Objective To investigate the clinical and imaging features of hypoglycemic encephalopathy (HE) and transient ischemic attack (TIA).Methods A total of 29 HE patients (HE group) and 43 TIA patients (TIA group) were enrolled, and the two groups were compared in terms of clinical symptoms, biochemical results, and imaging findings.Results As for the symptoms of hemispheric neurological impairment, compared with the TIA group, the HE group had a higher proportion of patients with disturbance of consciousness (69.0% vs 27.9%, P<0.01) or slow response (24.1% vs 16.3%, P<0.05). As for the symptoms of focal neurological impairment, compared with the HE group, the TIA group had a higher proportion of patients with weakness (62.8% vs 24.1%, P<0.01) or sensory disturbance (69.7% vs 13.8%, P<0.01). Compared with the TIA group, the HE group had significantly higher levels of glycosylated hemoglobin, total cholesterol, and low-density lipoprotein (P<0.05 or P<0.01). Compared with the TIA group, the HE group had a significantly higher proportion of patients with carotid intimal thickening, mild stenosis, or moderate stenosis, as well as significantly higher carotid intima-media thickness and total carotid plaque score (P<0.05). Head CT angiography showed that compared with the TIA group, the HE group had a significantly higher proportion of patients with vascular stenosis (82.8% vs 51.2%, P<0.05), as well as a significantly higher proportion of patients with moderate stenosis (24.1% vs 14.0%, P<0.05), severe stenosis (17.2% vs 7.0%, P<0.01), or occlusion (13.8% vs 7.0%, P<0.05); the HE group also had a significantly higher proportion of patients with the involvement of two blood vessels (24.1% vs 11.6%, P<0.05) or three or more vessels (24.1% vs 11.6%, P<0.05).Conclusions HE mainly manifests as hemispheric neurological impairment, while TIA mainly manifests as focal neurological impairment. Compared with TIA patients, HE patients have severer metabolic disorders, greater intracranial vascular stenosis and involvement, and a higher proportion of moderate stenosis, severe stenosis, or occlusion.