A patient with transient ischemic attack; best next step in management is to

• A. Administer recombinant tissue plasminogen activator
• B. Admit and order a diffusion-weighted MRI
• C. Discharge on aspirin with outpatient evaluation within 72 hours
• D. Emergent left carotid endarterectomy

Answer: (B)

Transient ischemic attack requires urgent evaluation to prevent a full stroke. The best next step is to admit the patient for immediate brain imaging with diffusion-weighted MRI. DWI is highly sensitive for detecting even small acute brain abnormalities and helps identify patients who have had a tiny infarct or ongoing ischemia, which in turn guides risk stratification and management. Early imaging also facilitates rapid planning for secondary prevention (start antiplatelet therapy if not already given, initiate statin, control risk factors) and timely vascular assessment to determine if any intervention is indicated.

Thrombolysis is not used for TIAs since there is no persistent vessel occlusion with ongoing deficits to treat. Emergent carotid endarterectomy is reserved for clear, high-grade symptomatic carotid stenosis identified on imaging and after stabilization. Discharging with outpatient evaluation within 72 hours delays essential imaging and worsens short-term stroke risk, so inpatient MRI-guided workup is preferred.