Avoiding the Big One
Someone dies every 3.5 minutes from a stroke. 80 percent of “brain attacks” are preventable. A ministroke could be the prelude to a full-blown stroke.

By Linda Greider

February 2007

Gayle Wegener was enjoying a peaceful snooze in her recliner. But when she woke up to go to the bathroom, she realized that something was horribly wrong. For one thing, she couldn't seem to focus her eyes. And she had a brutal headache, "like someone hammering in the center of my head."

"I tried to get up and I couldn't," says Wegener, 65, of Littleton, Colo. "I couldn't get my feet to do what I wanted them to do." She reached for her husband's nearby cane, struggled to her feet and made it shakily to the bathroom. Within 10 minutes her symptoms had disappeared.

What Wegener experienced was a typical transient ischemic attack—or TIA—sometimes called a "ministroke." And what she did about it—nothing—is typical, too.

It turns out "nothing" is the worst thing to do. New studies confirm that TIAs are an important warning of more serious things to come. Almost 10 percent of people who have a TIA will have a major stroke within a week, and another 20 percent within three months. When certain risk factors like advanced age or high blood pressure are present, that figure goes up.

"TIAs are emergencies, whether symptoms go away or not," warns S. Claiborne Johnston, M.D., director of the Stroke Service at the University of California, San Francisco, and co-author of a report in Lancet Neurology last April summarizing recent research.

The symptoms of ministroke [see "Stroke Warning Signs"] are identical to those of full-blown stroke, which kills 200,000 Americans a year. Stroke is the third-leading cause of death after heart disease and cancer, and the number one cause of adult disability.

Unlike major stroke, which can cause paralysis, impaired memory, speech or vision loss, or death, TIAs are not fatal. Nor do they leave any permanent disability. The body resolves a TIA without any intervention, sometimes in just a few minutes. People either brush off their symptoms or are so relieved when they disappear that they don't do what doctors say is crucial: get to an emergency room as fast as possible. Immediate diagnosis and treatment are crucial to prevent a devastating subsequent stroke.

"You should take people who've had TIAs more seriously than anybody else because as you intervene, you may prevent them from having a full-blown stroke with its risk of dying or permanent disability," says Bruce Ovbiagele, M.D., director of the Olive View-University of California, Los Angeles, Stroke Program.

New guidelines developed by doctors in the clinical neurology department at Britain's Oxford University can help determine which TIA patients are most likely to have a major stroke. Called the "ABCD" test, the scoring system takes into account (A) age, (B) blood pressure, (C) clinical symptoms, such as weakness or headache, and (D) duration of the TIA.

The Oxford scientists have urged that the test become standard practice in evaluating TIA patients. They say that people at the highest risk are those over age 60 who have blood pressure above 140 over 90, have weakness on one side or speech disturbance during a TIA, and symptoms that lasted an hour or longer. TIA patients with such symptoms are sometimes hospitalized for more intensive testing and treatment.

About 85 percent of major strokes and all TIAs are ischemic—meaning they're caused by a clot or plaque that blocks the blood flow to the brain—and are treated with clot-busting medications. The other 15 percent of strokes are "hemorrhagic," caused by a flood of blood into the brain.

Imaging tests can detect brain changes in up to half of those who have had a TIA, but these ministrokes appear to leave no permanent damage. Chances of damage are greater in the case of a major stroke, when the brain has been deprived of blood for a longer period and brain cells have died.

Although Gayle Wegener didn't consult a doctor about her TIA symptoms at the time, she did by coincidence have a long-scheduled appointment with her gynecologist the morning after the episode. While Wegener didn't recognize her symptoms as those of a ministroke, the doctor did and sent her to a specialist for immediate diagnosis and treatment.

"I feel blessed," she says of the, well, stroke of good luck that may have saved her life.

Linda Greider is a freelance writer who lives in Washington.