In June 2016, the ACEP Board of Directors approved a new clinical policy on the evaluation of adult patients with suspected transient ischemic attack (TIA), which was developed by ACEP’s Clinical Policies Committee. This clinical policy can also be found on ACEP’s website and has been submitted for inclusion on the National Guideline Clearinghouse website.

TIA is part of a spectrum that involves ischemia of the central nervous system, with approximately 240,000 cases a year in the United States. Although most TIAs last less than one to two hours, by definition, TIAs have a resolution of symptoms within 24 hours without evidence of an acute infarction on imaging. Since approximately 15 percent of all ischemic strokes are preceded by a TIA, timely evaluation for high-risk conditions, such as carotid stenosis and atrial fibrillation, is important.

Based on the feedback from the ACEP membership, the committee focused on four clinical questions about the evaluation of TIA in the emergency department. A systematic review of the evidence was conducted, and the committee made recommendations (A, B, or C) based on the strength of evidence (see Table 1). This clinical policy received input and comments from emergency physicians, neurologists, and members of the American Heart Association/American Stroke Association during the 60-day open-comment period. These responses were used to refine and enhance this clinical policy.

Critical Questions and Recommendations

Question 1. In adult patients with suspected TIA, are there clinical decision rules that can identify patients at very low short-term risk for stroke who can be safely discharged from the emergency department?