Treat “mini-strokes” as an emergency, not a gentle warning

Treat "mini-strokes" as an emergency, not a gentle warning

Transient ischemic attack needs a new name. Its current nickname, mini-stroke, doesn't fill the bill either. Both suggest something small and passing, a fleeting problem you can put off until you have the time to do something about it. What's needed is something that conveys urgency and harm, because a transient ischemic attack (TIA) is often followed by a full-blown stroke. Getting evaluated and treated right away — within minutes of having a TIA, if possible — can lower the chances of having a stroke.

At the outset, there's little difference between a TIA and the most common kind of stroke, an ischemic stroke. They look the same, feel the same, and are caused by the same thing — a blood clot or bit of cholesterol-filled plaque that is blocking blood flow in an artery that nourishes part of the brain. The big thing that separates a TIA from a stroke is how long it lasts. A TIA is over quickly, often fading away within hours, if not minutes, while a stroke lasts longer than 24 hours. The blockage can cause any of the following:

  • numbness or weakness in your face, arm, or leg, especially on one side of the body
  • inability to move your fingers, a hand, arm, or leg
  • sudden confusion
  • difficulty speaking or understanding what someone is saying
  • trouble seeing with one or both eyes or hearing with one or both ears
  • dizziness, trouble walking, or loss of balance or coordination
  • rapid and severe headache.

In the case of a TIA, the blockage is small enough or fragile enough that the body's self-repair systems can reopen the artery, which stops the symptoms. Larger or sturdier blockages lead to strokes.

Rapid action

Lack of solid information on the long-term impact of TIAs has made consensus difficult on how best to treat them. The results of two trials, dubbed SOS-TIA and EXPRESS, are tipping the balance toward a rapid response.

In SOS-TIA, French researchers set up a hospital clinic in Paris that was open around the clock to evaluate and treat people within hours of having what appeared to be a TIA. Just 1% of those seen at the clinic had a stroke within three months, far fewer than the 6% expected based on the participants' signs, symptoms, and health.

A similarly dramatic reduction in stroke was seen in the EXPRESS study, carried out in the area around Oxford, England. Among people who were quickly evaluated for a TIA, 2% had a stroke within three months compared to 10% whose follow-up visits were a few days to two weeks after their TIAs.

Preventing the worst

The American Heart Association and National Stroke Association offer these recommendations for preventing stroke after a transient ischemic attack:

  • rapid evaluation, preferably within 12 hours of the onset of symptoms
  • access to same-day diagnostic imaging
  • aggressive attention to blood pressure, cholesterol, diabetes, atrial fibrillation, and other conditions
  • control of risk factors such as smoking, obesity, and physical inactivity
  • use of aspirin, aspirin plus extended-release dipyridamole (Aggrenox), or clopidogrel (Plavix) to prevent the formation of further blood clots
  • surgery (carotid endarterectomy) or endovascular therapy (angioplasty with or without a stent) to open a narrowed or blocked carotid artery.

Changing habits

Although it will be impossible to prevent all post-TIA strokes, we can do a lot better. But that will take work on three fronts:

Recognition. Knowing the signs and symptoms of a TIA is the first step toward making it a truly transient problem.

Response. If you think you or someone you are with is having a TIA or stroke, call 911 or your local emergency number right away. If it's a stroke, getting to the hospital within 60 minutes makes you eligible to receive a clot-busting drug that can greatly reduce the damage caused by a stroke. If it's a TIA, prompt evaluation can help prevent a stroke.

Reorganization. So far, only a few hospitals have set up dedicated stroke centers that are able to rapidly evaluate people having TIAs and strokes. There is a movement under way to create more such centers, but it won't happen quickly.

In the meantime, if you think you are having a TIA, or just had one, treat it like the emergency it is and get help right away.

July 2009 update