Dr. Roach: Recurrent TIAs cause for great concern
Dear Dr. Roach: I have a 69-year-old woman friend who has been having TIAs for over a year. She averages one a week. Doctors are puzzled. They last 15 to 20 minutes, with drooling and numbness on the left side. I am very worried about what is going to happen. Is this normal for an older person? Aren’t TIAs a prelude to a major stroke? What do you think should be done?
Dear Anon.: A transient ischemic attack is a temporary loss of function of the nervous system. It is similar to a stroke, but a stroke causes permanent damage to cells of the nervous system. (In a stroke, symptoms may improve despite permanent damage, and this is due to the nervous system’s ability to find new ways to perform the functions of damaged areas.) A TIA is worrisome in itself, since even a brief episode of poor blood flow to the brain may cause permanent damage. However, TIAs are worrisome also because they predict a higher likelihood of developing a stroke, which can range from minor damage to catastrophic loss of brain function and death.
TIAs and strokes, unfortunately, are all too common, but I would never characterize them as normal. A TIA should be looked at as an emergency: One colleague of mine said it’s “chest pain of the brain,” and people with TIAs should be rapidly evaluated. The evaluation can be complex, but generally includes imaging studies of the brain, usually an MRI or CT scan, and an evaluation of the blood flow to the brain by MRA, CTA or ultrasonography. Often, the blood vessels of the neck and chest need evaluation, as does the heart itself; it can send blood clots to the brain, causing recurrent TIA. Abnormal heart rhythm, such as atrial fibrillation, can be a cause for TIA.
I don’t know how extensive the evaluation of your friend has been thus far. If she already has had an extensive workup done, it is reasonable to consider some less-common possibilities. Sometimes seizures can appear clinically similar to TIAs, as can multiple sclerosis and other related conditions.
If your friend would like, perhaps you could accompany her to her next visit, so you can get a better idea of how thorough her medical team has been, and consider a fresh look. Continued TIAs are very worrisome to me.
Dear Dr. Roach: I’m 85 years old, and my doctor wants me to go for another bone scan. I’m reluctant to go through with the test. At my age, I don’t think medication will do me any good. I take calcium and vitamin D.
Dear E.C.: I do understand when patients tell me that they don’t want to undergo unnecessary tests and procedures due to their age, but some tests make more sense than others. The reason I would recommend that you follow your doctor’s advice in this case is that the test itself is simple and not dangerous, and because it’s fairly likely that at age 85, you may have osteoporosis. If you do have osteoporosis, there is effective treatment (both medication and not), even at age 85, that will reduce your likelihood of a fracture. I have seen fractures lead to long-term suffering too many times.
Email questions to ToYourGoodHealth@med.cornell.edu.