Thursday, June 22, 2017

“Mini-stroke,” I Hate You

When I discuss strokes, stroke-like symptoms, “mini-strokes”, TIAs with patient, I realize that there is a lot of misinformation out there, not only from the internet, but also due to the patient’s lack of medical training (which makes sense of course) and, frankly, coming from us doctors.

All doctors have different ways of explaining things, some better than others, either because they misjudge what the patient is willing to understand or is capable of understanding overall or understanding just in the complicated moment, or because maybe they themselves are not completely confident in the cause of symptoms or proper neurologic terminology or actual proper pathophysiology.

I present an example that I particularly hear quite frequently:


I don’t know what this means.

I don’t know if the person had a SMALL stroke, or transient ischemic attack (TIA) that someone has called a mini-stroke or they are interpreting as a mini-stroke. Or I don’t if they didn’t have anything clot/stroke/TIA-related at all and maybe they just had some temporary symptoms that were related to, say, a urinary tract infection that got out of hand, too much cold medication, the wrong medication/medication side effect, an anxiety attack, etc.

I wish the term mini-stroke would go away.

Either you had a stroke (which is permanent and NOT temporary or transient).

Or you didn’t.
If you have a TIA, by definition it is transient (since the “T” always stands for transient) and therefore NOT permanent (I guess we would call that a PIA—PERMANENT ischemic attack—but we don’t use that terminology) and a TIA is therefore NOT a stroke, so a mini-stroke cannot be a TIA. That’s like saying it was a…. “small-permanent-non-permanent lack of blood flow to my brain”… which inherently makes no sense.

I admit I am biased by profession. But am I splitting hairs? Does it matter if I understand what happened as a TIA or mini-stroke or small stroke? Of course it does. Why would we worry about funny moles on our skin or our fat or wrinkles or kidney function but not the details of what is or isn’t happening regarding the blood supply to our brain that we are conscious with?

Now, someone can be told they had a “small” stroke, but that is like saying I only got shot with a small gun versus a big gun. A .22 in the head is a great tool of the assassin and a .44 magnum bullet shot into your foot by Dirty Harry is problematic but theoretically you could still run a marathon after it healed. Like real estate, it is all about location, location, location.

A “small” stroke in your brainstem can kill you or devastate you. A “small” stroke in your speech center can prevent you from understanding language or speaking language forever.

If you have ANY stroke, of ANY size, you are definitively more likely to have more strokes unless something changes… so ANY stroke to me is LARGE in its implication. And TIAs are associated with a much higher risk of subsequent stroke within the following hours, days, and months, so calling either of these phenomenon “mini-strokes” does the patient a severe disservice.

In summary:

A stroke is permanent and is a big deal no matter how big or small it is.

A TIA is NOT a mini-stroke; it is a NON-permanent lack of blood flow that did NOT permanently damage the brain but suggests you are HIGHLY likely to have a stroke in the near future if something isn’t done.

There is no such thing as a mini-stroke in my book.