Because of the trust you have with your patients, you are in a unique position to notice, evaluate, and act on neurologic and other conditions your patients experience. As you are interacting with your patients, it helps to watch for symptoms of a transient ischemic attack (TIA) stroke. During your examination you can delve deeper and ask the patient pertinent questions and use your own judgment to determine next steps. Here is more on how to proceed.

How to Notice Changes in Patients

The overwhelming majority of patients with acute stroke will report no preceding neurologic symptoms until the stroke occurs, said James E. Siegler, MD, vascular neurologist, assistant professor of neurology, and director of the Comprehensive Stroke Center at the University of Chicago in Chicago. “However, a small proportion of patients will report early signs or symptoms, which may herald a more serious cerebrovascular event to come,” he said.

While primary care physicians and practitioners are poised to react to neurologic concerns of their patients, there are significant issues that should not be ignored.

“First, transient neurological symptoms are extremely common, and most do not represent ischemic cerebral injury,” Siegler said.

According to data from the Framingham Heart Study, the incidence of a TIA is approximately 1 per 1000 person-years — meaning more than 250,000 events among US adults each year. However, fewer than 6% of these are associated with a clinical stroke in the 3 months that follow, the study revealed.

Further, there is a wide variety of seemingly benign but potentially concerning neurologic symptoms, making it difficult to diagnose TIA with confidence, the vascular neurologist said. “Mild, nondisabling symptoms that may precede a larger, disabling stroke range from subtle signs like blurred vision and dizziness, common and innocuous complaints like headache, to more concerning symptoms like difficulty walking or clumsiness,” Siegler said.

Patient-Specific Approaches Key to Your Assessment

For patients at the high risk for a stroke, such as those who are elderly, have preexisting atherosclerotic vascular risk factors (hypertension, diabetes, tobacco use), heart disease, or other conditions, the primary care provider should be appropriately concerned when any new sudden neurologic symptom is reported, Siegler said.

The ABCD2 score has long been used to predict the risk for incident stroke, with higher ABCD2 scores reflecting higher risk for future stroke. Also Siegler noted that the National Institute for Health and Clinical Excellence recommends patients with an ABCD2 score ≥ 4 be evaluated and treated urgently for stroke — either in the emergency department or by a vascular neurology provider within the next 7 days. “This is a reasonable recommendation,” Siegler said.

How to Explain to a Patient What a TIA Stroke Is

Defining what a TIA stroke isn’t an easy story to tell.

“As a vascular neurologist who sees and treats these patients on a regular basis, I can attest to the difficulty of diagnosing a TIA,” Siegler said.

Symptoms of a TIA are brief (lasting minutes to < 24 hours) and result in no acute imaging abnormality. The majority of TIAs last only minutes and are probably ignored by most patients, he said, adding a TIA should be distinguished from a “transient neurologic deficit” in that a TIA indicates the cause of the deficit to be vascular in origin.

“This means the patient experienced a brief symptom which was causally related to ischemic injury to the brain. Because of this, symptoms should reflect injury to a cerebral or spinal vascular territory,” he said.

These symptoms can include vision loss in one eye or one side of the world, inability to speak, or weakness on one side of the body. “Equally importantly, symptoms of TIA should be sudden in onset and oftentimes unprovoked,” continued Siegler.

He said a patient’s hand should become immediately weak or vision loss should be sudden and nonprogressive to attribute the deficit to a vascular mechanism.

Nonspecific symptoms such as disorientation, dizziness, fatigue, memory impairment, and generalized weakness are often over diagnosed as TIAs in the community setting and are more likely the consequence of a nonvascular mechanism, he said. Some examples of nonvascular causes of transient neurologic events are listed below:

• Migraine
• Compressive nerve injury
• Anxiety/stress
• Ocular “floaters”
• Intoxication
• Cardiac arrhythmias
• Dehydration
• Urinary tract infection

As you know, the ABCD2 score lists some of the most common symptoms of TIA. Another resource is BE FAST that’s mnemonic to use when educating patients, caregivers, and community members about stroke warning signs and symptoms, said Siegler. Here are some directives:

• Balance. Is there a sudden change in balance or gait?
• Eyes. Is there a sudden change in vision, including loss of vision or double vision?
• Face. Is there weakness to one side of the face?
• Arm. Is there weakness to one arm or hand?
• Speech. Can the person speak or be understood?
• Time to get to the hospital!

“While this tool is useful, 1 in 8 patients with a stroke may not have symptoms captured by BE FAST and other stroke symptoms to be aware of include a sudden, explosive headache; sudden unexplained nausea or vomiting; and sudden clumsiness of a hand or arm,” he also noted.

Why Early Detection and Treatment Is so Significant

When an ischemic or hemorrhagic stroke occurs, brain tissue dies rapidly, said Fadi B. Nahab, MD, vascular neurologist, associate professor, Departments of Neurology and Pediatrics and Division of Vascular Neurology at Emory University, and stroke quality director, Emory Healthcare, both in Atlanta.

“In one study there was loss of 1.9 million brain neurons per minute in an acute stroke,” he said. “Treatments are most effective for reducing disability and death when initiated early to reduce the amount of brain tissue lost.”

Primary care providers play a key role in primary stroke prevention. “Aggressive control of vascular risk factors can reduce the risk for stroke by over 80%,” he said.

Additionally, patient education of warning signs and symptoms that should prompt a 911 call can help patients arrive to stroke centers for treatments to reduce disability and death risks, said Nahab.

Caregivers and family members are often the first to recognize something is wrong. “They may notice the patient’s face is drooping, their speech is different, or they may find a family member on the ground,” said Siegler.

What Type of Short-Term Lifestyle Changes Should You Suggest?

For any patient with stroke or TIA, the American Heart Association emphasizes its Life’s Essential 8’s, which are measures that influence the heart and overall health. This can be easier said than done, but it is worth emphasizing to your patients to reduce the risk for a recurrent stroke or heart attack, said Siegler. Consider recommending these suggestions, and Siegler has provided the messaging to share with your patients.

• Eat better. A diet rich in fruits, vegetables, whole grains, nuts, legumes, and lean proteins is ideal, with limited red meats, simple sugars, and alcohol.
• Be more active. Adults should get 2.5 hours of moderate exercise per week.
• Quit tobacco. Any amount of tobacco, including one cigarette a day, is bad for heart and brain health.
• Get healthy sleep. Most adults need 7-9 hours of sleep. Adequate sleep promotes healing and improves brain function.
• Manage weight. Achieving and maintaining a healthy weight has enormous benefits. The optimal BMI is < 25.
• Control cholesterol. High levels of bad cholesterol (or “LDL” [low-density lipoprotein]) can lead to accelerated atherosclerotic disease, resulting in strokes, heart attacks, and peripheral artery disease.
• Manage blood sugar. Simple starches like those from soda, candy, and sweets can increase blood sugar, damaging blood vessels leading to stroke, heart attack, and kidney disease.
• Manage blood pressure. The target blood pressure for most adults should be < 120/80 mm Hg.

Siegler and Nahab reported having no disclosures.