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To prospectively evaluate the diagnostic efficacy of combining head and neck computed tomography angiography (CTA) with the ABCD2 score (Age, Blood pressure, Clinical features, Duration, Diabetes score) for detecting carotid artery stenosis in patients with transient ischemic attacks (TIAs) over an extended follow-up period. In this single-center prospective cohort study, 416 TIA patients (January 2020-January 2025) were stratified into high-risk (ABCD2 ≥4, n = 200, 48.08%) and low-risk (ABCD2 <4, n = 216, 51.92%) groups. High-risk patients underwent head-neck CTA within 2 hours of symptom onset, followed by digital subtraction angiography (DSA) within 48 hours if CTA revealed ≥50% stenosis. Low-risk patients received CTA within 24 hours, with DSA escalation for clinical deterioration. Diagnostic confirmation required combined ABCD2 ≥4 and CTA ≥50% stenosis in high-risk patients. DSA served as the reference standard. Diagnostic accuracy, sensitivity, and specificity were analyzed using chi-square tests. Among 416 patients, 231 underwent both CTA and DSA. CTA detected cerebrovascular stenosis/occlusion in 169 cases (70.13%), showing significant discordance with DSA (χ² = 14.785, P = 0.005). ABCD2 scores ≥4 were observed in 157/231 patients (67.97%), significantly correlating with cerebrovascular disease risk (χ² = 14.351, P < 0.001). The combined approach of CTA and ABCD2 score demonstrated a diagnostic accuracy of 88.74%, sensitivity of 91.15%, and specificity of 76.92% for post-TIA cerebrovascular stenosis. These values showed statistically significant improvements compared to either method alone (all P < 0.05), while no significant difference was observed versus the reference standard DSA (χ² = 0.914, P = 0.339). Head and neck CTA combined with the ABCD2 score offers significant advantages in the early diagnosis of carotid artery stenosis in TIA patients.