It’s Sunday dinner with the whole family. The children are playing with their cousin’s new toy. The dinner table juggles two sets of conversations and the demand for dessert. You go to the kitchen to help grandma prepare the cake and---
“What did you say, Grandma?”
She tries to say something, perhaps to pass her the knife, but it doesn’t come out right. Her speech is garbled and hard to understand. She furrows her brows but it creases in only half of her face. Her right hand is unusually slumped to her side.
Is this a stroke?
Panic sets in. You call in the rest of the family. Something’s wrong with grandma. Except that not everyone agrees that it is a stroke. “I’ve seen the ads on TV say that you shouldn’t be able to raise both hands up,” Dad said. But grandma, with much effort, was able to do this-- albeit the right hand is a bit lower than the left.
Mom decides that calling the ambulance is still the best course of action and heads for the phone. Just then, Grandma says, “You don’t have you.” Her voice is still a bit garbled, but better than before. Her reassuring smile starts to reach both sides of her face. “I think I feel much better now.”
What was that all about?
You could have sworn that what you saw were the classic symptoms of stroke. You memorized them just in case situations like this arise (FAST for Facial drooping, Arm weakness, Speech difficulties, and Time to call emergency services). And they were symptoms of a certain kind of stroke.
I’m talking about a transient ischemic attack or a mini stroke.
A stroke can happen when the vessels supplying blood to some brain tissues are blocked-- this is what they mean by ischemic. The symptoms of a stroke depend on which part of the brain is not getting enough blood. Thus, the symptoms are not always the same and not always straightforward. Most often, this can be seen as slurred speech. Sometimes, the symptoms are the classic numbness and weakness on half of the body. Other times, the blood is kept from an unusual part of the brain and can manifest in equally unusual symptoms. These include dizziness, double vision, and weakness on both sides.
This description of a stroke can sound a little bit scary. We picture grandma conscious one moment and then down on the floor the next because of this weakness. But in reality, it isn’t always as dramatic. Reality can just be an odd tingling sensation in half the body. This creates a gap between expectations and reality. Sadly, there is a tendency not to seek professional care when symptoms don’t sound as bad as how we expect it to be.
That’s where we run into some problems.
Stroke vs Mini Stroke
A mini stroke or a transient ischemic attack (TIA) used to be defined by a time limit. Transient previously meant that the stroke symptoms would only last for less than 24 hours. The symptoms would go away if it was a mini stroke and persist if they were more serious.
When the definition is phrased like this, most would wait for around a day to see if this is a full blown stroke or not. Except that this 24hour rule is arbitrary and not reflective of reality. Majority of mini stroke episodes last for less than an hour. So if it’s been three hours and your symptoms are still there, all waiting would do is worsen the damage. 
This used to be the definition. Within the last decade, this was changed. Transient now means “a brief episode of neurologic symptoms but without tissue damage”. How do we find out if there is tissue damage? One needs a brain scan.
The change in definition is meaningful because it changes the initial reaction to symptoms of a stroke. Instead of debating whether or not this is enough to warrant a visit to the ER, there is a greater push to seek professional care. After all, grandma needs a brain scan anyway. Because when a patient has a stroke or is suspected to have a stroke, this is our biggest enemy.
Related: Neuroplasticity and Recovering from Stroke
Delays in Care
A review of several studies, done in 2019, showed that around a third of patients with mini stroke delayed consultation with a healthcare professional by more than 24 hours. Those who did see someone within the day often recognized that this was possibly a stroke. This may also be because most of those who consulted immediately had difficulty moving a part of their body. Thankfully, these were also the people who have a higher risk of stroke following that event.
Did you catch that?
See, a mini stroke is not just a milder version of a medical emergency. It is also an omen that something worse may happen if things continue as they are. A mini stroke does not increase the risk of having a stroke only in some distant future. The risk is actually much higher just a few days after a mini stroke episode, with as much as half happening within 2 days of an episode. The risk of a cardiac event such as a heart attack also increases after having a mini stroke.
So, what do you do when grandma says that she feels better and that she doesn’t want to be a bother to anyone at Sunday dinner?
Perhaps, the safest bet is still to bring grandma to the nearest stroke-ready hospital. Especially if the symptoms do not resolve immediately-- because that might not be a simple mini stroke.
The healthcare providers in the hospital may ask a few questions about grandma’s risk for a stroke. They may use a machine to scan her brain for any potential damage. They may also do a few other tests on her blood and on her heart to look for what caused the mini stroke in the first place. Most importantly, if another stroke does happen, then our loved ones will be in an institution that may immediately administer treatment.
Because time is brain and mini strokes aren’t as benign as we previously thought.
- Nadarajan V, Perry RJ, Johnson J, et alTransient ischaemic attacks: mimics and chameleonsPractical Neurology 2014;14:23-31.
- Mc Sharry J, Baxter A, Wallace LM, Kenton A, Turner A, French DP. Delay in seeking medical help following Transient Ischemic Attack (TIA) or "mini-stroke": a qualitative study. PLoS One. 2014;9(8):e104434. Published 2014 Aug 19. doi:10.1371/journal.pone.0104434
- Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. 2009;40(6):2276-2293. doi:10.1161/STROKEAHA.108.192218
- Dolmans LS, Hoes AW, Bartelink MEL, Koenen NCT, Kappelle LJ, Rutten FH. Patient delay in TIA: a systematic review. J Neurol. 2019;266(5):1051-1058. doi:10.1007/s00415-018-8977-6