Name: TIA — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

A TIA is a warning shot. The deficit is gone, the patient looks well — and the stroke risk is highest in the next 48 hours. The ED is often the only contact during that window, so the chart has to show a careful history, a complete exam, the workup arranged, and a disposition that gets the patient covered before the stroke arrives.

01What's at stake

Stroke risk after TIA is roughly 5%–10% at 2 days and 11%–17% at 90 days, and about half of the strokes within a week happen in the first 24 hours. ED misdiagnosis is reported as high as 60%, and "symptoms resolved" is falsely reassuring — in one same-day clinic series, 26% of patients with reportedly resolved symptoms still had a deficit on careful exam. The defensible chart is built on the documented history and exam, not on the fact that the patient feels normal now.

02Can't-miss & mimics

Evolving stroke — the deficit may recur or complete; TIA, transient symptoms with infarction, and stroke are a continuum.
Hypoglycemia — check a glucose on everyone; the cheapest reversible mimic.
Arterial dissection — especially in younger patients; neck pain, Horner syndrome.
Seizure (Todd paralysis), complicated migraine, mass lesion — common mimics (seizure ~44%, migraine ~24% in one cohort).
Paroxysmal atrial fibrillation — a single normal ECG does not exclude it.

03History & exam

Abrupt, "negative" focal symptoms (loss of strength/speech/vision) fit ischemia; diffuse "positive" symptoms (confusion, LOC, lightheadedness) usually don't. → true TIA vs mimic
Stuttering / recurrent episodes signal an unstable plaque — high risk even if currently asymptomatic. → aggressive workup
Amaurosis fugax, transient limb-shaking? → carotid territory / tight stenosis
Complete, stepwise neuro exam — cranial nerves, visual fields, strength, sensation, language, coordination. NIHSS = 0 does not exclude a deficit, and posterior-circulation findings (truncal ataxia, visual changes, Horner) are poorly captured by NIHSS.

Skip the typing

Work the case in the Stroke / focal deficit Workup — it records last-known-well, glucose, the neuro exam, and pathway decisions, and assembles an MDM that documents the deficit, the workup, and disposition reasoning for the high-risk window.

04Workup & disposition

Glucose on everyone; basic labs and coagulation studies per AHA/ASA.
Neuroimaging within 24h — DWI-MRI is preferred; non-contrast CT is falsely negative in at least a third of TIAs. Adding CT angiography raises the negative predictive value toward MRI levels.
Vascular imaging (carotid/intracranial) and ECG in all; consider prolonged rhythm monitoring for occult AFib (a single ECG finds it in only ~2%).
Secondary prevention — antiplatelet therapy (or anticoagulation for cardioembolic source), statin, BP control; symptomatic carotid stenosis ≥70% benefits from endarterectomy within 2 weeks.
Disposition — admit / observation unit / rapid-access TIA clinic. AHA/ASA: consider hospitalization for ABCD2 >2, evidence of focal ischemia, or when 2-day follow-up isn't realistically achievable. Front-load the workup; don't send the patient into the high-risk window with only a routine referral.

05Risk tools & evidence

ABCD2 — Age >60, BP >140/90, Clinical features (unilateral weakness 2 / speech without weakness 1), Duration (≥60 min 2 / 10–59 min 1), Diabetes. A general gauge of short-term risk only — it is miscalculated in ~a third of ED cases and should not be the sole basis for disposition. Johnston SC, et al. Lancet. 2007; Perry JJ, et al. CMAJ. 2011.
Urgent treatment works — front-loaded evaluation and secondary prevention reduced early recurrent stroke by ~80%. Rothwell PM, et al. (EXPRESS) Lancet. 2007.

06What to document

▼ weak

"Arm numbness, resolved. Neuro normal, CT head negative. F/u neurology. Discharged."

▲ defensible

"Abrupt right-arm weakness and dysarthria lasting ~20 min, single episode, now resolved; glucose 96. Complete neuro exam including visual fields, coordination, and gait — confirmed back to baseline, no residual deficit. CT/CTA without hemorrhage or LVO; carotid imaging and ECG obtained, telemetry arranged for occult AFib. Aspirin and statin started. Admitted to observation given the highest stroke risk is within 48h and rapid outpatient workup not assured. ABCD2 noted but not used as the sole disposition driver."

07Where charts fail

Treating "symptoms resolved" as a rule-out — a quarter still harbor a deficit on careful exam.
Charting "neuro normal" without the stepwise exam, or trusting NIHSS = 0.
Stopping at a normal CT (one-third falsely negative) with only a delayed referral.
Accepting one normal ECG and not pursuing paroxysmal AFib.
Letting an ABCD2 score (or a consultant's reliance on it) be the documented reason for discharge.

08Sources

Siket MS, Edlow JA. Transient ischemic attack: an evidence-based update. Emergency Medicine Practice (EB Medicine). 2013;15(1).
Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: AHA/ASA scientific statement. Stroke. 2009;40(6):2276-2293.
Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after TIA. Lancet. 2007;369(9558):283-292.
Perry JJ, Sharma M, Sivilotti ML, et al. Prospective validation of the ABCD2 score in the ED. CMAJ. 2011;183(10):1137-1145.
Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of TIA and minor stroke on early recurrent stroke (EXPRESS). Lancet. 2007;370(9596):1432-1442.

TIA: documentation that holds up