Two neurologists argue that calling T.I.A.s what they are — minor strokes — could prompt patients to seek the help they need more quickly.
On a recent afternoon in Bastrop, Texas, Janet Splawn was walking her dog, Petunia, a Pomeranian-Chihuahua mix. She said something to her grandson, who lives with her and had accompanied her on the stroll. But he couldn’t follow; her speech had suddenly become incoherent.
“It was garbled, like mush,” Ms. Splawn recalled a few days later from a hospital in Austin. “But I got mad at him for not understanding. It was kind of an eerie feeling.”
People don’t take chances when 87-year-olds develop alarming symptoms. Her grandson drove her to the nearest hospital emergency room, which then transferred her to a larger hospital for a neurology consultation.
The diagnosis: a transient ischemic attack, or T.I.A.
For decades, patients have been relieved to hear that phrase. The sudden onset of symptoms like weakness or numbness (often on one side), loss of vision (often in one eye) and trouble with language (speaking, understanding or both) — if resolved in a few minutes — is considered “transient.” Whew.
But in a recent editorial in JAMA, two neurologists called for doctors and patients to abandon the term transient ischemic attack. It’s too reassuring, they argued, and too likely to lead someone with passing symptoms to wait until the next morning to call a doctor or let a week go by before arranging an appointment. That’s dangerous.
Better, they said, to call a T.I.A. what it is: a stroke. More specifically, a minor ischemic stroke. (Almost 90 percent of strokes, which afflict 795,000 Americans a year, are ischemic, meaning they result from a clot that reduces blood flow to the brain.)
Until recently, T.I.A.s “were played down,” said Dr. J. Donald Easton, a neurologist recently retired from the University of California, San Francisco, and an author of the editorial. “The person thinks, ‘Oh, it’s over. It goes away, so all is well.’ But all is not well. There’s trouble to come, and it’s coming soon.”
The advent of brain imaging — first CT scans in the late 1970s, then the more precise M.R.I.s in the 1990s — has shown that many T.I.A.s, sometimes called ministrokes, cause visible and permanent brain damage.
“Very quickly, nerve cells and their connections start to die,” Dr. Easton explained. And the risk of a subsequent stroke, possibly a more severe one, is highest within the first 24 to 48 hours.
He and his co-author on the editorial, Dr. S. Claiborne Johnston, a neurologist at the University of Texas at Austin and former dean of its medical school, want people who experience these episodes to head for an emergency room, stat.
“We’re trying to get rid of a term that has comforted people in the past,” Dr. Johnston said. Because “your brain is likely injured and you don’t want it to be injured further, you need to come in right away.”
Dr. Jeffrey Saver, a stroke neurologist at U.C.L.A., called the proposed change in nomenclature “an intriguing, radical and potentially good idea.” The transient ischemic attack name dates to a 1975 report from the National Institutes of Health. So, he said, “this upends 50 years of classifying low-blood-flow events in the brain.”
But will health care professionals change their terminology? “The T.I.A. concept is deeply entrenched in medical thinking,” Dr. Saver said. “It’s the kind of idea that will gather adherents slowly.”
He supports the change, however, because “it reflects what we’ve learned over the last two decades — even very brief episodes of low blood flow to the brain lead to damage” and because calling such episodes “minor strokes” may lead patients to respond more quickly.
“The treatments for ischemic stroke are very time-dependent,” he explained. “Every minute counts towards getting a better outcome.”
In an emergency room or specialized stroke center, patients undergo a brain scan to be sure their symptoms resulted from a minor stroke rather than from a condition that can mimic it, like a seizure or a migraine.
Patients who have suffered minor strokes usually start taking two drugs, typically aspirin and clopidogrel, which prevent clotting. (Some may need other medications or a surgical procedure, like a stent placement.)
After three weeks, when the highest risk for another stroke has passed, most continue with just one drug, usually a low-dose aspirin. “It’s easy, it’s cheap and it’s well tolerated,” Dr. Johnston said.
Twenty years ago, when Dr. Johnston led an early study of stroke risk after a T.I.A., 10.5 percent of patients suffered another stroke within three months; half of those occurred within the first two days.
That rate has declined substantially, thanks to improved treatments for stroke, lower smoking rates and the widespread use of cholesterol and blood pressure drugs and blood thinners. Recent studies in The New England Journal of Medicine put the risk of a subsequent stroke, coronary syndrome or death after a T.I.A. at 6.4 percent in the first year and another 6.4 percent in years two through five.
For neurologists, however, that is still high, given how devastating a major stroke can be. A name change for T.I.A.s might lead to quicker responses that further reduce the rate of subsequent stroke risk.
Circumstances can arise when older people or their caregivers choose not to seek immediate medical help. In 2017, Maggie Flanagan was 88 and into her seventh year with Alzheimer’s disease when Therese Flanagan, her daughter and caregiver, suddenly noticed odd physical symptoms.
“She was sitting in a recliner next to me when her head tilted back a little and her eyelids started to flutter,” Ms. Flanagan said. “One eye was drooping a little. I held her hand and said, ‘Are you OK?’ There was no response at all.” Then, a couple of minutes later, “she was back.”
Before, when their mother was still able to make such decisions, she had signed a do-not-resuscitate order and an advance directive instructing that “she didn’t want her life prolonged,” her daughter said. The family agreed that taking her to a hospital would only cause fear and disorientation. She and her siblings decided not to call 911.
Maggie Flanagan’s doctor said that she had probably experienced a T.I.A.; she had a more serious stroke five months later and died the following year, at home in her Chicago apartment.
But most people choose treatment. Ms. Splawn, the dog owner from Texas, said she was feeling fine and expected to go home to Petunia shortly.
Patients treated appropriately for minor strokes will remain at a higher-than-normal risk for another stroke, especially in the first year, Dr. Saver said. But “by two or three years out, the risk is just a little higher than for folks who never had a T.I.A. or a minor stroke.”
Wanda Mercer, for example, had a minor stroke four years ago, at age 66. An administrator at the University of Texas, she had donated blood during her lunch break, then fainted in an Austin restaurant. The staff called 911, but in the emergency room, everything seemed normal; she went back to work and regaled co-workers with her noontime adventure.
Suddenly, “I couldn’t find my words,” Dr. Mercer said. “I couldn’t articulate.” The problem lasted only seconds, but colleagues recognized a possible stroke and sent her back to the emergency room, where an M.R.I. revealed tissue damage. She has taken a statin, a cholesterol-lowering drug, and aspirin ever since.
“I’m lucky,” she said. “I haven’t had one adverse symptom since.”