Mini-strokes, maximum care

Warning: Doctors are starting a full-court press on the brief episodes that often precede devastating and disabling strokes.

Medicine & Science

January 19, 2004|By Jonathan Bor | Jonathan Bor,SUN STAFF

A brief attack of slurred speech, blurred vision or one-sided weakness might be a sign of a mini-stroke - an obstruction of blood flow in the brain that breaks up without causing serious damage.

But the common perception of mini-strokes as harmless episodes drives neurologists such as Marian LaMonte crazy.

"Because they occur briefly, people get lulled into thinking they aren't as important as strokes," said Dr. LaMonte, director of the brain attack team at the University of Maryland Medical Center.

What's important is that they're often harbingers of major strokes, the third leading cause of death in the United States and a common source of paralysis, dementia, speech impairment and other disability.

By ignoring the mini-stroke's warning, she said, patients and their doctors miss a great opportunity to address problems that, if left unchecked, could result in disaster.

Supported by a new research grant, the UM Medical Center has ramped up its emergency department to treat mini-strokes as aggressively as major episodes. In a whirlwind, 24-hour process, patients arriving by ambulance or other means are examined, given brain scans and started on blood-thinners, clot-busting drugs or other medications.

Some undergo a followup procedure in which a physician snakes a balloon catheter into the brain to clear an artery.

Before leaving the hospital, patients might start treatment for conditions such as high blood pressure or elevated cholesterol that can underlie strokes. Smokers are started on nicotine patches to help them quit the habit, and the sedentary are put on exercise.

Each year, about 600,000 people in the United States suffer major strokes, according to the American Heart Association. Some 167,000 die annually.

No one has a handle on the number of mini-strokes - known also as TIAs for transient ischemic attacks - in large part because so many are ignored. But research has shown that a third of those who suffer TIAs will experience major strokes within two years, and the most perilous period is the 24 hours after the small attack.

This, for LaMonte, is the greatest argument for evaluating and treating TIAs without delay: "If we could get everyone in and we rapidly found out why they were having the TIA before those 24 hours were up, we could prevent that big, disabling stroke, which the mini-stroke was just a warning of."

Dr. John Marler, associate director of the National Institute for Neurologic Disease and Stroke, said many doctors treat mini-strokes too casually.

"We're talking about people walking out of emergency departments without even being told to take aspirin," said Marler, a stroke specialist. Aspirin is often given because of its blood-thinning capability.

Because the public knows so little about them, Marler added, people who have recurrent mini-strokes are often fooled into thinking that the pattern will continue without harm.

"The TIAs may train patients to wait around and hope that it gets better - when what they should be doing is calling 911," he said.

Most mini-strokes are caused by temporary obstructions in the arteries that deliver oxygen to the brain. They often start with a fatty plaque breaks off of the wall of the carotid artery in the neck or a vessel in the brain. A clot forms in its place and grows large enough to obstruct blood flow before it dissolves and washes away.

"In the case of a mini-stroke, the patient just had the good fortune that their own body was able to break up that clot," said LaMonte. A major stroke occurs when the body's lysis system - its internal repair mechanism - isn't enough.

Some TIAs are caused by clots that break loose from the heart and travel to the brain. These occur in people suffering from atrial fibrillation, an abnormal rhythm. In rare instances, mini-strokes result from the breakage of tiny blood vessels in tumors.

Though TIAs are defined as brain attacks whose symptoms last no more than an hour, the symptoms typically pass in minutes.

During this time, the patient might have trouble getting words out or understanding what someone is saying. Other symptoms include headache, a weak leg or hand, a drooping face or lost vision.

LaMonte described a patient who suddenly couldn't read the prices on one side of a menu. He blinked a few times, and his vision returned.

Though some patients seek medical attention immediately, others delay because the symptoms don't seem important.

"It's human nature to think, `I just don't want to make a big deal out of something that will just go away,'" said LaMonte. Also, the stroke itself can dull a person's sense that something bad has happened, so it's up to a family member to notice the problem and summon help.

Under its current grant, the University of Maryland Medical Center wants to learn whether handling TIAs in the emergency room is safe and practical. Later, it plans to seek funding for long-term research to see whether the approach prevents fatal or disabling strokes.

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