When a patient tells a physician about a sudden episode of weakness, loss of vision, or loss of sensation that occurred but then quickly resolved, both the patient and the physician may feel a sense of relief. In many cases, the patient may not even seek medical evaluation. These events, when vascular in origin and not seizures or migraines, have been termed transient ischemic attacks (TIAs) by physicians, and are often called “mini-strokes” by patients. But as discussed by Drs. Shruti Sonni and David Thaler in this issue of the Journal, there is nothing “mini” about their significance.
In some ways, the perception of TIA (as opposed to stroke) has paralleled our understanding and initial misperception of non-ST-segment elevation myocardial infarction (NSTEMI). This type of acute coronary event was thought to be less severe than acute ST-elevation MI (STEMI), and patients with NSTEMI and unstable angina have historically not received the aggressive acute and preventive therapy received by patients with STEMI. But with the advent of more sensitive markers of myocardial necrosis, we now know that NSTEMI and unstable angina can be associated with significant tissue injury, and that the outcome after a year or so can be the same as or worse than if the initial injury was associated with ST-segment elevation.
A similar story has evolved with TIA. With sensitive diffusion-weighted magnetic resonance imaging, brain injury can often be detected even when it is not seen on computed tomography. Patients are often not evaluated as completely for reversible vascular lesions and may not receive aggressive secondary prevention. Yet shortly after suffering a TIA, a patient is even more likely to have another neurologic event than if the initial event had been a small stroke. And the neurologic event will more likely be a stroke with residual neurologic deficit.
All are reasons to educate our older patients—particularly those with diabetes, atrial fibrillation, peripheral vascular disease, and hypertension—about the significance of even apparently self-limited neurologic events. A TIA is a major warning signal.