# Transient Ischaemic Attack (urgent referral) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: NICE Guideline NG128: Stroke and transient ischaemic attack 2019 · ESO Guidelines for the management of ischaemic stroke 2021 · Egyptian National Drug Formulary - Cardiovascular 2024 (clopidogrel monograph) · Transient Ischemic Attack - StatPearls - NCBI Bookshelf - disease-level clinical article (tia-referral-full.txt) · Egyptian National Drug Formulary - Cardiovascular 2024 (ticagrelor monograph, acute coronary syndrome regimen) - Verified date: 2026-08 ## Verified against - NICE Guideline NG128: Stroke and transient ischaemic attack 2019 - Egyptian National Drug Formulary - Cardiovascular 2024 (clopidogrel monograph) - Transient Ischemic Attack - StatPearls - NCBI Bookshelf - disease-level clinical article (tia-referral-full.txt) - Egyptian National Drug Formulary - Cardiovascular 2024 (ticagrelor monograph, acute coronary syndrome regimen) ## Treatment metadata - Acetylsalicylic acid — 300 mg — oral.solid - Clopidogrel — 75 mg — oral.solid - Ticagrelor — 90 mg — oral.solid ## Complete treatment card ```text TRANSIENT ISCHAEMIC ATTACK (URGENT REFERRAL) Sources: NICE Guideline NG128: Stroke and transient ischaemic attack 2019 · ESO Guidelines for the management of ischaemic stroke 2021 · Egyptian National Drug Formulary - Cardiovascular 2024 (clopidogrel monograph) · Transient Ischemic Attack - StatPearls - NCBI Bookshelf - disease-level clinical article (tia-referral-full.txt) · Egyptian National Drug Formulary - Cardiovascular 2024 (ticagrelor monograph, acute coronary syndrome regimen) Review status: REVIEWED against 3 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (6) - Onset is abrupt and the deficit is at its worst immediately - Attacks usually run for minutes and rarely exceed an hour, often clearing before the patient is seen - A curtain rising or falling over the vision points at the internal carotid artery - Disturbed language or a lost visual field marks a cortical event rather than a lacunar one - Atrial fibrillation or a recent myocardial infarction in the history suggests a cardiac embolic source [ischaemia] - Ask about the vascular risk load: coronary disease, smoking, drug misuse, obesity, diabetes, lipids, hypertension, and clotting or stroke in the family [hypertension · obesity] SIGNS - what you find (6) - Focal neurological deficit and disturbed speech are the commonest findings - Cranial nerves may show blindness in one eye, misaligned gaze, facial droop, hemianopia, double vision, abnormal tongue movement, swallowing difficulty or hearing loss [double vision · facial weakness · hearing loss · hemianopia · loss of vision] - Motor findings: one-sided weakness of limb, face or tongue, raised tone, clonus, rigidity, abnormal reflexes [one-sided weakness] - Examine the heart and listen over the carotids for a bruit [bruit] - A Hollenhorst plaque seen on fundoscopy signals internal carotid disease [plaques] - The fundus also carries vascular change from raised blood pressure or diabetes [hypertension] TESTS (8) - Plain head CT first, followed by multimodal brain MRI inside 24 hours of onset - Diffusion-weighted MRI within the first day is preferred, being more sensitive than CT for small infarcts - Where diffusion MRI is barred or unavailable, use CT with angiography and perfusion; perfusion reveals the penumbra - Vessel imaging must be done urgently as part of the work-up - Carotid duplex screens well, but narrowing over 50% has to be confirmed on CTA or MRA - Bloods: full blood count, ESR, clotting, metabolic panel, lipids, fasting glucose and HbA1c - ECG with echocardiography looks for a cardiac source, patent foramen ovale, valve disease, thrombus or atheroma - Holter or longer outpatient rhythm recording suits a cortical infarct with no clear embolic source, hunting intermittent atrial fibrillation IF NOT THIS - what else fits (10) - Migraine with aura, one of the two commonest mimics - Epileptic seizure - Meningitis - Encephalitis - Multiple sclerosis - Syncope, a simple faint - Peripheral vertigo - Functional neurological disorder - Transient global amnesia - Hypoglycaemia and other acute metabolic encephalopathy Source StatPearls "Transient Ischemic Attack" - disease-level clinical article Status traced to the source above Rx: Main treatment | Alternative to clopidogrel - clopidogrel CYP2C19 loss-of-function variant MAIN TREATMENT - choose one 1. ACETYLSALICYLIC ACID [1st line] Adult 300 mg once daily orally immediately in primary care (if no suspicion of intracranial hemorrhage or active bleeding) until specialist TIA assessment within 24 hours Peds 1-5 mg/kg/day [child max 75 mg] (Child 1 month-11 years: 1-5 mg/kg once daily, no single dose above 75 mg; Child 12-17 years: 75 mg once daily. NICE NG128 is an adult guideline and states no paediatric dose - it gives adult aspirin as 300 mg daily. A transient ischaemic attack in a child is a referral, not a primary-care prescription: it points to sickle cell disease, cardiac disease, an arteriopathy or a clotting disorder, and needs paediatric neurology.) 3kg -> 3-15 mg/day 4kg -> 4-20 mg/day 5kg -> 5-25 mg/day 6kg -> 6-30 mg/day 7kg -> 7-35 mg/day 8kg -> 8-40 mg/day 9kg -> 9-45 mg/day 10kg -> 10-50 mg/day 11kg -> 11-55 mg/day 12kg -> 12-60 mg/day 13kg -> 13-65 mg/day 14kg -> 14-70 mg/day 15kg -> 15-75 mg/day 16kg -> 16-75 mg/day (upper capped) 17kg -> 17-75 mg/day (upper capped) 18kg -> 18-75 mg/day (upper capped) 19kg -> 19-75 mg/day (upper capped) 20kg -> 20-75 mg/day (upper capped) 21kg -> 21-75 mg/day (upper capped) 22kg -> 22-75 mg/day (upper capped) 23kg -> 23-75 mg/day (upper capped) 24kg -> 24-75 mg/day (upper capped) 25kg -> 25-75 mg/day (upper capped) 26kg -> 26-75 mg/day (upper capped) 27kg -> 27-75 mg/day (upper capped) 28kg -> 28-75 mg/day (upper capped) 29kg -> 29-75 mg/day (upper capped) 30kg -> 30-75 mg/day (upper capped) 31kg -> 31-75 mg/day (upper capped) 32kg -> 32-75 mg/day (upper capped) 33kg -> 33-75 mg/day (upper capped) 34kg -> 34-75 mg/day (upper capped) 35kg -> 35-75 mg/day (upper capped) 36kg -> 36-75 mg/day (upper capped) 37kg -> 37-75 mg/day (upper capped) 38kg -> 38-75 mg/day (upper capped) 39kg -> 39-75 mg/day (upper capped) 40kg -> 40-75 mg/day (upper capped) 41kg -> 41-75 mg/day (upper capped) 42kg -> 42-75 mg/day (upper capped) 43kg -> 43-75 mg/day (upper capped) 44kg -> 44-75 mg/day (upper capped) 45kg -> 45-75 mg/day (upper capped) 46kg -> 46-75 mg/day (upper capped) 47kg -> 47-75 mg/day (upper capped) 48kg -> 48-75 mg/day (upper capped) 49kg -> 49-75 mg/day (upper capped) 50kg -> 50-75 mg/day (upper capped) Source NICE Guideline NG128: Stroke and transient ischaemic attack 2019 for the indication and the adult dose; the paediatric band above is from Egyptian National Drug Formulary - Cardiovascular 2024 (acetylsalicylic acid monograph): "Child 1 month-11 years: 1-5 mg/kg once daily (max. per dose 75 mg); Child 12-17 years: 75 mg once daily", given there for antiplatelet prevention of thrombus formation after cardiac surgery - not for this indication. Why Immediate loading dose of aspirin 300 mg in primary care significantly reduces early recurrent stroke risk after TIA while urgent specialist evaluation is arranged. Caution URGENT SPECIALIST REFERRAL REQUIRED: All suspected TIA patients must be assessed by a stroke specialist or TIA clinic within 24 hours. DO NOT give aspirin loading dose if patient is already taking anticoagulation (e.g., warfarin, DOACs) or has an active bleeding disorder; refer urgently without aspirin. Advise patient NOT to drive until evaluated and cleared by stroke specialist assessment. Everyone who has had a suspected TIA should have specialist assessment and investigation within 24 hours of the onset of symptoms. Egypt ASPOCID 300 MG 200 TABS. CID 80.00 EGP (0.40/unit) 2. CLOPIDOGREL [2nd line] Adult 75 mg once daily (or 300 mg loading dose if aspirin-intolerant) after specialist evaluation - Long-term secondary prevention Peds Specialist pediatric neurology supervision required. Source Egyptian National Drug Formulary - Cardiovascular 2024 (clopidogrel monograph) Why Antiplatelet that inhibits P2Y12-mediated platelet aggregation, used for long-term secondary prevention of further TIA or ischaemic stroke after specialist evaluation; also an option in the acute setting for patients with genuine aspirin hypersensitivity. Caution First-line antiplatelet agent for long-term secondary prevention of TIA/ischaemic stroke after specialist evaluation (NICE TA210 / NG128); also used in acute setting for patients with true aspirin hypersensitivity. Discontinue 5-7 days before elective surgical procedures after consulting specialist. Monitor for signs of gastrointestinal bleeding or rash. In patients with recent lacunar stroke (within 180 days), adding clopidogrel to aspirin does not reduce stroke recurrence but increases major hemorrhage and all-cause mortality. The risk of stroke is highest in the first 48 hours after a transient ischaemic attack, and about 20% of patients have a stroke within 3 months if they are not evaluated and treated. RED FLAG - A patient with high-risk features needs hospital admission for acute management, not only an outpatient appointment. The high-risk features are a raised clinical risk score, a subacute or acute infarct on CT or MRI, 50% or greater stenosis of the ipsilateral carotid, another transient ischaemic attack within the last month, or an acute cardiac process or arrhythmia. A reassuringly low clinical risk score does not exclude critical carotid artery stenosis, which can present that way. Complete resolution of the symptoms does not make the episode benign; sudden unilateral weakness, facial droop, speech difficulty, vision loss, sensory change, dizziness or gait instability still require immediate emergency evaluation. Tell the patient to call emergency services rather than making their own way in or waiting to see whether the symptoms come back. Clopidogrel needs CYP2C19 to become active, and a loss-of-function variant common in Central and South Asian patients reduces its effect. Transient loss of vision described as a curtain rising or descending points to a problem in the internal carotid artery. Where atrial fibrillation or another cardioembolic source is identified, oral anticoagulation, not an antiplatelet, is the recommended secondary prevention. Roughly half of hospital admissions for suspected stroke turn out to be mimics, so alternative diagnoses must be actively excluded. Symptomatic internal carotid artery stenosis of 70% or greater is an indication for revascularisation. Egypt BLOTAGRIL 75MG 30 F.C. TABS. MEDIZEN PHARM... 33.00 EGP (1.10/unit) ITOLAVIX 75 MG 30 F.C. TABS. SIGMA > INTER... 54.00 EGP (1.80/unit) BORGAVIX 75MG 30 F.C. TABLETS BORG 66.00 EGP (2.20/unit) SIGAGREL 75MG 10 F.C. TAB. SIGMA 30.00 EGP (3.00/unit) CLOPACIRC 75 MG 30 F.C.TABS. COPAD PHARMA 117.00 EGP (3.90/unit) THROMBO 75MG 30 F.C.TAB. EIPICO 123.00 EGP (4.10/unit) PLATENOR 75MG 30 TAB. HI-PHARM > EG... 150.00 EGP (5.00/unit) PLAVIX 75 MG 28 F.C.TABS. SANOFI WINTHR... 311.00 EGP (11.11/unit) ALTERNATIVE TO CLOPIDOGREL - CLOPIDOGREL CYP2C19 LOSS-OF-FUNCTION VARIANT 3. TICAGRELOR [2nd line] Adult Initially 180 mg for 1 dose, then 90 mg twice daily, in combination with aspirin. That is the formulary's acute coronary syndrome regimen; it states no regimen for TIA or stroke. Peds No paediatric dose is stated in either document; the formulary's ticagrelor monograph gives adult dosing only. Source Egyptian National Drug Formulary - Cardiovascular 2024 (ticagrelor monograph, acute coronary syndrome regimen) Why Two documents, one claim each, and the row says which is which. The INDICATION comes from this condition's own article, which names ticagrelor squarely: it is active as given, so no genetic difference in enzyme handling can blunt it, which makes it the logical pick where the patient carries a loss-of-function CYP2C19 variant for clopidogrel. The DOSE comes from the Egyptian formulary's ticagrelor monograph, whose own indications are acute coronary syndrome and prior myocardial infarction - TIA and stroke are not among them, which under the August 2026 ruling is silence, not prohibition. The formulary's contraindications ARE a bar and are printed on the row. Caution CONTRAINDICATED on the formulary's own list: hypersensitivity to ticagrelor - angioedema being the example given - or to anything else in the product; bleeding that is active and pathological, a peptic ulcer for instance; any previous intracranial haemorrhage; and severe hepatic impairment. A previous intracranial haemorrhage rules this drug out, and a TIA patient is exactly the population in whom that history must be asked for. The dose above is NOT a TIA dose. What the formulary licenses is the prevention of atherothrombotic events after an acute coronary syndrome, and in the patient with a past myocardial infarction who is at high risk of one - the 180 mg load and 90 mg twice daily are that regimen, used here because no document available to this project states a TIA- specific one. The article's evidence is for a short course started early: in CHANCE-2, ticagrelor with aspirin outperformed clopidogrel with aspirin at 1 year, provided it was begun inside 24 hours and run for 21 days. The formulary allows up to a year, but for acute coronary syndrome. Neither document states a duration for TIA. Start after specialist TIA assessment, not instead of it - this card is an urgent- referral pathway. Discontinue at least 5 days before surgery where bleeding risk is high. Egypt THROMBOLINTA 90MG 30 F.C. TABS. GLOBAL NAPI P... 219.75 EGP (7.33/unit) LINTARAM 90MG 30+20 F.C. TABS. RAMEDA 203.25 EGP (10.16/unit) TICALOGUARD 90 MG 30 F.C. TABS. MARCYRL PHARM... 411.00 EGP (13.70/unit) WESTGRELOR 90MG 10 F.C.TABS. WESTERN PHARM... 137.00 EGP (13.70/unit) BRILIQUE 90MG 56 F.C. TABS. ASTRA ZENECA 1064.00 EGP (19.00/unit) LINGABRIQUE 90 MG 28 ODT FUTURE PHARMA... 382.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)