Editing Transient ischemic attack (section)

== Treatment ==
By definition, TIAs are transient, self-resolving, and do not cause permanent impairment. However, they are associated with an increased risk of subsequent ischemic strokes, which can be permanently disabling.<ref>{{cite journal | vauthors = Mohan KM, Wolfe CD, Rudd AG, Heuschmann PU, Kolominsky-Rabas PL, Grieve AP | title = Risk and cumulative risk of stroke recurrence: a systematic review and meta-analysis | journal = Stroke | volume = 42 | issue = 5 | pages = 1489–1494 | date = May 2011 | pmid = 21454819 | doi = 10.1161/STROKEAHA.110.602615 | s2cid = 18230964 | doi-access = free }}</ref> Therefore, management centers on the prevention of future ischemic strokes and addressing any modifiable risk factors. The optimal regimen depends on the underlying cause of the TIA.

=== Lifestyle modification ===
Lifestyle changes have not been shown to reduce the risk of stroke after TIA.<ref>{{cite journal | vauthors = Lawrence M, Pringle J, Kerr S, Booth J, Govan L, Roberts NJ | title = Multimodal secondary prevention behavioral interventions for TIA and stroke: a systematic review and meta-analysis | journal = PLOS ONE | volume = 10 | issue = 3 | pages = e0120902 | date = 20 March 2015 | pmid = 25793643 | pmc = 4368743 | doi = 10.1371/journal.pone.0120902 | doi-access = free | bibcode = 2015PLoSO..1020902L }}</ref> While no studies have looked at the optimal diet for secondary prevention of stroke, some observational studies have shown that a [[Mediterranean diet]] can reduce stroke risk in patients without cerebrovascular disease.<ref name=":2" /> A Mediterranean diet is rich in fruits, vegetables and whole grains, and limited in red meats and sweets. Vitamin supplementation has not been found to be useful in secondary stroke prevention.<ref name=":2" />

=== Antiplatelet medications ===
The [[Antiplatelet drug|antiplatelet medications]], [[aspirin]] and [[clopidogrel]], are both recommended for secondary prevention of stroke after high-risk TIAs.<ref>{{Cite web |date=2020-02-13 |title=Preventing Stroke in Patients with Atrial Fibrillation - Evidence Update for Clinicians {{!}} PCORI |url=https://www.pcori.org/evidence-updates/preventing-stroke-in-patients-atrial-fibrillation-evidence-update-for-clinicians |access-date=2024-09-09 |website=www.pcori.org |language=en}}</ref><ref name=":2">{{cite journal | vauthors = Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA | display-authors = 6 | title = Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association | journal = Stroke | volume = 45 | issue = 7 | pages = 2160–2236 | date = July 2014 | pmid = 24788967 | doi = 10.1161/STR.0000000000000024 | author19 = American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease | doi-access = free }}</ref><ref name=Hap2018>{{cite journal | vauthors = Hao Q, Tampi M, O'Donnell M, Foroutan F, Siemieniuk RA, Guyatt G | title = Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis | journal = BMJ | volume = 363 | pages = k5108 | date = December 2018 | pmid = 30563866 | pmc = 6298178 | doi = 10.1136/bmj.k5108 }}</ref> The clopidogrel can generally be stopped after 10 to 21 days.<ref name=Hap2018/> An exception is TIAs due to blood clots originating from the heart, in which case [[anticoagulant]]s are generally recommended.<ref name=":2" /> After TIA or minor stroke, aspirin therapy has been shown to reduce the short-term risk of recurrent stroke by 60–70%, and the long-term risk of stroke by 13%.<ref>{{cite journal | vauthors = Rothwell PM, Algra A, Chen Z, Diener HC, Norrving B, Mehta Z | title = Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials | journal = Lancet | volume = 388 | issue = 10042 | pages = 365–375 | date = July 2016 | pmid = 27209146 | pmc = 5321490 | doi = 10.1016/S0140-6736(16)30468-8 }}</ref>

The typical therapy may include aspirin alone, a combination of aspirin plus extended-release [[dipyridamole]], or [[clopidogrel]] alone.<ref name=":2" /> Clopidogrel and aspirin have similar efficacies and side effect profiles. Clopidogrel is more expensive and has a slightly decreased risk of GI bleed.<ref name=":2" /> Another antiplatelet, [[ticlopidine]], is rarely used due to increased side effects.<ref name=":2" />

=== Anticoagulant medications ===
Anticoagulants may be started if the TIA is thought to be attributable to [[atrial fibrillation]]. Atrial fibrillation is an abnormal heart rhythm that may cause the formation of blood clots that can travel to the brain, resulting in TIAs or ischemic strokes. Atrial fibrillation increases stroke risk by five times, and is thought to cause 10-12% of all ischemic strokes in the US.<ref name=":2" /><ref name=":4">{{cite journal | vauthors = López-López JA, Sterne JA, Thom HH, Higgins JP, Hingorani AD, Okoli GN, Davies PA, Bodalia PN, Bryden PA, Welton NJ, Hollingworth W, Caldwell DM, Savović J, Dias S, Salisbury C, Eaton D, Stephens-Boal A, Sofat R | display-authors = 6 | title = Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis | journal = BMJ | volume = 359 | pages = j5058 | date = November 2017 | pmid = 29183961 | pmc = 5704695 | doi = 10.1136/bmj.j5058 }}</ref> [[Anticoagulant]] therapy can decrease the relative risk of ischemic stroke in those with atrial fibrillation by 67%<ref>{{cite journal | vauthors = Shoamanesh A, Charidimou A, Sharma M, Hart RG | title = Should Patients With Ischemic Stroke or Transient Ischemic Attack With Atrial Fibrillation and Microbleeds Be Anticoagulated? | journal = Stroke | volume = 48 | issue = 12 | pages = 3408–3412 | date = December 2017 | pmid = 29114097 | doi = 10.1161/STROKEAHA.117.018467 | s2cid = 3831870 | doi-access = free }}</ref> [[Warfarin]] and [[DOAC|direct acting oral anticoagulants (DOACs)]], such as [[apixaban]], have been shown to be equally effective while also conferring a lower risk of bleeding.<ref name=":4" /><ref>{{cite journal | vauthors = Proietti M, Romanazzi I, Romiti GF, Farcomeni A, Lip GY | title = Real-World Use of Apixaban for Stroke Prevention in Atrial Fibrillation: A Systematic Review and Meta-Analysis | journal = Stroke | volume = 49 | issue = 1 | pages = 98–106 | date = January 2018 | pmid = 29167388 | doi = 10.1161/STROKEAHA.117.018395 | hdl-access = free | s2cid = 204046043 | hdl = 2434/748104 }}</ref> Generally, anticoagulants and antiplatelets are not used in combination, as they result in increased bleeding risk without a decrease in stroke risk.<ref name=":2" /> However, combined antiplatelet and anticoagulant therapy may be warranted if the patient has symptomatic coronary artery disease in addition to atrial fibrillation.

Sometimes, [[myocardial infarction]] ("heart attack") may lead to the formation of a blood clot in one of the chambers of the heart. If this is thought to be the cause of the TIA, people may be temporarily treated with warfarin or other anticoagulant to decrease the risk of future stroke.<ref name=":2" />

=== Blood pressure control ===
Blood pressure control may be indicated after TIA to reduce the risk of ischemic stroke. About 70% of patients with recent ischemic stroke are found to have hypertension, defined as systolic blood pressure (SBP) > 140 mmHg, or diastolic blood pressure (DBP) > 90 mmHg.<ref name=":2" /> Until the first half of the 2010s, blood pressure goals have generally been SBP < 140 mmHg and DBP < 90 mmHg.<ref name=":2" /> However, newer studies suggest that a goal of SBP <130 mmHg may confer even greater benefit.<ref>{{cite journal | vauthors = Reboussin DM, Allen NB, Griswold ME, Guallar E, Hong Y, Lackland DT, Miller EP, Polonsky T, Thompson-Paul AM, Vupputuri S | display-authors = 6 | title = Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines | journal = Journal of the American College of Cardiology | volume = 71 | issue = 19 | pages = 2176–2198 | date = May 2018 | pmid = 29146534 | doi = 10.1016/j.jacc.2017.11.004 | pmc = 8654280 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Katsanos AH, Filippatou A, Manios E, Deftereos S, Parissis J, Frogoudaki A, Vrettou AR, Ikonomidis I, Pikilidou M, Kargiotis O, Voumvourakis K, Alexandrov AW, Alexandrov AV, Tsivgoulis G | display-authors = 6 | title = Blood Pressure Reduction and Secondary Stroke Prevention: A Systematic Review and Metaregression Analysis of Randomized Clinical Trials | journal = Hypertension | volume = 69 | issue = 1 | pages = 171–179 | date = January 2017 | pmid = 27802419 | doi = 10.1161/HYPERTENSIONAHA.116.08485 | s2cid = 42869560 | doi-access = free }}</ref> Blood pressure control is often achieved using [[diuretic]]s or a combination of diuretics and [[ACE inhibitor|angiotensin converter enzyme inhibitors]], although the optimal treatment regimen depends on the individual.<ref name=":2" />

Studies that evaluated the application of blood pressure‐lowering drugs in people who had a TIA or stroke, concluded that this type of medication helps to reduce the possibility of a recurrent stroke, of a major vascular event and dementia.<ref name="Blood pressure-lowering treatment f">{{cite journal | vauthors = Zonneveld TP, Richard E, Vergouwen MD, Nederkoorn PJ, de Haan R, Roos YB, Kruyt ND | title = Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack | journal = The Cochrane Database of Systematic Reviews | volume = 7 | pages = CD007858 | date = July 2018 | issue = 8 | pmid = 30024023 | pmc = 6513249 | doi = 10.1002/14651858.cd007858.pub2 }}</ref> The effects achieved in stroke recurrence were mainly obtained through the ingestion of angiotensin-converting enzyme (ACE) inhibitor or a diuretic.<ref name="Blood pressure-lowering treatment f"/>

=== Cholesterol control ===
There is inconsistent evidence regarding the effect of [[Low-density lipoprotein|LDL-cholesterol]] levels on stroke risk after TIA. Elevated cholesterol may increase ischemic stroke risk while decreasing the risk of hemorrhagic stroke.<ref>{{cite journal | vauthors = Manktelow BN, Potter JF | title = Interventions in the management of serum lipids for preventing stroke recurrence | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD002091 | date = July 2009 | volume = 2019 | pmid = 19588332 | pmc = 6664829 | doi = 10.1002/14651858.CD002091.pub2 }}</ref><ref>{{cite journal | vauthors = Cheng SF, Brown MM | title = Contemporary medical therapies of atherosclerotic carotid artery disease | journal = Seminars in Vascular Surgery | volume = 30 | issue = 1 | pages = 8–16 | date = March 2017 | pmid = 28818261 | doi = 10.1053/j.semvascsurg.2017.04.005 | url = https://discovery.ucl.ac.uk/id/eprint/1572171/ }}</ref><ref>{{cite journal | vauthors = O'Regan C, Wu P, Arora P, Perri D, Mills EJ | title = Statin therapy in stroke prevention: a meta-analysis involving 121,000 patients | journal = The American Journal of Medicine | volume = 121 | issue = 1 | pages = 24–33 | date = January 2008 | pmid = 18187070 | doi = 10.1016/j.amjmed.2007.06.033 }}</ref> While its role in stroke prevention is unclear, [[statin]] therapy has been shown to reduce all-cause mortality and may be recommended after TIA.<ref name=":2" />

=== Diabetes control ===
[[Diabetes mellitus]] increases the risk of ischemic stroke by 1.5–3.7 times, and may account for at least 8% of first ischemic strokes.<ref name=":2" /> While intensive glucose control can prevent certain complications of diabetes such as kidney damage and retinal damage, there has previously been little evidence that it decreases the risk of stroke or death.<ref name=":3">{{cite journal | vauthors = Castilla-Guerra L, Fernandez-Moreno MD, Leon-Jimenez D, Carmona-Nimo E | title = Antidiabetic drugs and stroke risk. Current evidence | journal = European Journal of Internal Medicine | volume = 48 | pages = 1–5 | date = February 2018 | pmid = 28939005 | doi = 10.1016/j.ejim.2017.09.019 }}</ref> However, data from 2017 suggests that [[metformin]], [[pioglitazone]] and [[semaglutide]] may reduce stroke risk.<ref name=":3" />

=== Surgery ===
If the TIA affects an area that is supplied by the [[carotid artery|carotid arteries]], a [[Carotid ultrasonography|carotid ultrasound]] scan may demonstrate [[stenosis]], or narrowing, of the carotid artery. For people with extra-cranial carotid stenosis, if 70-99% of the carotid artery is clogged, [[carotid endarterectomy]] can decrease the five-year risk of ischemic stroke by approximately half.<ref name=":5">{{cite journal | vauthors = Rerkasem A, Orrapin S, Howard DP, Rerkasem K | title = Carotid endarterectomy for symptomatic carotid stenosis | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | pages = CD001081 | date = September 2020 | issue = 9 | pmid = 32918282 | doi = 10.1002/14651858.CD001081.pub4 | pmc = 8536099 | s2cid = 221636994 }}</ref> For those with extra-cranial stenosis between 50 and 69%, carotid endarterectomy decreases the 5-year risk of ischemic stroke by about 16%.<ref name=":5" /> For those with extra-cranial stenosis less than 50%, carotid endarterectomy does not reduce stroke risk and may, in some cases, increase it.<ref name=":5" /> The effectiveness of carotid endarterectomy or carotid artery stenting in reducing stroke risk in people with intra-cranial carotid artery stenosis is unknown.<ref name=":2" />

In carotid endarterectomy, a surgeon makes an incision in the neck, opens up the carotid artery, and removes the plaque occluding the blood vessel. The artery may then be repaired by adding a graft from another vessel in the body, or a woven patch. In patients who undergo carotid endarterectomy after a TIA or minor stroke, the 30-day risk of death or stroke is 7%.<ref name=":5" />

[[Carotid stenting|Carotid artery stenting]] is a less invasive alternative to carotid endarterectomy for people with extra-cranial carotid artery stenosis. In this procedure, the surgeon makes a small cut in the groin and threads a small flexible tube, called a [[catheter]], into the patient's carotid artery. A balloon is inflated at the site of stenosis, opening up the clogged artery to allow for increased blood flow to the brain. To keep the vessel open, a small wire mesh coil, called a stent, may be inflated along with the balloon. The stent remains in place, and the balloon is removed.

For people with symptomatic carotid stenosis, carotid endarterectomy is associated with fewer perioperative deaths or strokes than carotid artery stenting.<ref name=":1">{{Cite journal|last1=Müller|first1=Mandy D.|last2=Lyrer|first2=Philippe|last3=Brown|first3=Martin M.|last4=Bonati|first4=Leo H.|date=2020|title=Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis|url=|journal=The Cochrane Database of Systematic Reviews|volume=2020|issue=2 |pages=CD000515|doi=10.1002/14651858.CD000515.pub5|issn=1469-493X|pmc=7041119|pmid=32096559}}</ref> Following the procedure, there is no difference in effectiveness if you compare carotid endarterectomy and carotid stenting procedures, however, endarterectomy is often the procedure of choice as it is a safer procedure and is often effective in the longer term for preventing recurrent stroke.<ref name=":1" /> For people with asymptomatic carotid stenosis, the increased risk of stroke or death during the stenting procedure compared to an endarterectomy is less certain.<ref name=":1" />

People who undergo carotid endarterectomy or carotid artery stenting for stroke prevention are medically managed with [[Antiplatelet drug|antiplatelets]], [[statin]]s, and other interventions as well.<ref name=":2" />