'These are warning strokes.' New guidance on TIAs could have big impact.

February 16, 2023
Illustration of woman's head showing arteries leading to her brain.
In a transient ischemic attack, a blood clot blocks an artery for a short period of time. Image used with permission from the American Heart Association

If you have a transient ischemic attack, or TIA, you need to get help immediately. It may be a warning that you’re about to have a stroke. If you get the right kind of help, you may be able to prevent that.

“It is very common, especially in rural areas, for TIAs to go unrecognized. Then the patient goes on to have a stroke that could have been prevented,” said vascular neurologist Parneet Grewal at MUSC Health’s Comprehensive Stroke Center.

Prevention is the goal of a new scientific statement from the American Heart Association. It’s aimed at making sure doctors and nurses across the country, including those in rural areas that may not have stroke experts, follow the right steps to take care of patients who have had TIAs.

Grewal, an assistant neurology professor at the Medical University of South Carolina, said the guidance could save lives. “Historically, people have been calling TIAs mini strokes. But these are not mini strokes. These are warning strokes. Ten to 18% of these people, within the next 90 days, will have a stroke, with almost half occurring within two days of the TIA.”

The American Heart Association statement spells out what doctors should do to try to keep that from happening, from comprehensive evaluation to risk assessment scoring. It includes specifics for health care providers in rural areas.

Parneet Grewal, MBBS Assistant Professor, Department of Neurology 
Dr. Parneet Grewal

Grewal said no matter where a patient lives, getting the right care starts with recognizing the signs. “In a TIA, basically the symptoms are the same as stroke symptoms. It's only that they're very transient. They’re temporary. We tell our patients to watch for sudden loss of balance, sudden vision loss, an uneven smile, check if one arm is weak or if you're having slurred speech or trouble talking. Those are all warning symptoms of a stroke.”

If that’s happening to you or someone you’re around, Grewal said you need to get to an emergency department as soon as possible. If you’re in an area that doesn’t have a neurologist, your doctor may be able to use telehealth to connect with a stroke expert at MUSC Health or another hospital with neurological expertise. It just needs to happen quickly, Grewal said.

“The duration of TIA symptoms is typically less than 60 minutes, but we don't want people to wait 60 minutes before they come to the ED. You don't know if in the end, it will be a stroke or a TIA.”

If it’s a TIA, Grewal said a series of evaluations should follow. One test checks something called the patient’s ABCD2 score. “It can help decide if you’re in the low-risk group or the high-risk group for having a stroke.”

  • The “A” stands for age. Your stroke risk doubles every 10 years after you turn 55, according to the Centers for Disease Control and Prevention.
  • “B” is for blood pressure. High blood pressure raises the risk as well.
  • “C” is for clinical features of the TIA, such as weakness and speech problems.
  • “D” stands for duration of symptoms and whether the patient has a history of diabetes. The shorter the time the symptoms lasted, the lower the patient’s risk of a stroke. Diabetes doubles the risk.

But the ABCD2 test isn’t the only assessment that should follow a TIA, Grewal said. “Everybody with a TIA should have a noncontrast CT head done,” Grewal said, referring to a computed tomography brain exam. “There are some things that can mimic a TIA, like a brain mass or a hemorrhage. So noncontrast CT at least helps us rule out those things quickly in the Emergency Department.” 

The patient also needs an MRI to see if the attack did any damage to the brain, Grewal said. “About 40% of the patients who have TIA symptoms, when we do their MRI, they have abnormalities on the MRI. So they then are actually diagnosed with a stroke and not a TIA at that point,” Grewal said.

That’s not all. “If they fall in the high-risk category, based on the ABCD2 score, they get admitted to the hospital. Patients also need to undergo vessel imaging; get an evaluation for cardiovascular risk factors, such as diabetes or hypertension; and get a thorough cardiac workup.” 

Grewal said TIA patients considered lower risk should be seen in a stroke clinic, ideally within 48 hours or at most within a week, for further examination. But she knows there have been challenges in making sure TIA and stroke patients get the right care. “Despite the fact that we have had improved emphasis on stroke symptoms, there have been a lot of disparities in the treatment rate, mortality and 30-day readmissions in rural areas.”

The reasons for that vary. “It can be due to multiple causes, including patient health literacy, clinicians with an unconscious bias or people aren’t aware of what it means to have a TIA. And then also access to care and quality of care that you receive in these communities can make a big difference.”

She said the new AHA guidance should help. “I think this is something that needs constant education and reinforcement. I think this statement will lead to a change in practice just because it is specifically focused on that target demographic. It’s now up to each hospital to review the current policies related to TIA and stroke to create a pathway for adequate care and management."

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