January 2007

Sunny asks:
My husband and I had a very scary incident last night. He became very dizzy and fell to the floor. I went to him and asked if he was okay. He couldn't speak for approx. 15 seconds and then when he did speak, he slurred his words for an estimated 15 additional seconds. He tried to get up right away after his fall but stumbled for a minute because he could not get his balance. He denied any pain at the time of the event but reported that he had an earache earlier in the day. He also stated that he thought that an earthquake was occurring because the room was moving so violently. He never had any facial droop or unilateral weakness. He doesn't really remember falling but I heard him fall. Of course, I took him to the ER. He had a completely normal MRI.

The Doctor stated he saw some swelling inside of the canal of his right ear. The Doctor states that he believes, the episode occurred as the result of an ear infection (swimmer's ear) and not a TIA. Does this sound like a TIA to you or could it be the ear infection? Should we seek a second opinion? My husband has high cholesterol and his father died at age 43 from a brain aneurysm. How do we treat a TIA?

Dr. MacKenzie, MD, responds:
You have a number of good questions, and unfortunately, usually it's pretty hard to make a diagnosis from an email. But I think you hit the nail on the head: a TIA comes and goes, leaving no trace, so how can you know for sure if one has come and gone?

The short answers to your questions are the following:

1. Unless your husband also has an aneurysm, the family history of aneurysm almost certainly does not increase the likelihood that your husband had a TIA.


2. TIA is a "ministroke" which comes and goes, leaving no deficits behind. In some sense, it is a stroke that is really lucky, leaving the patient without disability. What separates it from "the big one?" We only know in hindsight. We start the treatment of TIA by making the diagnosis, and sometimes that can be hard. Once the diagnosis is made, we treat it much the same as a stroke, which is to say that we do a workup to identify all of the possible causes, in the least invasive way possible, so that we can prevent another spell from happening or turning into "the big one." An MRI is easy to do and gives some peace of mind, but a cerebral arteriogram is hard to do, and CAN result in a stroke, so we don't like to do one of those unless we really think it will HELP the patient.
   
   Usually we start medicine or medicines to address those risk factors and lower the likelihood of a TIA recurring as a full blown stroke. For example, there was a study recently called "SPARCL", published August 10, 2006 in the New England Journal, which showed that if you have a TIA and LDL between 100-190, you can lower your risk of recurrent stroke by starting a high dose statin (in this case, it was atorvastatin). It makes all the sense that if your LDL is even higher, then a high dose statin should help even more. It makes some sense that if your LDL is lower, a statin can still help, though we don't really have evidence for that from the SPARCL trial. We try aggressively to treat other risk factors like obesity, diabetes, high blood pressure and smoking, since these all contribute hugely to the development of vascular disease that causes strokes.
   
   There are other things we do, too, such as (frequent) antithrombotics like aspirin, but you get the idea. A TIA is a big stroke waiting to happen. And whether or not this episode was a TIA or an ear infection, if your husband has risk factors for stroke/TIA (cholesterol, smoking, high blood pressure, obesity, diabetes), they should be treated to prevent "the big one."


3. You are correct, your husband's symptoms could be due to an ear infection or some other inner ear problem. It's reassuring that the MRI of the brain did not reveal a stroke. Your point about your husband having ear pain earlier in the day, in conjunction with the doctor having seen some swelling during the exam, is reassuring and increases the likelihood that this was just an ear problem.
   
   When the problem is from an ear infection, sometimes on the MRI they can see the infection or inflammation in the ear canal. There is actually a diagnosis called "labyrinthitis" where people feel sick and vomit, and typically lie on the ground holding onto the floor because they are certain they will fall or fly off into space.


4. If a second opinion would make you and your husband feel reassured, you could have him seen by a neurologist or an ENT or both (for example, in the clinic). There, they might come up with the same answer ("it's in the ear") or a different one.

Joy asks:
Both my parents had strokes which were fatal, my father at 64 and my mother at 88. I realize this puts me at a very high risk. I have high blood pressure which is being controlled thru medication. Given my genetics what can I do to prolong/prevent getting a stroke?

Dr. Sansing, MD, responds:
The most important thing you can do to prevent a stroke is modify your risk factors. I'm glad to hear that your blood pressure is controlled on medication. It should be less than 130/85. You should also have your cholesterol tested and make sure it is normal. An active, healthy lifestyle is very important. Make sure your weight is normal, that you get regular aerobic exercise, and that you eat a healthy, low-fat diet. Do not smoke tobacco or use any illegal drugs. Work closely with your primary care physician to make sure all of these risk factors are controlled, and if he or she thinks you still have an increased risk of stroke, you may benefit from taking a baby aspirin. But talk to your doctor before starting any new medication.

Dr. Bark asks:
Can MRI of the brain with contrast detect TIA and must more than 1 test be performed for a more accurate diagnosis?

Dr. Sansing, MD, responds:
A TIA is a clinical diagnosis. A patient who has symptoms that are consistent with an area of the brain not functioning for a short time should be presumed to have had a TIA, even if all brain imaging is normal. Although an MRI is very good at detecting brain injury, it can miss small areas of injury, especially if blood flow was restored after only a few minutes or if the injury occurred in the brainstem (the back of the brain). Also, there are different scans that make up an MRI; some of them are better at showing injury a few days after injury, and some of them only show it very early after injury. So, it depends on what scans were done and when and how long blood flow was blocked. If a TIA is suspected based on the symptoms, the patient needs the tests for why it happened and not to be reassured by a normal MRI.

Ranae Asks:
I am 38 years old. I had a stroke in Nov 05. No high blood pressure or anything. Just when to bed on a Saturday night. I got up at 2am, when to the bathroom, when back to bed about three mins, later could no move my rigth side. Will my rigthside get better. I am still in therapy.

Dr. Sansing, MD, responds:
I'm sorry to hear that you had a stroke. Recovery takes a long time, and I'm glad to hear that you are still getting physical therapy. Although the most rapid period of recovery is often in the first few months, there is often improvement for as long as two years after the stroke. This is especially true in young people, like you. So don't lose hope -- you are just beginning your recovery. Keep working with the therapists and force yourself to use your weak side as much as you can.

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