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Patient Education - Healthcare Professional Response

Mr. C. posed this same question to several other healthcare professionals. Click on their pictures to see how they would have answered his question. 

Neurologist/Stroke Expert Response

TIA stands for Transient Ischemic Attack. That's "medicalese", but what it means is that you had a spell which is a warning that you are at increased risk for having a stroke. You might think of the warning spell that you just had as a "gift," because it gives us a chance to intervene and to try to prevent you from going on to have a major stroke.

A stroke is damage to the brain that occurs because the blood supply is cut-off, or because of bleeding into the brain or around the brain. It can give you permanent problems like inability to speak or understand what is being said, loss of vision in one eye or on one side, numbness, weakness, paralysis, loss of balance, problems walking.

Right now we need to figure out why you had this spell, so that we can try to prevent your having another spell or a stroke. You might be wondering how much risk you're really at. This will sound very scary, but you need to understand that your risk of having a stroke, a heart attack or dying would be about 8% a year over the next 5 years if we did nothing.

We're going to do a number of tests right away because the highest risk of your having a stroke is in the coming month. We will use the results to help figure out what caused your spell, and to select the most appropriate treatment. The aspirin that they started you on in the emergency department has been shown to reduce the chances of stroke for patients like you. However, there may be additional or other treatments that we can provide once we understand exactly why your spell occurred.

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Neurologist/Stroke Expert Note

It is extremely urgent to evaluate Mr. C quickly. Delaying would be like playing roulette with his brain. Mr. C's speaking voice has been his livelihood for many years. Imagine how devastating it would be to him if he were to be permanently deprived of the ability to speak clearly by a stroke. 

Family Physician Response

Mr. C, do you have any experience with the term TIA? TIA means Transient Ischemic Attack. Basically this translates to a brief moment of changed function in the brain due to decreased blood flow. Once blood flow returns, brain function becomes normal again. In your case there was momentary reduced blood flow to one of the parts of your brain that involves speaking, but once blood flow came back you could talk normally again. Some of the tests they did in the emergency department were to confirm that what you had was a TIA, and that's what it looks like to me right now. The CT scan of your brain showed that there was no bleeding. The EKG results showed us that your heart was doing all right. They also did a blood test and found nothing abnormal like blood that was too thick.

I've just given you a lot of information. Do you have any questions? (Mr. C asks, "Why did they give me aspirin? I don't have a headache."). Aspirin decreases the stickiness of cells in the blood, so they won't clump together and form a clot. In patients like you who have had a TIA, aspirin can protect against forming a blood clot. You will only need to take one aspirin a day, because it has a long-lasting effect. Do you think you'll be able to do that? Now we are to going to do some more tests because we need to know just what caused the temporary blockage of blood flow in your brain. If the blockage happens again and stays around too long, it could cause permanent damage to your brain. (At this point I would ask Mr. C if he has any particular concerns. Most people would ask --"did I have a stroke?" I think it's better to let the patient raise this issue, but if he didn't I would say something like, "many people who have had a TIA are wondering if this was a stroke."). I can reassure you that you did not have a stroke. The TIA was a warning sign-- and we need to work together to take care of it, so that you won't have a stroke.

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Family Physician Note

You are giving this patient a lot of complicated and frightening information. Be sure to stop frequently and check-in with him to validate that he understands what you've said. You might ask him questions or ask him to summarize what you've just told him. 

Emergency Room Physician Response

Mr. C, the episode when you couldn't talk right was the result of decreased blood flow to your brain. This was temporary, but it was a warning that a more serious event may occur in the future. We use the phrase Transient Ischemic Attack or TIA to describe this--it just means that there was a brief interruption of blood flow. We'll need to do a more complete physical exam as well as some further testing to help us figure out just what caused this to happen.

At this point I would probably ask Mr. C if he knows what a stroke is. (Some people confuse stroke with myocardial infarction). In the most common kind of stroke, blood flow to part of the brain has been permanently blocked. This can cause problems like inability to speak, paralysis, coma or even death. You're fortunate in that you've been given a warning that you may have disease in the blood vessels of your brain. Your age, gender, race, and history of hypertension all increase the chances of your having this problem. However, we have new medications, and can also help you make other changes in your life that will reduce the risk of your having a stroke.

We have started you on aspirin. This is an amazing drug that decreases pain and also thins the blood, making it less likely that you'll have a clot in your brain. Aspirin may prevent or at least decrease the chances that you will have another episode like the one you just had. A daily aspirin has also been shown to be protective against cardiac disease, which you may also have. This is why we advise most men over the age of 40-45 to take a daily aspirin.

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Emergency Room Physician Notes

Physicians in the Emergency Department were the first to see Mr. C. Our job was to figure out why he could not talk clearly at breakfast. Before making a tentative diagnosis of TIA, we would consider a differential of other conditions that could present in this fashion. A detailed history from the patient and his wife would rule out a more chronic mental status change, head trauma, or side effects of medications. Bedside evaluation would determine blood sugar levels, and pulse oximetry detect any hypoxia. We would also look for some indication of generalized hypotension or cardiac arrhythmia, which might have reduced overall systemic blood flow and contributed to his symptoms. If our initial work-up suggested the diagnosis of a TIA, we would request a consult with a neurologist to help guide Mr. C's further evaluation. 

Nurse Practitioner Response

Mr. C, A TIA is a transient ischemic attack. This means that you had a brief moment of diminished blood supply to your brain. A TIA can occur for different reasons, and right now we're not sure which one caused your TIA. However we do know that when there's been high blood pressure, like you have, this can affect the lining of the blood vessels so that there is decreased blood flow through them. The brain needs oxygen and nutrients carried by the blood to be able to function. If part of your brain gets too little blood, it ceases to function right. In your case the part of the brain that got less blood for a little while is involved in telling your speaking muscles how to move.

A TIA is a warning sign that you're at risk for a bigger event that could leave you with permanent deficits. This bigger event we're worried about is called a stroke--or maybe the term you have heard used for stroke is "shock--a shock to the brain". In a stroke, your brain has gone without oxygen and nutrients long enough to cause significant damage. That's what we're trying to prevent, and that's why you're getting all these tests. The tests are to find out specifically why this happened to you, so that we can prevent something worse. 

You asked me why they told you to take an aspirin every day. As we discussed already, you probably have changes in the lining of your blood vessels that have made their diameter narrow. This makes it more difficult for blood to get through.The aspirin keeps the blood thin so that it can flow easier through the narrowed blood vessels in your brain. When the blood is thin, it won't clot so easily. So you may notice that next time you cut yourself, it will take longer for the bleeding to stop.

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Nurse Practitioner Note

Mr. C's world has been turned upside down by what has just happened to him. He is very likely feeling overwhelmed and scared. This means that he probably won't hear, absorb, remember much of what you say the first time. The information will need to be repeated several times. Don't be surprised if he asks you many of these same questions again the next time you see him.

Neurologist Response

Mr. C, a TIA stands for Transient Ischemic Attack. It is sometimes called a mini-stroke. However, it's not really a stroke at all, because in a TIA none of your brain gets permanently hurt like it does after a stroke. Unfortunately, we're still not very good at making strokes go away once they've occurred. Many people think that because we have these new clot-busting drugs, we can just fix up someone once they have a stroke. However, the clot-busting drugs don't work for everybody, so it's really important that we prevent strokes from happening in the first place. We're concerned about you because TIAs are warning signs that a stroke might happen.

Strokes often occur when a little bit of "stuff" gets stuck in an artery in your brain. Hardening of the arteries can lead to build up of cholesterol or fat on the insides of your arteries. Sometimes blood clots can also form on the inside of arteries. If a bit of this stuff breaks off and flows along with the blood until it gets stuck in a smaller artery, it may block it. Then you get symptoms, like when you had trouble talking this morning. If you are lucky, the little bit of stuff falls apart and travels on to some smaller artery where it won't cause any symptoms. That's probably what happened to you. If you're not lucky, the stuff in the artery remains stuck there and permanently blocks it. Then you get a stroke, and you have permanent symptoms because the part of your brain that the artery goes to will die. 

Our job now is to look for the place in your body where the "stuff" came from, and then try to figure out how we can prevent it from blocking up a brain artery again. We're going to do some tests on the arteries that supply your brain to look for material that is collected there. If we don't find anything there, we'll look to see if there are problems with your heart that might have caused blood clots to form there. Depending upon what we find, you might need treatment like stronger medicines than aspirin. For now I want you to keep taking an aspirin every day because we know it's good at preventing TIAs and stroke. Even though you don't need a prescription to get it, aspirin is still a strong medicine. It works to make your blood less sticky so the blood is less likely to form little clots inside your arteries.

Review Key Facts

Neurologist Note

Try to make your explanation fit with the patient's own experience. Keep referring back to what actually happened to him or her. Also, make analogies that a patient can understand--for instance, describing the action of aspirin as making the blood less "sticky" is an idea that most patients can grasp. You could also make the analogy that the lumen of blood vessels can be narrowed by atherosclerotic plaque much as a drainpipe can be clogged by grease and hair-- most people have experienced that at home.