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Health Matters: A New Stroke Strategy
Aggressive treatment of mini-strokes could help prevent major attacks
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By LAURA LANDRO
As part of a new push to prevent potentially deadly strokes, doctors are focusing on a risk that was often underplayed in the past: transient ischemic attack, or TIA, caused by a temporary blockage of blood flow to the brain.
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Often called a mini-stroke or warning stroke, the signs are similar to the real thing: sudden numbness or weakness on one side of the body, trouble speaking or seeing, confusion and dizziness. But because the clots dissolve quickly, and symptoms go away within an hour, patients often fail to report the experience to a health-care provider. And when they do, they may not be treated as an urgent case.
In recent years, however, a growing number of studies have shown that there is as high as a 17% risk of having a stroke within 90 days of a TIA, with half the strokes occurring in the first two days. That has led to the development of new clinical guidelines that emphasize the importance of fast evaluation and treatment.
Change in Philosophy
"We've come a long way from 10 years ago when doctors often didn't believe a TIA was an emergency," says S. Claiborne Johnston, director of the Clinical and Translational Science Institute at the University of California, San Francisco. While more doctors now use a scoring system to determine who is most likely to have a stroke based on such factors as age over 60, the duration of symptoms, and the presence of diabetes and high blood pressure, Dr. Johnston says the current thinking is that after a TIA, "pretty much everyone should be treated as if they are high risk."
Associated Press
A brain scan shows possible damage caused by a stroke.
Dr. Johnston, an author of updated guidelines published last year by the American Heart Association and the American Stroke Association on the prevention of stroke in patients with previous stroke or TIA, is currently investigating a new treatment approach for the critical hours after a TIA or minor stroke. At present, patients are often given aspirin to thin their blood; Dr. Johnston's study aims to determine whether combining aspirin and the clot-preventing drug clopidogrel (known by the brand name Plavix) in an initially high dose can thin the blood more dramatically and reduce stroke risk by 20% or more.
Of the estimated 800,000 strokes a year in the U.S., as many as 30% are preceded by a TIA. They can strike young people, but increasing age, especially after 55, is a major risk factor, along with a family history of stroke, and a condition known as atrial fibrillation, a type of abnormal heartbeat. Smoking and heavy drinking increase the risk; keeping blood pressure, weight and cholesterol under control can help reduce it.
Head to the ER
Some patients can have one or more TIAs without going on to have a stroke. But generally, "transient ischemic attack is the smoke before the fire," says Michael A. Ross, assistant professor in the department of emergency medicine at Emory University School of Medicine in Atlanta and director of observation medicine at Emory's hospital.
Anyone who has symptoms of a stroke or TIA should get to an emergency room as soon as possible, Dr. Ross says. Even if the symptoms have passed, patients can be held for observation or admitted so doctors can search for the cause, by performing brain scans, electrocardiograms and other tests to determine whether there may be a blood clot from the heart that has traveled to the brain, or whether the arteries in the neck have narrowed.
If the cause is a narrowing of the arteries in the neck, performing surgery to repair the blocked artery within two weeks can reduce stroke risk by 30%, Dr. Ross says. But getting the surgery arranged as an outpatient within that time frame can be very difficult, so it is best to have the surgery before being discharged. "The longer you wait, the more likely you are to have a stroke," he says.
Finding the Problem
Tawanda Johnson-Gray, 40, says she had four TIAs between the ages of 33 and 35 that were initially misdiagnosed. But by the fourth one, doctors determined that her recurrent TIAs were linked to a hole in her heart and a disorder that caused abnormal clotting of her blood. She was prescribed a blood thinner as a preventive measure.
Ms. Johnson-Gray, who started her own nonprofit to raise awareness of stroke risk among minorities in the Phoenix area and is an adviser to the state of Arizona on stroke-related issues, says she has lasting weakness in her left side as a result of the last TIA, but feels blessed to be able to warn others of the dangers. "I could very well have had a massive stroke that could have killed me or totally paralyzed me," she says.
Ms. Landro is an assistant managing editor for The Wall Street Journal and writes the paper's Informed Patient column. She can be reached at next@wsj.com.
A version of this article appeared December 10, 2012, on page R8 in the U.S. edition of The Wall Street Journal, with the headline: A New Stroke Strategy.
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