TIA (Mini Stroke) Symptoms: A Trip to the ER
Medical Author: Benjamin C. Wedro, MD, FAAEM
Medical Editor: Melissa Conrad Stöppler, MD
The event
A 73 year old woman is vacuuming when her left leg becomes weak and she has
difficulty standing. Her face and left arm become numb. She calls for her
husband, who helps her to a chair, and even though the symptoms resolve within
five minutes, they decide to go to the hospital. In the hospital parking lot,
they debate whether they should go into the Emergency Department or just turn
around and go home.
This woman has suffered a TIA, or transient ischemic attack, which is
basically a stroke that
resolves on its own. Since the right side of the brain controls
the left side of the body (and vice versa), she suffered reversible damage to
her right brain and that caused her left leg to get weak and also developed
numbness on the left side.
After some discussion, the woman decides she wants to seek medical care, and
she and her husband walk through the Emergency Department doors. The doctor and
nurse take a medical history to find out what happened. All of the symptoms have
resolved, so the next step is follow-up care. The healthcare team asks the
patient if she has any of the known risk factors for stroke (which are the same
for heart disease):
The symptoms
The doctor advises the woman that there is a need to rush to medical care
because if the symptoms do not resolve, there is a very narrow window of time to
use alteplase (Activase, TPA), a clot busting drug, to reverse the stroke. Within three hours of the
onset of stroke symptoms, the patient needs to get to the hospital, have the
initial diagnosis made, have blood tests drawn, a
CT scan done to insure that
bleeding is not the cause of the stroke, a neurologist needs to be consulted,
and the drug given. The earlier the patient is given TPA for stroke, the better
the potential outcome and the lower the risk of complications.
A TIA is a stroke that resolves. Most symptoms get better on their own within
minutes, but by definition, it may take up to 24 hours for the neurologic
deficits to resolve. Because there is no way of knowing when a stroke begins, or
whether it will resolve on its own, the EMS system (Emergency Medical Services)
or 911 needs to be activated at the first sign of stroke. These
symptoms of
stroke include:
- weakness or paralysis on one side of the body,
- confusion,
- speech or vision difficulties and
- due to circulation problems at the base of the brain, loss of coordination
and balance and falling without notice.
Unfortunately, many patients do not qualify for TPA because they or their
family do not recognize the symptoms of stroke and wait too long at home. The
three hour window is very narrow. In some large hospitals, the window can be
extended a couple of additional hours, if the hospital has the capability of injecting
the drug directly into the blocked artery in the brain. This requires both a
radiologist with special skills to thread a catheter or tube into the brain
blood vessels and a hospital with the necessary equipment to do the procedure.
The diagnosis
The woman and her husband are reassured after the physical examination that
all is well, but the doctor wants to do some testing. And electrocardiogram
(EKG) is performed to confirm normal heart rhythms and a CT scan of the brain is
done, since small areas of bleeding can also cause stroke and TIA. After these
results return as normal, a carotid ultrasound is obtained to ensure that there
is no critical narrowing of the carotid artery, which would require surgery.
The doctor sits at the bedside with the woman and her husband and is pleased
to tell them that the tests are normal. But plenty of time is spent discussing
the potential risks for having a future stroke. While this time, the symptoms
resolved, there is no guarantee that future episodes will get better.
TIA is diagnosed first by physical examination of the patient, including a
full neurologic examination. This may include:
Assessing whether the patient is alert and oriented.
- Checking vision and eye movements.
- Looking for weakness in facial muscles.
- Testing power and sensation of all extremities.
- Looking for alteration in balance and coordination.
- Checking speech, recognition, and reading.
In most Emergency Departments, if there is concern for continued stroke
symptoms, a standardized assessment will be done, often using the
National
Institute of Health Stroke Scale.
The doctor also may listen to the neck for
bruits, or abnormal sounds, made
by narrowing of the carotid arteries causing decreased blood flow. The heart is
often checked to look for the irregular pulse of
atrial fibrillation. The rest
of the physical examination is performed to look for other medical conditions
that may contribute to a stroke or TIA.
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