All Patients Should Be Admitted to the Hospital After a Transient Ischemic Attack

Before choosing a management strategy for the patient described, the first question is a diagnostic one. What happened and why? The most probable diagnosis, but certainly not the only one, is transient ischemic attack (TIA). We might increase our diagnostic certainty with MRI; acute infarction on diffusion-weighted imaging confirms the diagnosis of an ischemic neurovascular event. However, in the short-term, this will not change our management, because the absence of a diffusion-weighted imaging lesion does not exclude TIA, and the pretest probability of TIA is high based on the patient's age, symptoms, and negative head CT. So proceeding with a working diagnosis of TIA, the most dangerous potential cause of the patient's symptoms is sensible. This leads directly to the next question: why might she have had a TIA? The cause might be cardioembolism (10% to 20% of patients with TIA) or large-artery stenosis (15%–20% of patients).1 This matters because, if present, the risk of short-term recurrence is high (particularly with large-artery stenosis), and these mechanisms require specific early interventions beyond standard antiplatelet and statin therapy. Testing to evaluate whether these mechanisms caused her …