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Next we want to look at the arteries from the heart, all the up into the brain and there are three major tests that we’ll do to evaluate that. Any of the three are reasonable to use and that’s often dependent on the institution that you’re at, what they excel at. The first one that we would consider something called the carotid ultrasound. A carotid ultrasound is noninvasive where they put an ultrasound device over your neck and can actually look at the blood flow of the carotid artery. The next one is something called an MR-Angiogram and that’s just an Mri where they actually, they change the settings on the MRI machine to look at blood vessels rather than the brain sitting still. And the last option is something called a CT angiogram. Ct Angiogram is a cat scan or a CT scan and what they’ll do is they’ll inject dye and as that dye goes through your vessels, they can actually track it with the CT scan. Any of those three may be reasonable to do. Next we’ll want to look at the heart, the structure of the heart, and the rhythm of the heart. So the first way we do that is with a 12 lead EKG. So they put the leads on your, on your chest and look at your heart rhythm. And then next we actually do an echocardiogram frequently looking at the structure of the heart, looking at the valves, looking for anything that could cause a clot. Last thing, and this actually has a blood test, is going to be looking at your blood glucose, looking for any signs of diabetes, how well the diabetes is controlled, and then also your cholesterol. Another thing that we want to be very aware of because treating that can reduce your risk of future stroke.
The causes of stroke and TIA are identical. I’m going to talk about the causes, but you may hear me use the term stroke or TIA and I point out they’re exactly the same thing here. The same case, the same risk factors that we’re going to be talking about. So the first and foremost was factor is high blood pressure. The single biggest risk factor for stroke. If your blood pressure is way too high, you can actually have stroke symptoms simply from the high blood pressure. We call that hypertensive emergency. So blood pressure needs to be addressed. Diabetes is an important one. Diabetes increases the risk of stroke by six times in some studies and so making sure the diabetes is well controlled through diet, exercise and medications as needed. The next big issue is going to be cholesterol paying very careful attention to cholesterol, wanting that total cholesterol less than 200 and your LDL, which is your bad cholesterol, low lower than a hundred preferably. There’s an irregular heart rhythm called atrial fibrillation. This is the most common irregular heart rhythm in adults. It gets more common as we get older. And it is the most common cause from your heart to cause a stroke, where a blood clot can form in the heart and then be ejected out of the heart up into the brain. And then there are a few that go together, specifically a physical inactivity and obesity. They’re both risk factors for stroke. I’m wanting to address them. Activity wise, we should be doing between about 30 minutes, four to five times a week. And lastly, smoking is critically important. This is the number one worldwide preventable cause of death, and certainly risk factor for stroke.
To confirm the diagnosis of TIA is difficult. Often this is a disease of sort of exclusion, meaning we’ve excluded a stroke, we’ve excluded other things, and all we’re left with is a TIA. I point out that because it’s a diagnosis of exclusion. This is sometimes a diagnosis that can be a little difficult to be certain about. That being said, you’ll do all the workup that we just talked about and you know, you’ll rule out that there’s been a stroke on the MRI, and you’ll rule out that there are some other obvious cause, a brain tumor or other things and you’ll assess someone’s risk factors for stroke. But you know, given the set of symptoms that someone has and the lack of a clearcut stroke, often that’s how we diagnose the TIA. That’s how we confirm it. And it’s at the end of the day, a diagnosis of exclusion, meaning we’ve excluded every other possibility that we can think of.
So the treatment for TIA really hinges on the notion, the fundamental notion that a TIA is a stroke that can be prevented. So the treatment is identifying or looking really, really carefully for any stroke risk factor, high blood pressure, diabetes, high cholesterol, smoking, obesity, physical inactivity and addressing it aggressively. And then also looking for other clearcut things that would change your management like again, carotid stenosis that needs to be treated. And again, we can see that on any of the imaging modalities we talked about. Atrial fibrillation or irregular heart rhythms or severe cardiac disease that we address those issues based on what we find, and any other problems within the brain itself. Again, the important thing here is recognizing the stroke that could happen and trying to prevent it. The strategies that generally you’re going to see every doctor do, they’re going to give you some type of blood thinner. Aspirin is the most common one, but there are other ones such as a drug called aggrenox or another drug called Plavix or clopidogrel. And they’ll also want to aggressively treat things like cholesterol frequently with statins, on top of blood pressure control. Those are the things you’ll see most universally. Again, sort of going back to the beginning here, the fundamental issue here is the stroke that could happen and looking for the stroke risk factor that we can help affect to reduce your future risk of stroke.
The lifestyle changes that are associated or that we have to sort of pay attention to with TIA are really specific to the fact that the TIA was a stroke that could have happened and it didn’t. And so all the workup is trying to identify the risk factors that pertain to you. Again, is it a high blood pressure? Is it diabetes? Is it smoking? Is it physical activity? Is it medication changes that need to be made? Adding a statin? Taking blood thinners? Whatever they are, those need to be instituted in your life. This is one chance you have to prevent the stroke that could happen. And keep in mind we’re doing a really good job at preventing death from stroke. It’s gone from the third leading cause of death to the fourth leading cause of death to the fifth leading cause of death. But it is still the leading cause of long-term disability and there are fates worse than death. The TIA is your second chance and the lifestyle changes that you make after your TIA will have the biggest effect on whether or not you have a stroke. Now keep in mind that lifestyle changes, like we talked about, those risk factors that we talked about, they have a huge effect on your risk of future stroke. I point out over and over again, 8 out of every 10 strokes and heart attacks are preventable. If you can institute these things into your daily life. And again, today is your chance to make that change before the big stroke happens.
So the BEFAST acronym applies absolutely to TIA. The key here though is that it’ll be transient. It’ll come and it’ll completely go away. And it’s really, I can’t stress the importance enough. Don’t be fooled by the fact that went away. Don’t be fooled by the fact it wasn’t painful. This is something that needs to get evaluated and needs to be evaluated very quickly and preferentially that place to get evaluated is the emergency room. If the ER is not possible, call your primary physician, talk to a doctor, get evaluated quickly.
My name is David Teeple. I’m a board certified neurologist and director of stroke. I’m here to talk to you today about transient ischemic attacks or TIAs.
So the first question that often sort of gets asked of me is what exactly is a TIA? And I would point out that there was a tremendous amount of confusion in the community, both by providers and by patients and families. So first of all, what is a TIA? It Tia is a stroke that doesn’t stick. And what do we mean by that? Well, generally a stroke is where a cla lands in the brain blocks an artery and the brain stops working. Well eventually, that clot causes permanent brain damage. That’s a stroke. With a TIA. A cloud goes up, blocks an artery, and that brain stops working. Someone has symptoms of a stroke, numbness, weakness, vision loss, but before that becomes permanent, before this permanent damage in the brain, that clot breaks up and it goes away. Typically a classic stroke is defined, or a TIA is defined as a stroke symptoms that lasts less than 24 hours. With the advent of MRI, which is the gold standard way for us to detect a stroke, what we have sort of gravitated to actually is what we call a tissue based diagnosis, which means someone has stroke symptoms, they go away, we do an MRI, and if there’s no damage, we know it was a TIA. If there’s damage, even if the symptoms are gone, it can still be a stroke. So the diagnosis is, or the definition has actually changed over the years. And that’s really what’s led to a lot of the confusion. I would also like to add or sort of point out that the name TIA, it actually has synonyms. I mean, people call them other things, mini strokes, being the most common one out there.
So what’s the difference between a TIA and a stroke? The key difference between a ta and a stroke is that there’s no brain injury with a TIA. Now, I’ll point out that if we look back the definition of TIA was really in the 1960s before the advent of MRI. And we thought that, okay, if you had symptoms the less than 24 hours and the symptoms totally went away, you must not have any permanent brain damage. And that was the definition of a stroke and permanent brain damage. What we found with MRI is that people can have symptoms that lasts an hour and they sometimes go away, but they actually have a stroke. It’s a small one, but they have a stroke. And so we’ve gone to what we call a tissue-based diagnosis where essentially, what we see is we see that the symptoms go away and the MRI shows no evidence of brain damage. And so again, that’s the definition of a tia symptoms go away, but most importantly there is no brain injury on MRI.
What’s unique or what’s important about a TIA? And this is an important thing for us to sort of talk about. Which is a TIA is a stroke that’s about to happen. And the way that we should sort of view it as really this is an opportunity for us to intervene and prevent the stroke that could happen. We know that in about somewhere between 15 to 20% of patients who have TIAs, they’ll go on to have a stroke. That risk is really high in the first couple of days and last until about three months. So if someone has a TIA, they shouldn’t delay. They need to get into the hospital to get evaluated rapidly.
The signs and symptoms of a TIA are, again, they’re identical to a stroke. And that includes vision loss and there’s a type of vision loss that with Tia is very common. It’s called amaurosis fugax. And that’s where a clot goes up the carotid artery and comes up and off of the carotid artery comes the artery to the eyeball. The central retinal artery, that clock comes up and blocks the artery to the eyeball. What’ll happen is you lose vision in one eye. It’s interesting the way that the arteries go to the eye. They sort of like this, there’s one up and one down. And so when there’s a blockage that happens, the blockage hits and the blood will stop flowing on the top or the bottom. And what you’ll get is you’ll get this painless vision loss, like a curtain coming down or a curtain coming up can last a couple of seconds, can last a couple minutes and goes away. And that’s something to pay very careful attention with. The other big symptoms of stroke or TIA, and again, I use the term interchangeably often because they’re the same thing at least at first. You can’t tell the difference between a TIA and a stroke when they’re happening. Will be weakness of the face. It will be half the face and it will be the lower half of the face. Weakness of the arm, weakness of the leg, inability to speak right, or inability to balance or walk. Any of those things happen, that should be a trip to the hospital even if they go away. And time is really critical here again, because within the first couple, even though that that risk for stroke less for three months, the risk is highest in those first few days after the TIA.
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