is still widely used.

Dr Li elaborated on the often-challenging diagnosis of TIA in cases of atypical symptoms, such as non-consensus TIA symptoms (e.g. isolated brainstem symptoms) and non-focal transient neurological attacks. (e.g. migraine-like, transient confusion/unresponsiveness) That should be taken seriously, especially in the elderly with vascular risk factors. She mentioned that isolated diplopia can be a sign of GCA requiring urgent steroid treatment and shared their experience on the most common TIA mimics such as migraine, syncope, peripheral vertigo, seizures, functional deficits and transient global amnesia. She mentioned useful features for the differential diagnosis, but also emphasised the importance of clinical judgement in these cases.

Dr Li mentioned the possible patient pathways and management options in patients with suspected TIA, such as the TIA clinic or specialist-led inpatient care. Secondary prevention is guided by risk stratification for future stroke: single antiplatelet (AP) for low risk, double AP (aspirin+clopidogrel) for high risk (ABCD² >=4). There are also evolving data looking at ticagrelor as an alternative to clopidogrel in patients with very high risk (ABCD² >=6 plus intracranial stenosis) or in those with clopidogrel resistance. Other treatment options are under study, such as colchicine, tirofiban or factor XI inhibitors (asundexian, milvexian).

From a consultation point of view, Dr Li highlighted that although the risk of recurrent stroke after TIA has significantly decreased over the last decade with the help of TIA clinics and effective and prompt secondary prevention, there is still room for improvement, and that TIA patients are not only at higher risk of stroke but also dementia. This latter is also true for tissue-based definition TIA (without a brain lesion), the pathomechanism of which is still poorly understood.

After the presentations, a few interesting questions from the audience were discussed. These included thrombolysis in TIA in case of repetitive symptoms such as crescendo TIA, or as presented in Case 5, with perfusion deficit and vessel occlusion on imaging despite resolution of symptoms. Finally, discussion on the recommended length of cardiac monitoring and lower sensitivity of DWI for minor stroke in posterior circulation ended the webinar.

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