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TIA: A Warning Not to be Ignored

Posted Aug 24 2008 1:49pm
PAUL J. MONIZ: Hi, there. I'm Paul Moniz. Thank you for joining us on this webcast. Today's topic is stroke, specifically a light stroke known as TIA or transient ischemic attack. TIA is certainly not a household term but knowing the warning signs could save your life. Each year a 150,000 Americans die of stroke. It is the third leading cause of death behind heart disease and cancer. Most people know a stroke is caused when a blot clot or hemorrhage reduces the flow of blood to the brain. What is not widely known is that a stroke does not have to produce physically devastating symptoms to cause damage. In fact, a patient may experience only mild dizzy spells, loss of balance and numbness and actually discount the symptoms as something else. In fact, that patient may have had a mini-stroke which could be a warning sign for something much more serious.

Here to discuss these mini-strokes or TIA are two specialists in the field. To my left is Dr. Ralph Sacco. He is an Associate Chairman of Neurology at Columbia University. Next to him, we have Dr. Dara Jamieson. She is also a neurologist at Pennsylvania Hospital and an Associate Professor of Neurology at the University of Pennsylvania.

How do we draw the distinction between TIA which most people have never heard of and regular stroke, so to speak?

RALPH L. SACCO, MD: Most people know the term "stroke" and they have someone, maybe in their family, that's had a stroke. Stroke will cause some kind of damage that is lasting -- weakness, numbness, tingling. Some kind of neurological symptom. Difficulty speaking. Slurred speech. Difficulty walking.

A TIA is something on more the mild side. It's transient. Usually the symptoms occur, resolve and are gone. Most of us define a TIA as something lasting less than 24 hours, although the new terms actually are maybe even less than an hour. Where they'll have transient neurological symptoms: sudden loss of vision, weakness on one side of the body, numbness, tingling, difficulty speaking, difficulty walking -- that would last only minutes to hours, and then resolve and leave you back to normal. That's what we would call a TIA. Actually nowadays, the term "brain attack".

PAUL J. MONIZ: The patient would really have no idea that they've just had a stroke.

RALPH L. SACCO, MD: They would know that they have neurological symptoms. Most people may recognize these symptoms, often ignoring them, but they wouldn't be left with lasting damage, whereas stroke will usually leave impairment, though many strokes will improve as well. It's kind of a continuum where the longer you have the neurological symptoms, the more likely that there has been some injury to the brain. While TIA, we think of has no injury actually has occurred but the fact that it's a warning that maybe injury could occur.

PAUL J. MONIZ: Dr. Jamieson, is it always a continuum? Is the TIA a warning sign and then stroke? Does it always progress to a more serious condition?

DARA JAMIESON, MD: Certainly patients need to be aware that TIAs are a warning, just like chest pain may be a warning of impending heart attack, a TIA may be a warning of an impending stroke. Although there are times when a patient can have TIAs -- one or multiple TIAs -- and don't actually go on to have a full, completed stroke within the next year or couple of years. But no matter what the outcome is, it always should be concerning to a patient and concerning to a physician and indicates that a patient needs to think about prevention of an ischemic stroke from occurring sometime in the future.

PAUL J. MONIZ: Who is at most risk for ischemic strokes?

RALPH L. SACCO, MD: Actually everybody is at risk for stroke -- young, old, men, women, all different race-ethnic groups. But there are certain groups that we want to target. Clearly stroke goes up with age. Age is one of our big factors. Men actually have stroke more frequently than women. However, women live longer so at any point in time where there are more women out there having stroke than men.

Race-ethnicity is very important. African American and Hispanics have strokes much more frequently. There are various risk groups. Some of the risk factors that we'll get a chance to talk about will also increase your risk of stroke. Nowadays we're concerned even about younger people because when a stroke hits somebody at a younger age, they can be left devastated and effect their whole productivity for the rest of their life.

PAUL J. MONIZ: But the age differential here is important for people to understand because a lot of patients or potential patients might not even think stroke is a possibility in their 30s or 40s, which could account for why they're discounting their symptoms. Do you see that especially with the younger patients? Do they tend to ignore it more?

DARA JAMIESON, MD: Certainly younger patients may rationalize their symptoms and say, "Oh, it's due to a back problem or I slept on my arm funny" or "I was just tired and that's why my speech was slurred." But we need to realize that there are certain types of strokes that occur in younger individuals. There are tearing of the artery type strokes, what we call dissection that can occur in young people. It can be heralded by a TIA.

Migraine can be associated with stroke. Recreational drug use can be associated with stroke. There are types of strokes that are seen in young individuals, as well as in older individuals.

PAUL J. MONIZ: What technically happens during one of these mini-strokes?

RALPH L. SACCO, MD: During a mini-stroke, the concern is that blood flow may be temporarily interrupted to the brain. That's what we call an ischemic stroke, rather than a bleeding stroke. Say something blocks an artery for an instant, causes reduced blood flow and causes some kind of temporary disturbance in the brain. Usually this blood flow is reduced either by a blockage, a hardening of the artery or say, a clot, that gets loose from somewhere and blocks an artery, or small arteries in the brain that then over time may block off. This reduces blood flow and causes the neurological symptoms.

PAUL J. MONIZ: You mentioned that TIA actually has another name. Tell us about this name change.

RALPH L. SACCO, MD: Recently and over the last few years, the National Stroke Association and the American Heart Association has been making a concerted effort to change the name TIA to "brain attack." Just like Dr. Jamieson was mentioning heart attack -- if we use the term brain attack, people may take it more seriously.

Brain attack is a warning sign. It's a definite risk for stroke and we want people to take these neurological symptoms seriously and get attention immediately. So that's why we want to add some urgency to the terms "stroke" and "TIA," and use the term perhaps "brain attack."

PAUL J. MONIZ: Dr. Jamieson, let's go through the symptoms more specifically for our audience. There are a lot of people who are watching this who may be concerned for themselves, for their spouse, for someone else they care about. What should they be looking for?

DARA JAMIESON, MD: As Dr. Sacco said, weakness on one side of the body is of concern, but it can be weakness in just the fingers, or weakness in the upper arm, or just weakness in the foot. It doesn't have to be the face, arm and leg. Same with numbness, although we think of numbness on one side of the body as being present with a TIA or stroke. It can be numbness in a very small portion of your body, such as just the hand or the foot.

Patient may be speaking on the phone and have slurred speech for a period of time -- not just one word, but if they have slurred speech for five minutes where people say, "Gee, I can't understand what you're saying." That could be a TIA. Some people have loss of vision in one eye like a shade coming down over the eye. Some people may note that they can't see off to one side. That commonly is picked up when they keep on bumping into things on one side of them. Difficulty walking, sometimes can be a TIA.

PAUL J. MONIZ: What about some of the risk factors specifically?

RALPH L. SACCO, MD: Specifically, some of the risk factors that are important for us to be focusing on, because you can prevent stroke and TIA, with things like high blood pressure, which is the No. 1 big risk factor for stroke. If you have it, please get it treated and there are ways to reduce it with lifestyle modification.

Diabetes. Cardiac disease, particularly a kind of cardiac disease that we call atrial fibrillation, a fancy term for an abnormal heart rhythm. That can be treated and controlled and reduce the risk of stroke.

The other thing is cigarette smoking. Heavy alcohol use. These lifestyle factors are clear risk factors for stroke. If you drink too much, clearly that will increase the risk of stroke. If you reduce to moderate quantities, you may actually have a reduced risk of stroke.

Then there are things like high cholesterol, hardening of the arteries in the neck. These are some of the risk factors for stroke that we need to be thinking about.

Physical inactivity. Something simple. If we're physically active, even walking quickly 20 minutes a day, three times a week. That will make a difference in terms of reducing the risk of stroke.

PAUL J. MONIZ: You talk about early intervention. People taking this seriously. What should they do if they suspect they may have had a stroke -- either right now as they're watching this perhaps, right after it happens, or they think, "Oh, two weeks ago this happened." Is there still evidence at two, three weeks, a month later?

RALPH L. SACCO, MD: If it really is a brain attack or a TIA, there may not be evidence. The first thing is recognition. We want everyone to know what the warning symptoms are. If they recognize that they've had these warning symptoms, then they need to get medical attention. If they're having it right now, we say, "Get medical attention and call 911" because what we call "time is brain." If you wait too long, you may not even have the opportunity to get some of the effective treatments for acute stroke. But if you have the symptoms, you recognize them now, and say hearing this broadcast you know you've had a TIA, see your doctor because there are things that should be done in the evaluation of such an individual to prevent a stroke.

PAUL J. MONIZ: Let's talk about that evaluation process. What tests specifically are done?

DARA JAMIESON, MD: Generally if you see your physician describing a TIA, your physician will be interested in knowing what's gone on in your brain and get an MRI scan of the brain, as well as sometimes an MRA scan to look at the blood vessels within the brain. Or the physician may order a carotid ultrasound to look at the blood vessels in the neck because sometimes people with TIAs have blockage of the carotid arteries in the neck that should be operated on. The surgery can prevent further damage and further strokes.

PAUL J. MONIZ: What is your message, Dr. Sacco, in closing for our audience relative to TIAs or brain attacks?

RALPH L. SACCO, MD: I think the key is recognition first. Recognize. Know the warning symptoms like we've identified. If you've had them, get some medical attention. Also, think about risk factors. You can prevent stroke. There are clearly risk factors our there. We've identified them and there are ways of managing and reducing your risk of stroke by just simple things, like changing your lifestyle. If everybody just did one thing, they will reduce the risk and make a big difference in terms of reducing the burden of stroke in the future.

PAUL J. MONIZ: All right. Some very important information and hopeful information as well. Dr. Dara Jamieson from Pennsylvania Hospital, thank you very much, and Dr. Ralph Sacco of Columbia University. Thanks for your time.

We hope that you have learned some important information about TIA or brain attacks. Remember if you suspect you may have had one, either recently or perhaps several months ago, contact your doctor. Thanks for joining us.

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