Do I really have to go to the hospital for my mini stroke?

Clinical pearls for frontline PCPs

JJ is a 75-year-old man who presents to the office after his wife made an appointment for him this morning for evaluation of an episode of garbled speech that occurred yesterday.

The medical assistant (MA) checked in the patient and recorded his medical history:

• smoking: one-half pack per day for 20+ years
• hypertension controlled with lisinopril 10 mg daily
• type 2 diabetes reasonably well controlled on extended-release metformin 500 mg daily; and
• ibuprofen 200 mg as needed for joint pain.

The MA summarized the patient’s history and described the reason for today’s appointment: “Doc, Joe is here reporting an odd spell yesterday where, all of a sudden, he began talking gibberish. He generally doesn’t talk a whole lot, but he was with his wife and she became concerned. The whole episode lasted about 15 minutes. He tried to downplay the episode, but his wife insisted that he come in for an evaluation. He had a similar episode about a week ago, but that time, it only lasted about 10 minutes. His vitals were good today except that his BP was slightly up at 150/90, but he seemed kind of nervous to me. His speech seemed normal to me today.”

The physician entered the room and noticed that the patient’s wife accompanied him for the visit. She did most of the talking.

Philip A. Bain

“Doctor, Joe has me really worried. He had a spell yesterday where he talked gibberish for about 15 minutes. He seemed to know what he wanted to say, but he just couldn’t get the words out.”

The patient’s wife then told me about a recent stroke education program at her church they recently attended. “I looked up what BEFAST stood for,” she said. “His speech returned to normal after about 15 minutes, so I thought that we could wait until this morning to see you. Funny thing, though, he had the exact same thing happen about a week ago, but that only lasted about 10 minutes. I wrote down the answers to BEFAST. His balance was ok, he did not tell me about any visual symptoms like double vision or black holes in his vision. I took a picture of him on my phone and as you can see, his face really wasn’t at all droopy or deformed. He did not have any weakness of his arms or legs.”

The physician examined the patient and noted that he had fluent speech. No facial asymmetry was noted. Strength appeared normal in all four extremities. His deep tendon reflexes had normal responses. Both toes were down going. Balance was normal, although he had difficulty getting up out of the chair. Examination of his other cranial nerves appeared normal. His cardiac exam revealed normal results — i.e., a regular heart rhythm and auscultation showed only a benign sounding soft systolic murmur at the left lower sternal border. The patient’s ECG showed normal sinus rhythm and appeared otherwise normal except for changes suggestive of left ventricular hypertrophy. Carotid exam showed normal upstrokes bilaterally without bruits. Likewise, normal CBC and metabolic panel, except for a blood sugar of 160. The eGFR was 50. The physician told Joe he was glad he came in to see him today.

“I am worried that you had a transient ischemic attack, or TIA. Some people call this a ‘mini stroke,’ but I don’t use that term because it seems to overlook the fact that there is a high risk of leading to a full-blown stroke, which can be a real life changer. I know that you and your wife live over 30 miles from the hospital. I am recommending that we admit you to the hospital for a day or so to do some important testing to make sure that you are not at high risk for a disabling stroke.”

Joe resisted at first.

“Doc, do we really have to go into the hospital? Can’t I just see how it goes?” he said. “How about if I just increase my blood pressure pill a little bit?”

The physician continued, “Joe, because you had one and possibly even two TIAs in a short period of time, you are at very high risk for developing a disabling stroke event in the next week. I don’t think that we could get the important tests that are needed to make sure that you won’t suffer a stroke soon enough. I am strongly recommending that you be admitted to the hospital to help us figure out what we can do to prevent a stroke from occurring.”

His wife stepped in and said that they will go over to the hospital right away.

The physician called the admitting hospitalist. Although he seemed somewhat reluctant to admit Joe, he agreed that getting the key tests as an outpatient would take as long as a week. The patient was admitted to a telemetry bed and underwent an MRI of his brain (diffusion-weighted imaging). This showed increased signal in the left frontal region. MRA of the brain and neck arteries showed normal intracranial arteries and a 50 % stenosis in the left internal carotid artery and a 30 % stenosis in the right internal carotid artery. Telemetry showed normal sinus rhythm throughout his hospital stay.

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A transthoracic echocardiogram was done and showed aortic sclerosis without stenosis. Specifically, the patient had a normal left ventricular ejection fraction and no LV clot. No valvular vegetations were seen, and a bubble study showed no evidence for a patent foramen ovale (PFO). A stroke specialist neurologist evaluated the patient and diagnosed a small vessel ischemic stroke involving Broca’s area likely related to hypertension, and other atherosclerotic risk factors like diabetes and smoking.

He recommended that because the patient is considered high risk using the ABCD2 score, the patient be given a loading dose of aspirin 325 mg, followed by 81 mg daily dose indefinitely. He also recommended clopidigrel 300 mg loading dose, followed by 75 mg daily for the next 21 days followed by indefinite therapy with low-dose aspirin 81 mg daily. He also recommended that the lisinopril dose be increased to 20 mg daily with a goal BP of less than 120/less than 80 mm Hg. He added atorvastatin 40 mg daily. He also asked the smoking cessation nurse to meet with the patient. The patient told the neurologist that this event had a big effect on his outlook and that he was finally ready to completely quit smoking. The smoking cessation nurse started the patient on varenicline.

The patient was discharged after 48 hours in the hospital with no residual neurologic symptoms. He was seen 1 week later by his primary care physician. BP was 110/80 mm Hg. He was tolerating his meds well and remained abstinent from tobacco.

Lessons learned

1. 1. TIA is defined as a sudden onset of focal neurologic symptoms due to a transient decrease in blood supply to the brain, spinal cord or retina. Vague, diffuse confusion or bilateral symptoms are rarely due to a TIA. The top 3 diagnoses for minor non-disabling neurologic deficits that are not TIA include seizure, migraine with aura and syncope.
2. 2. The previously used time-based definition of TIA as being a sudden onset of focal neurologic symptoms that lasts less than 24 hours has been replaced by a tissue-based definition. This is a transient episode of neurologic dysfunction caused by ischemia to the brain, spinal cord or retina without ischemic infarction on diffusion-weighted MRI.
3. The five main mechanisms of TIA include:
   a. Cardioembolic TIA with a source from the heart or aorta, artery to artery or from an unknown source.
   b. Small penetrating vessel TIA (also referred to as lacunar TIA).
   c. Large artery TIA due to low flow through a stenosis.
   d. Cryptogenic (no etiology identified after recommended testing).
   e. Other (drug induced, carotid dissection).
4. TIA should not be referred to as a “mini” stroke so as not to trivialize the significantly increased risk of subsequent stroke. TIA is a neurologic emergency requiring urgent evaluation. Consultation with a stroke specialist is strongly recommended.
5. Public service awareness programs like BEFAST have been helpful to educate the general public on possible symptoms of stroke that would need urgent treatment.
6. The decision to hospitalize a patient with TIA symptoms can be helped by using the ABCD2 scoring system because low-risk patients may be evaluated completely as an outpatient as long as the necessary testing can be accomplished quickly (as a rule, less than 48 hours). High risk features for progression from TIA to stroke include recent event, recurrent symptoms involving the same vascular territory, findings of ischemia on MRI and high ABCD2 score. If the patient is considered to be high risk for CVA or the testing cannot be completed within 48 hours, then the patient should be admitted for observation and testing.
7. Standard work-up includes brain imaging, such as diffusion-weighted MRI, to rule out acute tissue infarction. CT of the brain without contrast is often done first to make sure that there has not been an intracranial bleed followed by the diffusion-weighted imaging MRI. To assess the intracranial vessels and carotid vessels, an MRA with contrast can be performed. This can often be done with the MRI. Another option is a CT angiogram. If the symptoms suggest an anterior circulation ischemic event, a transcranial or Doppler ultrasound could be done in lieu of the MRA or CTA. An echo study should be ordered to rule out a low ejection fraction, left ventricular clot and/or heart valve vegetations. Bubble studies to rule out a PFO should generally be reserved for younger patients (< 60 years old) with TIA because PFOs are as common as 1:4 in the general population. Labs should include a CBC, a metabolic panel (including fasting blood sugar and creatinine), a HGBA1C and a lipid panel. RPR can be considered if the clinical situation is suggestive that syphilis could be a possibility.
8. It is important to search diligently for atrial fibrillation, especially in a patient who does not have an otherwise obvious source of ischemia because the treatment would be different (full anticoagulation rather than dual antiplatelet therapy). In patients with a higher risk of atrial fibrillation and no obvious explanation for their ischemic event, prolonged rhythm monitoring with a 30-day continuous monitor or even an implantable loop monitor may uncover atrial fibrillation that could go undetected on a standard ECG, on telemetry during a short stay in the hospital or even a continuous (e.g., Holter) monitor.
9. Treatment of a patient with a TIA or stroke without atrial fibrillation identified consists of aspirin and one of the two other available antiplatelet agents clopidogrel or ticagrelor. The aspirin should be dosed as a loading dose 160 to 325 mg, followed by a low dose (50 to 100 mg) daily indefinitely if no contraindications exist. The other short-term antiplatelet agent such as clopidogrel should be loaded with 300 to 600 mg, followed by 75 mg daily for a total of 21 days. After that, monotherapy with low-dose aspirin should be continued indefinitely.
10. Attention to secondary ASCVD prevention risk factors must be given, including BP treatment with a goal of less than 120/less than 80 mm Hg, blood sugar control (target HGBA1C less than 7), high-dose statin therapy such as atorvastatin 40 mg daily, regular aerobic exercise (40 to 80 minutes of moderate intensity physical activity per week at a minimum) smoking cessation and following a prudent diet such as the Mediterranean diet.

References:

• Amin HP, et al. Stroke. 2023;doi:10.1161/STR.0000000000000418.
• Favilla C, et al. #164 Stroke and TIA deconstructed.” The Curbsiders Internal Medicine Podcast. Available at: http://thecurbsiders.com/episode-list. Published August 5, 2019.
• Panuganti KK, et al. Stat Pearls: TIA. Available at: https://www.ncbi.nlm.nih.gov/books/NBK459143/. Updated July 27, 2023. Accessed Dec. 27, 2024.
• Kleindorfer DO, et al. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the American Heart Association/American Stroke Association Stroke. 2021;doi: 10.1161/STR.000000000000037.