June 7, 2005
Treating Ministrokes Is Crucial to Preventing More Devastating Strokes
By THOMAS M. BURTON
Staff Reporter of THE WALL STREET JOURNAL

Jose Yagin woke up feeling dizzy the morning of March 18, and his left
side was numb. He went to a nearby emergency room in San Francisco, but
doctors sent him home without treating the dangerous condition
afflicting him: He was having a ministroke.

The symptoms soon went away, but returned a week later. This time, a
friend took him to the University of California at San Francisco, a
stroke center. There, an imaging test quickly revealed that the carotid
artery on the right side of his neck -- a key artery feeding the brain
-- was more than 90% blocked. The doctors did surgery the next day to
clear out the fatty blockage, and Mr. Yagin, 65 years old, has felt
fine since.

There is a growing concern among neurologists that, in many cases,
patients and other doctors aren't recognizing or acting on the symptoms
of a ministroke, a warning sign that often means a larger, more
devastating stroke is on its way. Strokes are the leading cause of
disability in the U.S., and the No. 3 cause of death. Many of these
major strokes are preceded by a ministroke, in which symptoms such as
numbness and vision changes often vanish within an hour or two. Because
these symptoms go away, people often ignore them and some doctors miss
them, misdiagnosing symptoms as a migraine, low blood pressure, a heart
attack, anxiety or a seizure.

"These patients may get sent home with an aspirin," says Mark J.
Alberts, director of the stroke program at Chicago's Northwestern
Memorial Hospital. "This sends the wrong message, that this isn't a big
deal." Dr. Alberts says patients suffering from ministrokes at
Northwestern usually are hospitalized, just as they are with a major
stroke.

Officially, ministrokes are called "transient ischemic attacks" or
TIAs. The word "ischemic" means that oxygen flow to the brain is
blocked, usually by a blood clot and fatty plaque in an artery. Brain
tissue dies by the minute. The only difference between a full-fledged
stroke and a ministroke is the severity and the persistence of
symptoms: A ministroke's symptoms tend to disappear on their own,
typically in minutes or within one to two hours. Symptoms can last up
to 24 hours, but that is unusual.

Unlike a heart attack, strokes often appear with modest symptoms that
can be easy to ignore. Occasionally there can be a headache. Typical
symptoms include numbness or weakness in the face, arm or leg, often on
one side. Sudden difficulty speaking or a partial loss of vision or
double vision also can arise.

"If someone has a numb hand, and they woke up with it, they'll say,
'Maybe I slept on it,' " says Joseph Broderick, chairman of neurology
at the University of Cincinnati College of Medicine. He says that if
this numbness persists for five or 10 minutes or more, "that isn't
sleeping on it funny, and it requires urgent attention."

Neurologists estimate that there are up to 500,000 ministrokes annually
in the U.S. That compares to 700,000 full-blown strokes a year,
according to the American Stroke Association.

Treatment after ministrokes could include surgery to remove blockages,
and drugs to reduce the tendency of blood to clot, such as Plavix and
Aggrenox. It is critical that patients get evaluated immediately, since
the underlying cause of the mini-stroke -- such as a heart arrhythmia
causing clots -- may well produce a far more major stroke soon in which
large amounts of brain tissue die.

S. Claiborne Johnston, director of the stroke service at UCSF,
conducted a study in 2000 that showed just how urgently ministrokes
should be treated. He and colleagues studied 1,707 patients who had
ministrokes identified by emergency doctors at 16 Kaiser Permanente
hospitals in northern California. Within three months, 10.5% of those
patients suffered a far more damaging stroke, about half of these
within the first two days after the ministroke. Dr. Johnston says the
results show how devastating a misdiagnosis or delay in treatment can
be. Referring to the case of Mr. Yagin, Dr. Johnston says, "Mr. Yagin
took his symptoms seriously, but when he arrived at the first hospital
they weren't taken seriously."

One way for people to get top-notch stroke care is to find out before a
stroke occurs what hospital in their region is a stroke center, with
personnel trained to diagnose and treat stroke quickly. The Joint
Commission on Accreditation of Healthcare Organizations is in the
process of certifying such hospitals. See a list of current stroke
centers by state, or it may be obtained by calling JCAHO's customer
service number, (630) 792-5800.

Often, patients' own failure to recognize symptoms is the main problem.
William D. Hooper, of New Hope, Pa., had just come home from a bike
ride on April 25, 1999, when he noticed his left arm was numb up to his
elbow. Mr. Hooper, now 56 years old, also felt exhausted and noticed
that part of his face had grown numb. He was so dizzy he had to lie
down. But he was in denial that anything was seriously wrong with him
and continued to go to work for several days.

By the time he finally visited a cardiologist who quickly diagnosed a
ministroke, Mr. Hooper, who ran an electronic funds-transfer business
in New York, had lost brain function. He was confused enough that he
was doing things like pouring orange juice into the coffee pot. He
couldn't read road maps.

After rehabilitation, Mr. Hooper's cognitive problems have improved
significantly, though his energy level fell enough that he took early
retirement. During his treatment, he met former professionals who had
strokes that have incapacitated them. "Most people don't realize how
devastating it can be," he now says. "I was lucky."

http://www.jcaho.org/dscc/dsc/certified+organizations/certified+organizations-di
sease.htm#primestroke

Primary Stroke Center

Arkansas
Sparks Regional Medical Center

California
Good Samaritan Hospital
John Muir Medical Center
Kaiser Foundation Hospital - Santa Clara Medical Center
Kaiser Foundation Hospital-Santa Teresa
Mercy General Hospital
Mercy San Juan Medical Center
Mt. Diablo Medical Center
Stanford Hospital and Clinics
UCLA Medical Center
UCSF Medical Center
University of California, Irvine Medical Center
University of California- San Diego Medical Center

Colorado
Centura Health - Littleton Adventist Hospital
Swedish Medical Center

Connecticut
Hartford Hospital
Yale - New Haven Hospital

Florida
Bay Medical Center
Fawcett Memorial Hospital
Florida Hospital
Memorial Hospital West
Memorial Regional Hospital
Morton Plant Mease Healthcare
Parrish Medical Center
Shands Jacksonville Medical Center
Tallahassee Memorial HealthCare, Inc.
Tampa General Hospital

Georgia
Atlanta Medical Center
Grady Health System
Gwinnett Hospital System, Inc.
Medical College of Georgia Health, Inc.
Memorial Health University Medical Center
Piedmont Hospital, Inc.
St. Joseph's/Candler Health System
St. Mary's Health Care System, Inc.

Hawaii
The Queen's Medical Center

Illinois
Advocate Health Care
Northwestern Memorial Hospital
OSF Saint Francis Medical Center

Iowa
Mercy Medical Center - Sioux City

lndiana
Columbus Regional Hospital
Deaconess Hospital
Parkview Hospital, Inc.
St. Vincent Hospitals and Health Services

Louisiana
Ochsner Clinic Foundation

Kentucky
Jewish Hospital
University of Kentucky Hospital
University of Louisville Hospital

Massachusetts
Caritas St. Elizabeth's Medical Center

Maryland
Johns Hopkins Bayview Medical Center
The Johns Hopkins Hospital
University of Maryland Medical Center

Michigan
Borgess Medical Center
Bronson Methodist Hospital
Saint Joseph Mercy Oakland
Sparrow Hospital
Spectrum Health
University of Michigan Health System - MMC

Minnesota
Fairview Southdale Hospital
North Memorial Medical Center
St. John's Hospital
St. Joseph's Hospital
Woodwinds Health Campus

Missouri
Lester E. Cox Medical Center
Research Medical Center
St. John's Regional Health Center
Saint Luke's Hosptial of Kansas City

Montana
Deaconess Billings Clinic
St. Vincent Healthcare

Nebraska
The Nebraska Medical Center

New Jersey
Hackensack University Medical Center
Holy Name Hospital
The Valley Hospital
Virtua Memorial Hospital Burlington County

New York
Albany Medical Center
Good Samaritan Hospital
Ellis Hospital
Kaleida Health-Millard Fillmore Gates Hospital
Lutheran Medical Center
Maimonides Medical Center
Rochester General Hospital
Stony Brook University Hospital

North Carolina
Carolinas Medical Center
Duke University Hospital
Forsyth Medical Center
High Point Regional Health System
Presbyterian Hospital
Rowan Regional Medical Center
University of North Carolina Hospital

Ohio
Akron General Medical Center
Cleveland Clinic Foundation
HMHP - St. Elizabeth Health Center
Lakewood Hospital
Marymount Hospital
The MetroHealth System
Miami Valley Hospital
The Ohio State University Hospital
Riverside Methodist Hospital
University Hospitals of Cleveland

Oregon
Legacy Health System
Providence St. Vincent Medical Center
Rogue Valley Medical Center

Pennsylvania
Abington Memorial Hospital
Hospital of the University of Pennsylvania
Lancaster General Hospital
Lancaster Regional Medical Center
Lehigh Valley Hospital
Nazareth Hospital
UPMC Presbyterian Shadyside

South Carolina
Spartanburg Regional Healthcare System

Tennessee
Skyline Medical Center

Texas
Brackenridge Hospital
East Texas Medical Center Tyler
Memorial Hermann Hospital
Seton Medical Center
St. David's Hospital
St. Luke's Episcopal Hospital

Utah
University of Utah Hospital and Clinics

Virginia
CJW Medical Center
Sentara Hospitals Norfolk
University of Virginia Health System

Washington
Harborview Medical Center
Sacred Heart Medical Center
Southwest Washington Medical Center
Swedish Health Services, Stroke Program
Virginia Mason Medical Center

West Virginia
St. Mary's Medical Center

Wisconsin
Froedtert Memorial Lutheran Hospital
St. Vincent Hospital
Theda Clark Medical Center