Evaluating Management of Suspected Transient Ischaemic Attacks (TIA) in the Emergency Department

Introduction

Suspected Transient Ischaemic Attack (TIA) is a common and important reason for Emergency Department (ED) presentation in older adults. Local guidance recommends that patients should undergo CT head imaging, be prescribed aspirin and referred to the TIA clinic. However, a suspected TIA can create diagnostic uncertainty, making clinical decision-making challenging. We evaluated adherence to the local referral pathway to guide service improvement opportunities and identify variation in management according to final diagnosis.

Method

We conducted a retrospective audit of TIA referrals from University Hospital Crosshouse ED over a six-month period (18/12/2025-18/05/2026). Data collected included final diagnosis, time to specialist assessment, CT head imaging and aspirin use. Descriptive statistics were used to summarise outcomes. Differences in assessment times between those with/without a final diagnosis of stroke/TIA were compared using the Mann-Whitney U test. Association between a final diagnosis of stroke/TIA and CT imaging in ED was assessed using chi-squared analysis.

Results

A total of 147 patients were referred to the TIA clinic, with 62 (42%) diagnosed with stroke/TIA. Fifty-three (85%) of these patients underwent CT head imaging in ED. Undergoing CT head imaging in ED was associated with a final diagnosis of stroke/TIA  (χ²=3.876, p=0.049). Overall, 82 (56%) patients received loading dose aspirin in ED. Reasons for withholding aspirin included pre-existing anticoagulation (16,11%) and pre-existing antiplatelet therapy (25, 17%). No reason was documented in 19 (13%) cases. Of the 62 patients with a diagnosis of stroke/TIA, 35 (56%) received loading dose aspirin. Median time from referral to specialist assessment was two days, with no statistically significant difference between diagnostic groups. 

Conclusions

Adherence to aspects of the suspected TIA pathway varied. This work highlights an opportunity to develop clearer guidance on antiplatelet prescribing in ED, providing a basis for future quality improvement work and standardisation of TIA management.