Stroke subtypes and interventional studies for transient ischemic attack

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.