Don't Ignore Stroke Warning Sign

From the publishers of The New England Journal of Medicine

The Story

      Hurrying down the street completing errands, you suddenly feel your right leg and arm go numb. You become unsteady and sit down on a bench, noticing that you can't understand what passersby are saying. After a couple of minutes the feeling passes, and you go on with your errands.
      Ignoring those fleeting symptoms could be a mistake if they are caused by a transient ischemic attack (TIA), also called a mini-stroke. TIA symptoms last from seconds to 24 hours. But about a third of people who have a TIA later have a full-fledged stroke because the cause of the TIA often remains after the symptoms fade. Stroke is the nation's third leading killer and a major cause of disabilities.

      Like a stroke, a TIA is caused by a loss of blood to a brain region due to either a blood clot or a fatty deposit blocking a blood vessel (ischemic stroke) or, more rarely, a bleeding vessel (hemorrhagic stroke). The symptoms of TIA and stroke are identical (see chart). But a full stroke causes permanent brain damage, while a TIA usually fades without leaving the brain damaged.
      Too many people ignore TIA symptoms, according to a recent survey sponsored by the National Stroke Association (NSA). The telephone survey of 10,112 randomly selected Americans found that 2.5 percent of respondents had been diagnosed with a TIA, more than the 1 percent estimated in smaller studies. Perhaps more worrisome, 8 percent of the survey respondents had experienced symptoms of a possible TIA without pursuing an evaluation by a doctor. That translates into an estimated 1.2 million Americans with a possible undiagnosed TIA.
      What's more, the NSA also surveyed 200 primary-care physicians and found that many of them do not ask appropriate questions or order brain scans crucial for diagnosing people with TIA symptoms. Doctors and patients can work together to improve TIA recognition and treatment, as neurologist Pierre B. Fayad, M.D., explains. -- The Editors

The Physician's Perspective
Pierre B. Fayad, M.D.

      In the past decade, diagnosis and treatment of stroke in its earliest stages have improved dramatically. But the NSA survey shows that people's recognition of their stroke risk lags far behind our ability to prevent and treat strokes.
      People with symptoms of a TIA and their physicians should take steps to reduce the risk of future stroke because a TIA is second only to a first full stroke in predicting a subsequent stroke.
      How you should respond to TIA symptoms depends partly on your risk for a full stroke. Are you older than 60? Do you or your family have a history of strokes or TIAs? Do you have high blood pressure, diabetes, heart disease, atrial fibrillation (a heart rhythm disorder) or high cholesterol? Are you African American? Do you smoke or get little physical activity? The more questions you answer "yes" to, the greater your risk for stroke.
      If you have one or more risk factors and begin to experience symptoms of TIA or stroke, go immediately to an emergency room even if the symptoms last only a few seconds. If you have no risk factors and your symptoms last only a few minutes, you may not need emergency attention, but you should contact your physician as soon as possible. If your symptoms last more than a few minutes, go directly to an emergency room, even if you have no stroke risk factors.
      Determining which symptoms warrant medical attention can be difficult because some -- particularly dizziness, loss of balance and headache -- may be caused by less serious conditions. The key clues are the swiftness and severity with which the symptoms develop. For example, people who normally experience migraine headaches should suspect TIA or stroke if they have a headache that comes on more rapidly and is far more severe than their typical migraine. Similarly, dizziness and loss of balance or coordination are more likely to develop rapidly with a TIA or stroke than with other causes, such as a blood pressure-lowering drug. In general, any symptom that is sudden and severe should trigger suspicion of TIA or stroke.
      If the symptoms last more than a few minutes, you could be having a full stroke. In this case, the sooner you receive medical attention the better, because if the cause is an artery blockage, drug therapy started within three hours may prevent brain damage. And early treatment of hemorrhagic stroke may be life-saving. Even if these symptoms develop gradually, seek emergency medical attention if you've never had similar symptoms before and they persist. They may signal a different but still serious medical problem such as an infection or tumor.
      If your symptoms fade before you reach the hospital or doctor's office, your doctor must do some detective work to determine whether a TIA was the cause. That's because there is usually no lasting sign of brain damage after a TIA. Your doctor should order a brain scan to check for signs of a small stroke and to rule out other causes.
      Your doctor should make every effort to find the cause as quickly as possible because your risk of a full-blown stroke is highest in the weeks after a TIA, and many strokes happen within a day after a TIA. Tests and treatment will vary depending on what is and isn't known about the cause. For example, if the brain scan shows a hemorrhage, you may need surgery to stop the bleeding. If the brain scan reveals no cause, ultrasound of the carotid arteries (the main neck arteries supplying the brain) may show a dangerous narrowing that impedes blood flow. This condition is treatable with surgery or drug therapy. An echocardiogram (ultrasound image of the heart) may detect a heart problem that can increase the risk of blood clots, which are usually preventable with blood thinners. Blood tests may show that your blood has a high tendency to clot.
      In addition, stroke risk factors should be identified and, when possible, treated aggressively after a TIA. Although a cause is not found in up to 30 percent of TIA cases, you and your doctor should not give up too soon on finding a cause.

(Pierre B. Fayad, M.D., director of the Yale Vascular Neurology Program, helped design some of the questions used in the NSA survey.)

                                                                                                
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