UNMC stroke expert, colleagues publish statement in New England Journal of Medicine, recommends redefinition of ‘mini-strokes,’ condition warrants immediate attention

 

Citing an outdated medical definition of the 1950s and 60s that may

prevent thousands at risk for stroke from getting appropriate evaluation

and treatment, a group of eight recognized stroke experts, including a

University of Nebraska Medical Center neurologist, have recommended a change

of the definition for transient ischemic attack (TIA). The group has published

a consensus statement in the Nov. 21 issue of the New England Journal of

Medicine.

TIA, also referred to as a mini-stroke or minor stroke, is defined

by sudden, temporary stroke-like symptoms with no resulting permanent brain

damage, which last less than 24 hours. Experienced by about 2 million people

in the United States annually, TIAs are under-recognized, under-reported

and under-treated and flag persons at high risk for having a stroke, said

Pierre Fayad, M.D., Reynolds Centennial Professor and chairman of the UNMC

Department of Neurological Sciences, whos been studying stroke for 14

years and is part of the eight-member group.

Dr. Fayad said more than 10 percent of people who experience TIAs develop

a stroke within the following 90 days, and half of the strokes will happen

within 48 hours after the TIA. Dr. Fayad said its imperative that patients

seek immediate treatment for stroke-like symptoms, even if the symptoms

resolve within the first few minutes or hours.

When the current definition was created, it stated TIAs will resolve

in 24 hours, even though there was evidence that most would resolve within

the first hour, Dr. Fayad said. Other reasons for a redefinition of TIAs

are sophisticated medical technology, new drugs and greater knowledge of

TIAs and strokes.

Not only has the public been conditioned by the definition to wait and

see if stroke-like symptoms resolve within the current defined 24 hours,

many health professionals reinforce the idea. Some patients are told to

watch their symptoms and asked to come to the emergency room only if their

symptoms do not resolve. Thats a lot of time, Dr. Fayad said.

We are saying most TIAs will resolve within an hour, but even if someone

has a TIA, clinically, they may still have stroke resulting in permanent

damage to the brain, Dr. Fayad said. TIA should be considered exactly

like a stroke until proven that its not a stroke. Anyone with symptoms

should come to the ER. The symptoms of whether its a TIA or a stroke should

be left up to the physician who evaluates them.

He said TIA is a serious disease thats not being taken seriously enough,

not only by physicians and the lay public, but also some insurance companies

that refuse to pay for admissions to the hospital after a TIA, because

they feel its unnecessary. Evaluating people whove had a TIA and finding

out the cause is crucial, he said.

We are much more savvy and now have better tools at preventing and

treating stroke, Dr. Fayad said. Back then, when the initial definition

of TIA was crafted, there was no tissue plasminogen activator (tPA), no

magnetic resonance imaging (MRI), no computerized axial tomographic scan

(CAT scan) nor magnetic resonance diffusion. In most cases, the only way

physicians could evaluate stroke was to examine the patient and at most

do an angiogram.

The advent of MR diffusion in the last three to four years has added

fuel to the debate. We know that over half of patients who have a TIA have

changes on their MRI that suggest stroke. MRI diffusion can tell us within

minutes where there is a lack of blood flow in the brain. Even for those

whose TIAs resolve, it may tell us where that lack of blood flow happened,

whereas initially, all physicians had to rely on was what the patient told

them.

Dr. Fayad hopes the consensus statement will trigger a change in attitude

of health professionals and the lay public, so people having stroke symptoms

or a brain attack go to the emergency room as soon as possible and not

wait.

Stroke is a bad disease because, you can have a heart attack and still

look normal, Dr. Fayad said. You can have surgery to your belly and still

look normal. Once you have a stroke, it shows to everyone else around you

either in minor signs where your face is a little weak or your hand is

a little weak or in major signs where you are disabled.

Of the people who’ve had one or more TIAs, its estimated that more

than a third will later have a stroke, according to the American Heart

Association. Dr. Fayad said in a recent study, researchers found 15 percent

of patients who came to the ER with a TIA ended up having a stroke or another

TIA within the following several weeks.

TPA, a drug approved by the FDA in 1996, improves the odds of being

cured from stroke by 30 percent if given within three hours from the onset

of symptoms. TPA prevents stroke by dissolving clots. Most strokes are

due to clots.

It means the patient has to arrive at the emergency room, at most,

within two hours to be able to receive tPA, which doesnt happen most of

the time, and this is why tPA is only given in about 2 percent of all patients

who have stoke in the nation, Dr. Fayad said. You cant give tPA after

three hours because it increases the risk of complications.

If the definition of TIA remains the same, then patients would be encouraged

to stay at home to find out if its going to resolve or not on its own,

and not come to the ER, and that creates more delay. Unfortunately, by

the time they realize it did not resolve, and make it to the emergency

room, it will be too late, and they cannot get treatment.

Dr. Fayad said it has become imperative to try to avoid confusing patients

and doctors with arbitrary definitions and making patients wait at home,

miss a treatment or not be treated appropriately.

Stroke deprives some people of their independence, he said. You cant

shop, cant visit friends, cant eat, cant swallow, cant see, cant talk

and cant speak. It essentially deprives us of most of what defines us

as human beings.

Symptoms of a brain attack or TIA are: sudden numbness or weakness

of the face, arm or leg, especially on one side of the body; sudden confusion,

trouble speaking or understanding; sudden trouble seeing out of one or

both eyes; sudden trouble walking, dizziness, loss of balance or coordination;

and sudden, severe headache with no known cause.

In 1999, 167,366 people in the United States died from stroke (one in

every 14.3 deaths in the U.S.) according to the American Heart Association.

About 47 percent of the deaths occurred outside the hospital. Stroke, the

leading cause of death behind diseases of the heart and cancer, also is

the leading cause of serious, long-term disability in the U.S.

Strokes cause damage to the brain either due to lack of blood flow,

either from a clot or leakage of blood into the brain. Most who have strokes

are over age 65 and about 20 percent happen in patients under 55, even

children. Arteriosclerosis (hardening of the arteries) is one of the main

causes of stroke, Dr. Fayad said.