Ischemic Stroke and Transient Ischemic Attack (TIA) - Diagnosis and Acute Management

Effective Date: January 14^th, 2026

Scope

This guideline provides recommendations for the early recognition, assessment and acute management of ischemic stroke and transient ischemic attack (TIA) in adults ≥19 years old. Primary prevention, cerebral venous thrombosis, and hemorrhagic, pediatric, and pregnancy-related strokes are out of scope.

Key Recommendations

• NEW Treat suspected TIA or minor stroke presenting <48 hr as a medical emergency because stroke recurrence and/or progression is highest within this period.
• NEW Perform neuroimaging (non-contrast CT brain and non-invasive CTA arch to vertex) in all patients with suspected stroke/TIA, regardless of timing or persistence/resolution of symptoms.
• NEW Triage patients based on type of symptoms and time since onset (woke up with symptoms, <6 hr, 6–48 hr, >48 hr–2 weeks, >2 weeks) to determine the urgency of transport, neuroimaging, and specialist referral. Imaging is essential for assessing eligibility for reperfusion therapy (generally feasible within first 24 hr), and risk stratification.
• NEW Direct all patients with symptom onset <48 hr to a neuroimaging-capable ED, even if symptoms have resolved.
  • ​If symptoms are ongoing and onset <24 hr, contact 911 to activate stroke protocols to expedite imaging and assess eligibility for reperfusion therapy.
  • If symptoms have fully resolved OR onset is 24–48 hr, personal transport to nearest ED is an option. Alert ED about incoming patient. Patients should not drive themselves.
• ​NEW Consult with a stroke specialist (on-site or via Patient Transport Network) for urgent diagnostic and management decisions, including eligibility for reperfusion therapy (thrombolysis and/or endovascular therapy) and/or antithrombotic therapy (antiplatelet therapy [APT] or oral anticoagulant).
• NEW Initiate single APT prior to outpatient imaging in patients whose symptoms occurred >2 weeks ago and have now resolved. Consult with stroke specialist first if there is concern for high risk of intracranial hemorrhage.
• NEW Assess the risk of stroke within first week after a TIA by using the Canadian TIA Score.
• Urgently refer patients with symptomatic extracranial carotid artery stenosis (50–99% stenosis) to stroke prevention clinic and vascular surgery for potential carotid revascularization (surgery or stenting) to be performed ideally within 14 days.
• NEW Aim to admit patients to an acute stroke unit (i.e., a specialized, geographically defined hospital unit dedicated to the management of patients with stroke).

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