Transcription:
Understanding Transient Ischemic Attacks

Bill Klaproth: So when it comes to stroke, what is the difference between a stroke and a TIA, which is a transient ischemic attack often called a mini-stroke? Well, let's find out what Dr. Ilkcan Cokgor, a neurologist and a member of the medical staff at MarinHealth.

This is The Healing Podcast brought to you by MarinHealth. I'm Bill Klaproth. Dr. Cokgor, thank you so much for your time. It is always great to talk with you. So can you tell us what is the difference between stroke and a TIA?

Dr. Ilkcan Cokgor: So the TIA means transient ischemic attack in other words. It is a temporary interruption in blood flow to the area of the brain. Any small or large vessel, there is a blood clot stopping the blood flow to that part of the brain, but it doesn't last long enough to cause permanent damage. We call it a TIA clinically, if the patient's symptoms resolve within 24 hours, less than 24 hours. And stroke is total interruption of blood flow to the area of the brain that lasts long enough to cause permanent damage. And it is either from a blockage of a blood vessel or even the rupture of the arteries, which we call it hemorrhagic stroke, but it is still under the category of stroke. The brain gets deprived of its nutrients and oxygen. Transient ischemic attack and stroke symptoms are very similar to each other.

Bill Klaproth: So a TIA is kind of like a partial blockage that will then resolve itself within 24 hours. That's considered a TIA.

Dr. Ilkcan Cokgor: That's correct.

Bill Klaproth: And then you said the symptoms are similar with a stroke. So can you explain that to US?

Dr. Ilkcan Cokgor: Sure. Both the transient ischemic attack and the stroke symptoms are caused by a blockage of an artery where the region of that brain tissue didn't get enough blood supply. So mechanism of action is exactly the same, so the symptoms are the same. It will cause one sided or both sided weaknesses, numbness, tingling, vision changes, speech problems, balance, gait problems, coordination problems, drooling and drooping of one side of the face, altered mental status. All of that are the symptoms for both the TIA and the stroke.

Bill Klaproth: And then how do you treat a TIA? So the patient will come in, you'll do the history on the patient. And then if it's found out to be a TIA, how do you treat that?

Dr. Ilkcan Cokgor: We treat them exactly the same because there is a 10% chance that if a TIA goes untreated, the patient will have a real stroke within three months. So we admit these patients actually to the hospital and treat them as if they had a stroke. We do CT. CT angio of the brain and the neck, brain MRI, 2D echo with bubble, to look for that hole in the heart or the clot in the heart. We do blood work to look for their cholesterol levels, sugar levels and lipid levels besides the cholesterol like triglycerides. We look for smoking, alcohol, other the risk factors, genetic risk factors. We put them on telemetry, look for their heart rhythms, rule out any arrhythmias, so we do the workup exactly the same as a stroke patient.

Bill Klaproth: And then do you administer tPA then if it's an ischemic stroke or a TIA?

Dr. Ilkcan Cokgor: So, this is how it works. Yes, the patient may have a TIA. If we wait long enough, let's say we wait for 24 hours, the patient's symptoms resolve and we call it a TIA. However, we don't have the luxury to wait that long because it will be too late to administer a tPA. That's why we don't know when the patient shows up to ER, within the four and a half hours of time initial onset of the stroke symptoms, we don't know if they will turn out to be a stroke or a TIA, so we administer tPA no matter what, and it will help the symptoms to resolve hopefully, even there's a partial blockage. So it doesn't hurt the patient. It helps, if anything.

Bill Klaproth: Right. So if you see that it is a partial blockage, not a full blockage, you still will administer tPA. And just so our listener knows, TPA is the drug to help dissolve the blood clot, correct?

Dr. Ilkcan Cokgor: That's correct. Tissue plasminogen activator, which lyses the blood clot inside the blood vessel.

Bill Klaproth: So that's how you will treat the TIA. And it's also often called a mini-stroke, isn't that right? A TIA is a mini-stroke?

Dr. Ilkcan Cokgor: So TIA actually clinically is not called a mini-stroke. But sometimes the patient's symptoms resolve, altogether gone, but yet we do an MRI and we do see ischemic changes, which is acute in the MRI. That's when we call it a mini-stroke and/or silent stroke, but the patient's symptoms will recover in 24 hours.

Bill Klaproth: So you said a TIA is often a precursor to a more serious stroke. So what should patients look out for or do after a TIA to try to ward off or prevent a more serious stroke?

Dr. Ilkcan Cokgor: They should definitely not sit on their symptoms. They should come to the emergency room or call their doctors. Let's say the symptom lasted only 10 minutes and that's why they didn't go to the emergency room, they still need the full stroke workup and they need to be on a blood thinner. If the patient is diabetic, they need to be adjusted, the medicine needs to be adjusted. If they are not on any blood thinner, like aspirin, platelet agents like Plavix or Aggrenox or arrhythmia patients needing anticoagulant, they need to pay attention to the blood thinners. If the patient has these symptoms and not put on any blood thinners, their stroke risk will increase dramatically. And that's why they should definitely call their doctors, let them know about the symptoms and get a workup right away.

Bill Klaproth: Right. So we've been talking about the difference between a stroke and a TIA, but there's two main different types of stroke, right? There's an ischemic stroke and a hemorrhagic stroke. Can you tell us the difference between those two?

Dr. Ilkcan Cokgor: Sure. Ischemic stroke means the blood vessel is intact, the blood flow got interrupted with a clot. The hemorrhagic stroke, unfortunately, the blood vessel burst or ruptured or leaking blood and caused fresh blood to go to the brain tissue. Hemorrhagic strokes can cause severe edema. They are more life-threatening. Unless they stop bleeding, the patient actually gets an extension of the hemorrhagic stroke because the skull is thick, it doesn't expand. And that's why the blood will put pressure on the brain and will cause more clinical symptoms.

Bill Klaproth: Okay, thank you for that explanation. And then treatment for ischemic stroke as we've been talking about generally is the administration of tPA, that medicine that will help dissolve the blood clot, correct? For a hemorrhagic stroke, what is the treatment for that?

Dr. Ilkcan Cokgor: Hemorrhagic stroke is just opposite of the ischemic stroke. We try to reverse the hemorrhage. If the hemorrhage is caused by blood thinners like strong blood thinners, like the anticoagulants, we have some medications to reverse these anticoagulants and we sometimes give fresh plasma to reverse them. And we do stop every blood thinner that the patient is taking, including over-the-counter Advil, Aleve-like anti-inflammatory medications. Some supplements like fish oil, omega-3, vitamin E can thin the blood, so we stop those supplements as well. If we cannot reverse the clotting factors, if the patient is not on any blood thinner, but the hemorrhagic stroke happened because of high blood pressure, then we treat the blood pressure aggressively.

We usually admit these patients to the intensive care unit. We make sure that the patient is not having respiratory problems. If necessary, we intubate the patients. We check their heart rates, make sure the blood pressure gets under control and do supportive care. There are some times severe hemorrhages that need surgery. Neurosurgeons may have to go in and evacuate the blood or decompress the brain by taking part of the skull out. So there are surgical options and medical options to treat these patients.

Bill Klaproth: Yeah, I was just going to ask you, it sounds like there's different levels of hemorrhagic stroke. Some require immediate surgery. And others, it sounds like it could be a slow bleed where you're going to treat it with the treatment options you just talked about.

Dr. Ilkcan Cokgor: That's correct. It depends on the cause of the hemorrhage. And sometimes even there is traumatic stroke, that trauma can cause a bleed in the brain, but bleeds can cause ischemia and you can even see stroke plus bleed in the brain in an MRI.

Bill Klaproth: Got it. So then what is the recovery for someone with an ischemic stroke? And what is the recovery like for somebody with a hemorrhagic stroke?

Dr. Ilkcan Cokgor: Unfortunately, recovery is more prolonged, more difficult, more devastating for the hemorrhagic stroke. Both of them can cause permanent disability. It depends on the size of the ischemic stroke. If it is from a large vessel occlusion, if it is affecting a very important part of our brain, like frontal lobe, temporal lobe, occipital lobe, which means it affects vision effect, affects movement, it affects thinking, these ischemic strokes can take longer to heal. We usually recommend physical, occupational, speech therapy to both of these strokes, hematologic or ischemic. Hemorrhagic stroke causes more permanent damage and they may have disability forever. Ischemic strokes, we constantly continue with physical and occupational therapy at least one year up to two years before we think it is going to stay as permanent damage.

Bill Klaproth: Right. And I think it is important to mention that ischemic stroke actually accounts for 87% of all strokes, so the majority of strokes that people have are ischemic. Is that correct?

Dr. Ilkcan Cokgor: That's correct. Luckily, hemorrhagic strokes are much less common, 15 to 20%, and 87% is the ischemic stroke. Now in TIA, incidence is one in actually 1000 people US population. It is higher depending on the race, ethnicity, socioeconomy of different countries.

Bill Klaproth: That makes sense. Well, as we wrap up, Dr. Cokgor, is there anything else you want to add as we talk about the difference between a stroke and a TIA?

Dr. Ilkcan Cokgor: Please take the TIA as seriously as a stroke. Any patient even having one-sided weakness, numbness, vision problems, balance, gait, drooling, speech difficulty, even for five minutes should definitely contact their doctors, should get workup very fast. In fact, you're welcome to go to the emergency room. Tell them what happened to you. Even you have a normal neurological exam right then, we usually admit these patients. We usually do 24-hour monitoring and full workup in the hospital and put them on the blood thinners, appropriate blood thinners for the patient. So anybody with TIA symptoms should go to emergency room.

Bill Klaproth: Well, Dr. Cokgor, thank you so much. You've really left us with a lot of great information about this and we are much more informed now. So thank you so much for your time. We really appreciate this.

Dr. Ilkcan Cokgor: Thank you for the opportunity. And I hope it helps many of us in the future.

Bill Klaproth: Absolutely. Thank you again.

Dr. Ilkcan Cokgor: Thank you.

Bill Klaproth: And once again, that's Dr. Ilkcan Cokgor. And for more information, please visit mymarinhealth.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is The Healing Podcast brought to you by MarinHealth. I'm Bill Klaproth. Thanks for listening.