Transient ischemic attack (TIA) is the most important risk factor for
ischemic stroke. The risk is the highest in the first hours after symptom onset, and treatment must be initiated in emergency. In the acute phase,
antithrombotic agent is probably the most important treatment, but it is not excluded that
lipid-lowering agents and/or
antihypertensive drugs are also important. For current guidelines, monotherapy of
antiplatelet agent remains the gold standard in emergency. However, most recent data and meta-analysis support a combination
therapy of
clopidogrel and
aspirin. Data on treatment in the very acute phase of TIA in the different etiologic
stroke subtypes are also lacking especially for
cardioembolic stroke and the potential benefit of
anticoagulant. Long-term prevention mainly derived from large trials, in which TIA and minor
stroke patients have constituted the largest part. Patients with non-
cardioembolic stroke must be treated with
antiplatelet agent in monotherapy, and dual antiplatelet
therapy such as
clopidogrel plus
aspirin should be avoided, particularly in
lacunar strokes, whereas
anticoagulants are the treatment of choice for patients with
cardioembolic stroke. Major advances concerning
stroke prevention in patients with
atrial fibrillation have emerged with new oral
anticoagulant agents that are as effective as
vitamin K antagonists and safer, especially with regard to the risk of
intracranial hemorrhage. At variance with moderate and severe
cerebral infarction, oral
anticoagulants can be initiated without delay in TIA patients. Left atrial appendage closure seems to be a promising treatment in patients ineligible for anticoagulation. Aggressive management of vascular risk factors, including blood pressure as low as 130/80 mm Hg, intensive
statin treatment, smoking cessation and diabetes control, also plays a major role in the prevention of vascular event.