Mr G, a 65 year old right handed male, was found sprawled on the floor by his wi

Question

Mr G, a 65 year old right handed male, was found sprawled on the floor by his wife. When he woke, he appeared slightly confused and said something about everything looking blurry but couldn’t explain it well. He vaguely complained of a headache and a strange numbness in his right arm but his wife couldn’t make much sense of what he was trying to say. Mrs G said her husband was talking rapidly, but his words did not make any sense. She described it as if he was speaking meaningless words and irrelevant phrases. She was quite upset because it appeared that Mr G didn’t understand anything said to him and yet he seemed completely unaware of his condition. Mrs G noted that he was dragging his right arm and immediately called for an ambulance.
Mr G has been a chronic smoker for the last 40 years and has a history of type 2 diabetes.
Physical examination:
Vital signs: Temperature 38 C. Pulse=80. Blood pressure=150/100mmHg
BMI=32
Head: Minor abrasions and mild bruising
Heart: Regular rate, no murmurs
Lungs: Clear
Abdomen: Soft, normal bowel sound
Neurologic Examination:
Mental status: Alert. Mildly agitated. Speech fluent, but with meaningless words and phrases. Unable to repeat words correctly. Spontaneous speech filled with made up words and jargon. Minor impairment in reading and writing.
Cranial nerves: Pupils equal, round and reactive to light. Extraocular movements were intact. Visual field testing showed difficulty in seeing objects on patient’s right side. Facial sensation intact to light touch and pinprick. Smile was symmetrical on both sides. No dysarthria.
BMSC12007
Motor: Slightly increased tone in the right arm. Normal tone on the left side. Moved all four limbs, but was unable to steadily hold right arm over head.
Reflexes: Mildly increased reflexes in the right arm.
Coordination: Normal finger-to-nose and heel-to-shin test.
Gait: Patient took small steps hesitatingly, was able to walk without support.
Sensory: Temperature and light touch sensation intact on both sides. Decreased pinprick sensation on the right side. Graphesthesia and stereognosis normal in the left hand, absent in the right hand.

(Given the signs and symptoms above it strong suggest transient ischemic attack (TIA))

TASK: Discuss a most likely diagnosis for Mr G’s condition (TIA) by discussing risk factors and underlying pathophysiology. What can be other possible differential diagnosis? Support your answer with reasoning.

Explanation / Answer

Diagnosis for TIA

Transient Ischemic Attack. A brief stroke-like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke.Transient ischemic attack (TIA) is the medical term for neurologic symptoms, such as weakness or numbness, which begin suddenly, resolve rapidly and completely, and are caused by a temporary lack of blood in an area of the brain. TIAs are common, affecting at least 240,000 people each year in the United States.

Most TIAs result from narrowing of the major arteries to the brain, such as the carotid arteries. These blood vessels provide oxygenated blood to brain cells. These arteries can become clogged with fatty deposits, called plaques. Plaques partially block the artery, and can lead to the formation of a blood clot. This blood clot (thrombus) can further narrow or completely block the artery. More frequently, a blood clot will detach from the wall of the artery, travel along the bloodstream to smaller branches, and block blood flow to the area of brain fed by that artery.

In some cases, TIAs can be caused by blood clots that form in the heart and travel to the brain (called emboli). TIAs can also occur as a result of narrowing and closure of small blood vessels deep inside the brain.

If an artery remains blocked for more than a few minutes, the brain can become damaged or infarcted (that is, the tissue in that area dies).Some people call TIAs "warning spells" because anyone who has a TIA is at risk for a stroke. As a result, it is important to be aware of the signs and symptoms of TIA and seek treatment as soon as possible.

With a TIA, the symptoms resolve completely (usually within a few hours or less)

With a stroke, the symptoms may not resolve completely

Many people do not have a TIA before a stroke. However, a TIA is a warning sign that a person is at risk for a stroke. It is important to recognize and treat the symptoms of TIA to reduce the risk of having a stroke.

Symptoms of TIA are typically short-lived, lasting only a few minutes to hours. A TIA may occur only once, or may be recurrent (several times per day or once per year).

The most common symptoms of TIA include the following:

Hand, face, arm, or leg weakness or numbness

Difficulty speaking (garbled speech), slurred speech, or inability to speak at all

Blurred, doubled, or decreased vision in one or both eyes

These symptoms are identical to those of a stroke. When the symptoms first develop, it is not easy to tell if a person is having a stroke or TIA.

TRANSIENT ISCHEMIC ATTACK RISK FACTORS

A number of factors can increase a person's risk of TIA, including the following:

Age greater than 40 years

Heart disease (eg, atrial fibrillation, carotid stenosis)

High blood pressure

Smoking

Diabetes

High blood cholesterol levels

Illegal drug use or heavy alcohol use

Recent childbirth

Previous history of transient ischemic attack

Sedentary lifestyle and lack of exercise

Obesity

Current or past history of blood clots

Risk of stroke after TIA — The risk of stroke after a TIA is highest in the first few hours to days after the TIA. For example, the risk of having a stroke in the first two days after TIA has been estimated to be 4 to 10 percent. People with certain characteristics are thought to have a higher risk (eg, closer to 10 percent) of stroke compared with people without these characteristics.

Diabetes

Older than 60 years

Blood pressure (higher than 140/90), measured after the TIA

Weakness on one side of the body (eg, face, arm, leg) during the TIA

Speech problems during the TIA

TIA symptoms for 60 minutes or longer

TRANSIENT ISCHEMIC ATTACK DIAGNOSIS

Despite the fact that the symptoms of TIA usually resolve quickly, TIA is a medical emergency that should be evaluated as soon as possible because there is a high risk of a stroke after TIA. When to call for emergency medical assistance — Anyone who is concerned that they are having a TIA should call for emergency medical attention immediately. Brain imaging — Depending upon the results of the history and physical examination, the clinician will usually order blood tests and a brain imaging test (eg, CT scan or MRI). The imaging test allows the clinician to see the area of the brain affected by the TIA.

Blood vessel imaging — The larger blood vessels that supply the brain can also be imaged using CT or MRI; these scans are referred to as CTA (computed tomography arteriogram) and MRA (magnetic resonance arteriogram). Ultrasound can be used to determine if there are blockages in blood vessels.

Occasionally, a catheter must be inserted through a blood vessel in the groin and threaded up to the blood vessels of the neck, where dye is injected to highlight any areas of blockage. This is called conventional arteriography. Heart testing — An electrocardiogram (ECG) is usually performed to help the clinician diagnose and treat heart problems and identify abnormal heart rhythms that cause stroke as quickly as possible. In some people with TIA, the heart or the aorta can be the source of a TIA-causing blood clot. Other heart testing, such as an echocardiogram, may be needed. This test uses sound waves to examine the heart and the aorta (the large vessel that arises directly from the heart; blood vessels that supply blood to the brain originate in the aorta). Heart monitors (also called Holter or loop monitors) may be used to monitor the heart's rhythm for an extended period of time to detect paroxysmal (intermittent) atrial fibrillation.

TRANSIENT ISCHEMIC ATTACK TREATMENT

The optimal treatment of a TIA depends upon the presumed cause of the TIA, the time since the first TIA symptoms occurred, and the person's underlying medical problems.

The goal of treatment is to reduce the risk of having a stroke. There are several types of treatment:

Treating risk factors, such as high blood pressure

Antiplatelet therapy

Statin therapy

Anticoagulant therapy

Revascularization

Treating risk factors — Anyone who has had a TIA has an increased risk of having a TIA or stroke in the future, especially within the first 48 hours after the TIA. The treatments discussed above can significantly reduce this risk. In addition, lifestyle changes and careful management of underlying medical problems can help to reduce the risk of future strokes. These include the following:

Treatment of high blood pressure

Controlling diabets

Stopping smoking

Treating high cholesterol and lipids

Antiplatelet therapy — Platelets are a type of cell circulating in the blood that normally clump together to stop bleeding. In TIA, platelets clump together and form clots inside narrowed arteries. The platelets "plug" themselves and/or the clot that forms around the plug can temporarily block blood flow in the brain. Antiplatelet therapy is given to help prevent new clots from developing.

Dipyridamole and aspirin — Dipyridamole is a medication that may be given after a TIA to reduce the risk of stroke

Clopidogrel — Clopidogrel (brand name: Plavix) is an antiplatelet medication that is also used in patients after TIA to reduce the risk of stroke.

Cilostazol — Cilostazol is another antiplatelet medication that reduces the risk of ischemic stroke after TIA

Short-term dual antiplatelet therapy — In some cases, "dual antiplatelet therapy" with two medications (eg, aspirin plus clopidogrel) is started immediately after a TIA and continued for 90 days.

Anticoagulant therapy — Anticoagulants are often, but incorrectly, referred to as blood thinners. They work by decreasing the formation of blood clots. Anticoagulant therapy is usually recommended for selected people with an irregular heart rhythm (atrial fibrillation) who have had a TIA or are at risk for a TIA or stroke.

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