Introduction: Studies suggest that there is a significant discrepancy between emergency physicians diagnosis of TIA and confirmation by neurologists. The objectives of our study were to identify factors associated with neurologists confirmation of TIA in patients referred from the emergency department. Methods: Data were obtained from a prospective cohort study across more than 8 university-affiliated Canadian hospitals from 2006-2017 of adult patients diagnosed with a TIA or non-disabling stroke in the ED. Patients presenting after 1 week of symptom onset, receiving TPA as part of a stroke code, with a GCS<15 at baseline, and without a neurology assessment within 90 days were excluded. Univariate analyses were performed with t-tests or chi-square tests as indicated. Multivariate analysis with backward elimination was performed to identify unique predictors of TIA confirmation. Results: Of 8,669 patients diagnosed with TIA in the ED, 7,836 (90%) were assessed by neurology. The mean age of patients was 68.2 years and 71.1% presented with their first ever TIA. The rate of confirmation of TIA by neurology was 56%. The most common alternate diagnoses included migraines (26%), peripheral vertigo (10%), syncope (6%), and seizure (4%). The 3 strongest predictors of confirmation of TIA were infarct on imaging (OR 2.31, 2.03-2.63), history of weakness (OR 2.19, 1.95-2.48), and history of language disturbance (OR 2.05, 1.79-2.34). The 3 strongest predictors of an alternate diagnosis were syncope (OR 0.51, 0.39-0.67), history of bilateral weakness (or 0.51, 0.31-0.84), and confusion (OR 0.57, 0.48-0.67). Conclusion: The rate of TIA confirmation by neurology in our study was 56%. Emergency physicians should have a high index of suspicion of TIA in patients with history of weakness and language disturbance, and should resist referring to a stroke prevention clinic, patients with syncope, bilateral findings, or confusion.