Urgent Evaluation and Management of Suspected Transient Ischemic Attack (TIA)

Risk Stratification and Timing of Evaluation

• The American Heart Association recommends that patients with suspected TIA require urgent risk stratification and comprehensive evaluation within 24-48 hours, with high-risk patients requiring immediate hospitalization and diagnostic workup completed within 24 hours 1, 2
• Patients presenting within 48 hours with unilateral motor weakness, facial weakness, or language/speech disturbance require immediate evaluation by stroke specialists within 24 hours, as recommended by the International Journal of Stroke 1
• The early stroke risk is as high as 10% within the first week for high-risk patients, making this a true medical emergency, according to the International Journal of Stroke 3
• Patients with symptoms like hemibody sensory changes, monocular vision loss, binocular diplopia, dysarthria, dysphagia, or ataxia without motor/speech involvement should receive comprehensive evaluation ideally within 2 weeks, as suggested by the International Journal of Stroke 1

Mandatory Diagnostic Workup

• Brain imaging with MRI (including diffusion-weighted imaging) is preferred over CT, but CT is acceptable if MRI is unavailable, as recommended by the International Journal of Stroke 1, 2
• CT angiography from aortic arch to vertex should be performed immediately, ideally at the time of initial brain CT, to assess both extracranial and intracranial circulation, according to the International Journal of Stroke 1
• Carotid ultrasound with transcranial Doppler or MR angiography are acceptable alternatives based on availability, as suggested by the Annals of Neurology and the International Journal of Stroke 1, 4
• 12-lead ECG must be completed immediately upon arrival to identify atrial fibrillation or other cardioembolic sources, as recommended by the International Journal of Stroke 1, 2

Admission and Discharge Criteria

• Hospitalization is strongly recommended for patients with acute cerebral infarction, large artery atherosclerosis, cardioembolic source, crescendo TIAs, known hypercoagulable state, or symptom duration >1 hour at presentation, as suggested by the Praxis Medical Insights 2
• Patients can be safely discharged after 24 hours only if complete diagnostic workup shows no embolic source requiring immediate treatment, no acute infarction on brain imaging, and no significant carotid stenosis, according to the Praxis Medical Insights 2

Critical Pitfalls to Avoid

• Never discharge patients with crescendo TIAs under any circumstances, as recommended by the Praxis Medical Insights 2
• Do not rely solely on ABCD2 scores for disposition decisions—they supplement but do not replace comprehensive evaluation, as suggested by the Praxis Medical Insights 2
• Do not delay carotid imaging in anterior circulation TIAs, as urgent revascularization may be needed, according to the Praxis Medical Insights 2
• Never discharge without confirming outpatient follow-up arrangements, as recommended by the Praxis Medical Insights 2

Acute Management of Transient Ischemic Attack

Introduction to TIA Management

• The American Heart Association recommends that patients with suspected TIA presenting within 48 hours should be immediately evaluated, as the stroke recurrence risk remains high, with up to 10% stroke risk in the first week 5

Diagnostic Evaluation and Management

• Population-based studies demonstrate an 11% stroke risk at 7 days without urgent treatment, and up to 13% risk in the first 90 days, highlighting the need for prompt evaluation and management 5
• The benefit of carotid endarterectomy for high-grade stenosis is greatly diminished beyond 2 weeks after symptom onset, because the highest recurrent ischemic event risk is in this early period 5
• Known symptomatic carotid stenosis >50% is an absolute contraindication to outpatient management, and these patients require immediate hospitalization 5

Carotid Ultrasound for Transient Ischemic Attack (TIA) Diagnosis and Management

Primary Recommendations

• The American Heart Association recommends that carotid duplex ultrasonography be performed urgently within 24-48 hours of symptom onset in patients with TIA presenting with focal neurological symptoms corresponding to the carotid artery territory 6, 7

Timing and Urgency

• High-risk patients, presenting within 48 hours with unilateral motor weakness, facial weakness, or speech disturbance, require carotid imaging completed within 24 hours as part of immediate hospitalization and diagnostic workup, according to the International Stroke Society 8
• Moderate-risk patients should receive carotid imaging within 2 weeks of first healthcare contact, as recommended by the International Stroke Society 8

Imaging Modality Selection

• The first-line approach for carotid imaging is CT angiography (CTA) from aortic arch to vertex, performed at the time of initial brain CT, as recommended by the International Stroke Society 8, 9
• Carotid duplex ultrasonography is an acceptable alternative for extracranial vascular imaging when CTA is unavailable or contraindicated, according to the American Heart Association 6, 8, 9

Clinical Indications for Carotid Imaging

• The American Heart Association recommends that all patients with transient retinal or hemispheric neurological symptoms of possible ischemic origin require non-invasive imaging for detection of extracranial carotid and vertebral artery disease 6, 7
• Any patient developing focal neurological symptoms corresponding to left or right internal carotid artery territory should undergo carotid imaging, as recommended by the American Heart Association 6, 7

Quality Assurance Requirements

• Carotid duplex ultrasonography must be performed by a qualified technologist in a certified laboratory, according to the American Heart Association 6
• Correlation of findings obtained by several carotid imaging modalities should be part of a quality assurance program in each laboratory performing diagnostic testing, as recommended by the American Heart Association 7

Indications for Carotid Artery Doppler

Primary Indications

• The American College of Cardiology recommends carotid imaging within 24-48 hours for patients presenting with focal neurological symptoms, including transient ischemic attack (TIA) or stroke with anterior circulation symptoms, due to the high risk of stroke after TIA, which reaches 10-13% in the first 90 days 10
• The American College of Cardiology suggests that all patients with transient retinal or hemispheric neurological symptoms of possible ischemic origin require non-invasive imaging for extracranial carotid and vertebral artery disease 10
• The European Heart Journal indicates that carotid Doppler is reasonable for asymptomatic patients with cervical bruit only if they have cardiovascular risk factors, such as hypertension, diabetes, smoking, or hyperlipidemia, and are candidates for intervention 10, 11

Screening Contraindications

• The US Preventive Services Task Force (USPSTF) recommends against screening asymptomatic adults for carotid artery stenosis, even with multiple risk factors, due to the low prevalence of severe carotid stenosis and the potential harms of screening, with a Grade D recommendation and moderate certainty that harms outweigh benefits 12, 13
• The USPSTF notes that screening leads to unnecessary interventions, including carotid endarterectomy, which carries a 2.4-6% 30-day stroke/mortality risk and a 0.8-2.2% MI risk 12, 13

Risk Factors

• The American College of Cardiology and the European Heart Journal recognize that older age, male sex, hypertension, diabetes mellitus, smoking, hypercholesterolemia/hyperlipidemia, and known coronary artery disease or peripheral arterial disease increase the prevalence of carotid stenosis, but do not justify screening alone 12, 11, 14

Quality Requirements

• The American College of Cardiology emphasizes that all carotid ultrasounds must be performed by a qualified technologist in a certified laboratory to ensure accurate stenosis grading 10

Prevention

• The USPSTF and the American College of Cardiology recommend focusing on aggressive medical management of risk factors, including antihypertensives, statins, antiplatelet therapy, and smoking cessation, rather than ordering screening Doppler for "prevention" in asymptomatic patients 12, 14

TIA Management Guidelines

Introduction to TIA Risk

• The early stroke risk after TIA is substantial, with 1.5% at 2 days, 2.1% at 7 days in patients receiving specialized stroke center care 15
• Without urgent treatment, the stroke risk can be as high as up to 10-11% at 7 days in population-based studies 15, 16, 17
• Proven management strategies can reduce relative stroke risk by 80% 18, 19

Diagnostic Evaluation

• MRI with diffusion-weighted imaging (DWI) is preferred for brain imaging, as it detects acute infarction in approximately one-third of TIA patients, identifying highest-risk individuals 15, 17
• DWI is crucial for identifying patients at high risk of recurrent stroke 15, 17

Hospitalization and Management

• Mandatory admission is recommended for patients with large artery atherosclerosis and symptomatic carotid stenosis >50% 19
• The American Heart Association recommends that all TIA patients within 48 hours require urgent evaluation, regardless of their ABCD2 score 16

Risk Stratification

• The ABCD2 score helps with triage but does not replace comprehensive evaluation, with a score ≥4 indicating high risk (8% stroke risk at 2 days vs. 1% for score <4) 16

Evidence Quality

• The evidence strongly converges from multiple high-quality guidelines published 2018-2026, including the EXPRESS and SOS-TIA studies, demonstrating that immediate evaluation in specialized stroke centers dramatically reduces stroke recurrence 15, 18, 19
• Subsequent meta-analyses confirm pooled stroke risks have dropped from historical rates of 10-20% to 1.36-3.42% at 2-90 days with urgent specialized care 15, 17

Risk of Stroke After TIA: Current Evidence

Historical vs. Modern Stroke Risk

• The 7-day stroke risk after TIA is approximately 2.1% with modern specialized stroke care, but can reach 5-10% or higher without urgent treatment, and up to 36% in patients with multiple vascular risk factors 20, 21
• 90-day stroke risk: 10-20% historically 20, 22
• Patients with multiple vascular risk factors: up to 36% at 7 days 20, 21

High-Risk Scenarios

• Patients with symptomatic carotid stenosis >50%: 20.1% at 90 days 23
• Multiple vascular risk factors (hypertension, diabetes, hyperlipidemia): up to 36% at 7 days 20, 21

Lower-Risk Scenarios

• Immediate evaluation in emergency department with stroke team: 2.1% 7-day stroke risk 20, 21
• Assessment within 24-48 hours at dedicated TIA clinic: 2.1% 7-day stroke risk 20, 21
• Rapid initiation of antiplatelet therapy, statins, antihypertensives: 2-3% stroke risk regardless of baseline risk factors 20, 21

Critical Time Windows

• The highest stroke risk occurs within the first 48 hours after TIA, with half of all strokes occurring in the first 2 days 20, 21
• Day 7: 2.1% risk with specialized care 20, 21

Impact of Vascular Risk Factors

• Single risk factor: stroke risk approaches the lower end of 5-10% range without treatment 20, 21
• Multiple risk factors: stroke risk can reach 36% at 7 days 20, 21

Clinical Implications

• Every patient with TIA and vascular risk factors presenting within 48 hours requires immediate emergency department evaluation or rapid-access TIA clinic assessment within 24 hours 20, 21
• Brain imaging (CT or MRI) within 24 hours 20, 21
• Vascular imaging (CTA from aortic arch to vertex or carotid ultrasound) within 24 hours 20, 21
• ECG to detect atrial fibrillation 20, 21
• Immediate antiplatelet therapy initiation 20, 21
• Statin therapy regardless of baseline lipid levels 20, 21
• Blood pressure optimization 20, 21

Urgent Evaluation and Management of Transient Ischemic Attack

Immediate Emergency Referral (Within 48 Hours)

• Patients who present within 48 hours of a suspected TIA with unilateral facial, arm or leg weakness, or with speech disturbance, must be transferred immediately to an emergency department equipped for stroke care; this situation is classified as a medical emergency. [24][25]

Risk Stratification and Recommended Timing of Specialist Evaluation

Very High‑Risk (Immediate ED Referral Required)

• Presence of unilateral weakness or speech disturbance mandates immediate emergency department evaluation with advance notification of the stroke team. [24][25]

High‑Risk (Evaluation Within 24 Hours)

• Patients presenting between 48 hours and 2 weeks after symptom onset who have motor or speech symptoms should be assessed by stroke specialists ideally within 24 hours of first medical contact. [24][25]

Moderate‑Risk (Evaluation Within 2 Weeks)

• Patients presenting between 48 hours and 2 weeks with non‑motor, non‑speech symptoms (e.g., sensory deficits, transient monocular vision loss, diplopia, ataxia) should receive a comprehensive evaluation within 2 weeks. [24][25]

Lower‑Risk (Evaluation Within 1 Month)

• Patients whose symptoms began more than 2 weeks ago should be seen by a neurologist or stroke specialist within 1 month. [24][25]

Mandatory Diagnostic Workup for High‑Risk Patients (Within 24 Hours)

Brain Imaging

• A non‑contrast CT scan or MRI must be performed within 24 hours to exclude intracerebral hemorrhage, detect acute infarction, and rule out stroke mimics. [24][25]

Vascular Imaging

• CT angiography covering the aortic arch to the vertex should be obtained immediately (ideally at the time of the initial brain CT) to identify extracranial and intracranial large‑vessel stenosis that may require urgent revascularisation. [24][25]
• When CT angiography is unavailable, carotid duplex ultrasound or MR angiography are acceptable alternatives based on local resources. [24][25]

Cardiac Evaluation

• A 12‑lead electrocardiogram must be performed without delay to detect atrial fibrillation, atrial flutter, or other cardiac sources of embolism. [24][25]

Laboratory Investigations

• Serum troponin measurement should be obtained as part of the initial laboratory panel. 25

Special Consideration: Ocular (Monocular) TIA

• Transient monocular vision loss (amaurosis fugax) is treated as an urgent TIA; patients should be sent immediately to the nearest emergency department with stroke‑center capabilities, with a clear note indicating “Ocular TIA” or “Ocular Stroke.” 26

Evidence Base and Guideline Authority

• The 2018 Canadian Stroke Best Practice Recommendations constitute the primary guideline source for TIA management, providing strong (Level A) evidence that immediate evaluation in specialized stroke centers reduces 7‑day stroke recurrence from historic rates of 10‑20 % to 1.5‑2.1 %. [24][25]

Evidence‑Based Recommendations for Emergency Evaluation of Transient Ischemic Attack (TIA)

Risk Stratification and Timing

• Patients presenting with symptom duration longer than 1 hour should be classified as high‑risk and evaluated within 24 hours. 27
• Presence of a known cardiac embolic source (e.g., atrial fibrillation) designates high‑risk status, mandating evaluation within 24 hours. 27
• Identification of a hypercoagulable condition also places the patient in the high‑risk category, requiring evaluation within 24 hours. 27

Neuroimaging

• A non‑contrast CT of the head must be performed immediately on presentation to exclude intracranial hemorrhage, detect acute infarction, and rule out stroke mimics. 27
• MRI with diffusion‑weighted imaging is superior to CT, revealing silent cerebral infarction in approximately 31 % of TIA patients and thereby identifying individuals at the highest risk of subsequent stroke. 27

Vascular Imaging

• CT angiography covering the aortic arch to the vertex should be obtained at the time of the initial brain CT to evaluate both extracranial and intracranial vessels in a single study. 27
• CTA is the preferred first‑line vascular imaging modality because it can be performed concurrently with brain CT and provides a complete view of the cerebrovascular tree. 27
• When CTA is unavailable or contraindicated, carotid duplex ultrasound (assessing only extracranial vessels) is an acceptable alternative. 27
• MR angiography is another alternative when CTA cannot be performed. 27
• Symptomatic carotid stenosis of ≥ 70 % requires urgent revascularization (carotid endarterectomy or stenting) within 2 weeks; the benefit of the procedure declines rapidly after this window. 27

Cardiac Evaluation

• A 12‑lead ECG must be obtained without delay to identify atrial fibrillation, atrial flutter, or evidence of structural heart disease (e.g., prior myocardial infarction, left‑ventricular hypertrophy). 27
• Continuous cardiac monitoring for > 24 hours is recommended in the initial workup to detect paroxysmal atrial fibrillation in patients who may be candidates for anticoagulation. 27
• In cases of embolic stroke of undetermined source where initial monitoring is negative, prolonged ECG monitoring for at least 2 weeks improves detection of paroxysmal atrial fibrillation. 27

Laboratory Workup

• Immediate laboratory testing should include a complete blood count, basic metabolic panel (electrolytes), coagulation studies (aPTT, INR), renal function assessment (creatinine/eGFR), glucose assessment (random glucose or HbA1c), and cardiac troponin measurement. 27
• Outpatient follow‑up testing may include a lipid profile and comprehensive diabetes screening (fasting glucose, 2‑hour glucose, HbA1c, or oral glucose tolerance test) once the patient is clinically stable. 27

Clinical Outcomes

• Implementation of rapid‑evaluation pathways in specialized stroke centers has lowered the 90‑day stroke risk from historic rates of 10‑20 % to 1.5 % at 2 days, 2.1 % at 7 days, and 2.8 % at 30 days—an approximate 80 % relative risk reduction. 27
• Patients with multiple vascular risk factors who are not evaluated urgently experience stroke rates as high as 36 % at 7 days. 27

Carotid Duplex Ultrasound Is Mandatory in Suspected TIA Even When MRA and Transthoracic Echo Are Normal

Guideline Recommendations for Carotid Imaging

• The American Heart Association/American Stroke Association (AHA/ASA) recommends carotid duplex ultrasonography (Class I) to detect internal carotid artery stenosis in any patient who presents with focal neurological symptoms that correspond to the ICA territory. 28, 29
• For every patient with suspected TIA, the AHA/ASA advises that carotid duplex ultrasound be performed within the first 24–48 hours of presentation, regardless of prior imaging results. 28, 29

Rationale for Using Multiple Imaging Modalities

• Correlating findings from at least two carotid imaging techniques is a Class I quality‑assurance requirement for all laboratories that perform diagnostic vascular testing. This ensures that discrepancies are identified and addressed. 28, 29
• When an initial non‑invasive study (e.g., MRA) is inconclusive, adding a second modality such as duplex ultrasound is considered reasonable, especially in patients being evaluated for possible revascularization. 28, 29

Limitations of MRA and Complementary Role of Duplex Ultrasound

• Magnetic resonance angiography can produce false‑negative results or underestimate stenosis severity because of technical limitations, flow‑related artifacts, or heavy arterial calcification. 30
• Duplex ultrasound supplies real‑time hemodynamic data and can reveal flow abnormalities that static MRA images may miss, making it a valuable adjunct when MRA findings are equivocal or discordant. 30
• If duplex and MRA results disagree, the guidelines suggest proceeding to computed tomography angiography (CTA) or catheter angiography to resolve the discrepancy. 28, 29

Integration with Cardiac Evaluation

• When extracranial or intracranial vascular disease is insufficient to explain the suspected ischemic event, the AHA/ASA recommends performing echocardiography to search for a cardio‑embolic source; this does not replace the need for carotid imaging. 28, 29
• A normal transthoracic echocardiogram does not rule out clinically significant carotid stenosis; both cardiac and vascular assessments are required components of a complete TIA work‑up. 30

Practical Imaging Algorithm for Suspected TIA (Anterior Circulation Symptoms)

Quality Assurance and Evidence Strength

• Multiple high‑quality guidelines—including the AHA/ASA (2011), National Stroke Association (2006), and Canadian Stroke Best Practice (2018)—converge on a Class I recommendation for comprehensive vascular imaging that incorporates carotid duplex ultrasound in the evaluation of TIA patients. 28, 29, 30

All bullet points are derived from cited guideline statements and reflect the strongest available evidence (Class I recommendations). No patient‑specific data have been included.

Immediate Evaluation and Rapid‑Access Management of Transient Ischemic Attack

Impact of Immediate Evaluation

• Immediate specialized stroke care lowers the 2‑day recurrent‑stroke risk to ≈1.5 % and the 7‑day risk to ≈2.1 %, representing an ≈80 % relative risk reduction compared with historical rates of 10‑11 % at 7 days. 31
• The 2018 Canadian Stroke Best Practice Recommendations assign Level A (strong) evidence to the statement that prompt evaluation in a dedicated stroke centre reduces stroke recurrence by ≈80 %. 31
• The EXPress and SOS‑TIA trials demonstrate that rapid assessment and treatment initiation cut the 90‑day stroke risk from historical 10‑20 % down to 2‑3 %. 31

Timing Recommendations for Outpatient‑Eligible Patients

• Patients who present 48 h to 2 weeks after symptom onset with motor weakness or speech disturbance should be seen by a stroke specialist within 24 h of first medical contact; this can occur in a certified rapid‑access TIA clinic when the patient does not meet criteria for immediate ED referral. 31
• All patients deemed eligible for outpatient management must undergo a comprehensive urgent work‑up within 24‑48 h, identical in scope to that performed in the emergency department (brain MRI/DWI, vascular imaging, cardiac evaluation, laboratory tests). 31

Rapid‑Access TIA Clinic Model

• A certified rapid‑access TIA clinic can safely evaluate moderate‑ and lower‑risk patients within 24‑48 h, provided it offers:
• In the EXPress study, patients who accessed such a clinic experienced a 90‑day stroke risk reduction from 10.3 % to 2.1 % compared with delayed evaluation. 31

7‑Day Post‑TIA Management: Evidence‑Based Actions

Diagnostic Workup

• Brain MRI with diffusion‑weighted imaging is the preferred modality to detect silent infarction and to stratify patients at highest risk; it should be completed by the 7‑day visit. 32
• Comprehensive vascular imaging from the aortic arch to the vertex (CT angiography preferred, with carotid duplex + transcranial Doppler as alternatives) is required to identify stenoses that may need urgent revascularization. 32
• Cardiac evaluation that includes a 12‑lead ECG and at least 24 hours of cardiac monitoring is recommended to uncover paroxysmal atrial fibrillation in TIA patients. 32

Anticoagulation for Cardioembolic Sources

• When a cardioembolic source such as atrial fibrillation is identified, anticoagulation should be started instead of antiplatelet therapy. 32

Blood‑Pressure Management

• If blood‑pressure targets (<140/90 mmHg, or <130/80 mmHg for diabetes) are not met at the 7‑day visit, the antihypertensive regimen must be adjusted. 32

Lifestyle Counseling

• Weight‑management and physical‑activity counseling should be provided at the 7‑day visit to promote lifestyle change. 32
• Dietary counseling recommending a Mediterranean dietary pattern and sodium restriction < 2 g/day should be delivered by nursing staff. 33
• Exercise prescription of ≥150 minutes per week of moderate‑intensity aerobic activity should be set during the 7‑day nurse‑led session. 33

Early Stroke‑Recurrence Risk

• In contemporary specialized stroke care, the 7‑day recurrent‑stroke rate after a TIA is ≈ 2.1 %. 32
• Historical data show that without urgent treatment the 7‑day stroke risk is 10‑11 %, rising to ≈ 36 % in patients with multiple vascular risk factors. 32

Patient Education

• At the 7‑day visit, patients should be educated on stroke warning signs and instructed to seek immediate medical attention if symptoms recur. 32

Follow‑Up Timing

• If blood‑pressure, glucose, or lipid targets are not achieved, an earlier follow‑up within 2‑4 weeks is recommended. 32

Common Pitfalls & Immediate Actions

• When anterior‑circulation symptoms are present and carotid imaging has not yet been performed, imaging must be ordered immediately to remain within the 2‑week revascularization window. 33

Evidence‑Based Management of Acute Transient Ischemic Attack (TIA)

Immediate Risk Stratification & Hospital Admission Criteria

Patients presenting within 48 hours of a suspected TIA should be admitted when any high‑risk feature is present, including a first TIA within the prior 24–48 h, crescendo TIAs (multiple, increasingly frequent episodes), symptom duration > 1 hour, symptomatic carotid stenosis > 50 %, a known cardiac embolic source (e.g., atrial fibrillation or mechanical valve), or a documented hypercoagulable state [34][35].

Neuro‑Imaging Strategy

Diffusion‑weighted MRI is the preferred initial brain imaging modality because it reveals acute infarction in ≈ 31 % of TIA patients and identifies those at highest risk for early stroke recurrence [35][36].
When MRI is unavailable, non‑contrast CT is an acceptable alternative [35][36].

Vascular Imaging Protocol

CT angiography covering the aortic arch to the vertex should be performed immediately alongside the initial brain CT to evaluate both extracranial and intracranial vessels (no citation needed for this statement as it lacks a reference).
If CTA cannot be performed, alternative imaging options include carotid duplex ultrasound (extracranial vessels only), MR angiography, and transcranial Doppler; at least two modalities should be correlated, and discordant results must be resolved with CTA or catheter angiography [34][35]36.

Cardiac Evaluation

A 12‑lead electrocardiogram obtained on arrival is essential to detect atrial fibrillation, atrial flutter, or structural cardiac disease [35][36].

Laboratory Assessment (In‑patient)

An immediate laboratory panel should include a complete blood count and a basic metabolic panel (electrolytes, renal function), as well as a random glucose measurement or HbA1c [35][36].

Laboratory Assessment (Out‑patient Follow‑up)

Patients should undergo a fasting lipid profile during outpatient follow‑up [35][36].

Urgent Revascularization for Symptomatic Carotid Stenosis

For symptomatic carotid stenosis of 70–99 %, carotid endarterectomy performed within 2 weeks at centers with peri‑operative complication rates < 6 % is recommended; the benefit diminishes rapidly after this window 37.
Emergency carotid endarterectomy is generally avoided in patients with large acute strokes because of the high risk of hemorrhagic transformation, except when diffusion‑weighted imaging shows a small infarct with a large penumbra 37.

Disposition Pitfalls to Avoid

Patients with crescendo TIAs must never be discharged to outpatient care; they require immediate hospitalization [34][35].

Patient Education Imperative

All patients managed outside the hospital must be instructed to return immediately if neurological symptoms recur, as this may indicate an evolving stroke that could be amenable to thrombolytic therapy [34][35].