TIA

A transient ischemic attack should be considered a major warning sign of an impending future stroke. Up to 10% of
people will experience a stroke within three months of TIA. Since there is no way of predicting that stroke-like
symptoms will resolve, the patient and family need to be educated should symptoms occur, they need to access
medical care emergently activating the emergency medical services system and calling 911.
If a stroke occurs, there is a very short period of time where the thrombolytic (clot busting drugs
like alteplase [TPA]), can be used to reverse a stroke. In most hospitals, the drug can only be given within 4 1/2
hours of onset of stroke symptoms. In that time frame, the patient needs to get to the hospital, the diagnosis needs
to be made, laboratory tests and head CT scans need to be performed, neurologic consultation needs to occur,
and the drug administered. The longer the delay, greater the risk that the drug won't work and that complications
such as bleeding into the brain will occur.
Specialized interventional radiologists can inject TPA directly into the clot that has blocked the blood vessel in the
brain. This can extend the time frame to six hours or longer, but currently this treatment is not widely available.
TIAs should be considered the equivalent of angina of the brain. In heart disease, angina is the heart pain that
warns of potential heart attack. When heart muscle is damaged, it cannot be replaced or repaired. Similarly, brain
tissue is at risk when there is decreased blood supply and it, too, cannot be replaced.

TIAs are often warning signs that a person is at risk for a more serious and debilitating stroke. About one-third of those
who have a TIA will have an acute stroke sometime in the future. Many strokes can be prevented by heeding the warning
signs of TIAs and treating underlying risk factors. The most important treatable factors linked to TIAs and stroke are high
blood pressure, cigarette smoking, heart disease, carotid artery disease, diabetes, and heavy use of alcohol. Medical help
is available to reduce and eliminate these factors. Lifestyle changes such as eating a balanced diet, maintaining healthy
weight, exercising, and enrolling in smoking and alcohol cessation programs can also reduce these factors.

TIA does no harm or permanent damage to the brain, and the symptoms soon go. However, a TIA indicates that
you have a tendency to form blood clots in your blood vessels or heart. Therefore, if you have a TIA you have a
higher-than-average risk of developing a larger blood clot which may cause a stroke or heart attack in the future.
(See separate leaflet called Myocardial Infarction (Heart Attack) for more information.)

Without treatment - about 1-2 in 10 people who have a TIA have a stroke within the following year. This
is much higher than the average risk of someone of the same age having a stroke who has not had a TIA.
The most risky time is within the first month following a TIA - which is why treatment is advised as soon as
possible after you have a TIA. Also, within a year of having a TIA, about 3 in 100 people have a heart attack
(myocardial infarction) due to a blood clot in a blood vessel of the heart.

With treatment - the above risks are reduced. For example, in one research study published in 2007, the
conclusion stated ... "Early initiation of existing treatments after TIA or minor stroke was associated with an
80% reduction in the risk of early recurrent stroke."

TIAs do not cause lasting damage to the brain.

However, TIAs are a warning sign that you may have a true stroke in the coming days or months. More than 10% of people who have a TIA
will have a stroke within 3 months. Half of these strokes happen during the 48 hours after a TIA. The stroke may occur that same day or at a
later time. Some people have only a single episode, and some have more than one episode.

You can reduce your chances of a future stroke by following-up with your health care provider to manage your risk factors.

Prognosis
Stroke is the second leading cause of death worldwide. Mortality rates are declining, however. Over 75% of patients survive a first stroke
during the first year, and over half survive beyond 5 years.
SEVERITY OF AN ISCHEMIC VERSUS HEMORRHAGIC STROKE
People who suffer ischemic strokes have a much better chance for survival than those who experience hemorrhagic strokes. Among the
ischemic stroke categories, the greatest dangers are posed by embolic strokes, followed by thrombotic and lacunar strokes. Hemorrhagic
stroke not only destroys brain cells but also poses other complications, including increased pressure on the brain or spasms in the blood
vessels, both of which can be very dangerous. Studies suggest, however, that survivors of hemorrhagic stroke have a greater chance for
recovering function than those who suffer ischemic stroke.

LONG TERM COMPLICATIONS AND DISABILITIES

Many patients are left with physical weakness and often have accompanying pain and spasticity. Depending on the severity of the symptoms
and how much of the body is involved, these impairments can affect the ability to walk, to rise from a chair, to feed oneself, to write or use a
computer, to drive, and many other activities.
FACTORS THAT AFFECT QUALITY OF LIFE IN SURVIVORS
Many stroke survivors recover functional independence after a stroke, but 25% are left with a minor disability and 40% experience
moderate-to-severe disabilities. The National Institutes of Health (NIH)'s stroke scale helps predict the severity and outcome of a stroke by
scoring 11 factors (levels of consciousness, gaze, visual fields, facial movement, motor functions in the arm and leg, coordination, sensory
loss, problems with language, inability to articulate, and attention).
Those patients with ischemic strokes who score less than 10 have a favorable outlook after a year, while only 4 - 16% of patients do well if
their score is more than 20.
FACTORS AFFECTING RECURRENCE
The risk for recurring stroke is highest within the first few weeks and months of the previous stroke. But about 25% of people who have a
first stroke will go on to have another stroke within 5 years. Risk factors for recurrence include:

Older age
Evidence of blocked arteries (a history of coronary artery disease, carotid artery disease, peripheral artery disease, ischemic
stroke, or TIA)
Hemorrhagic or embolic stroke
Diabetes

Alcoholism
Valvular heart disease
Atrial fibrillation

Global prognostic scales In stroke rehabilitation venues, the Orpington Prognostic Scale (OPS) [123,124]
and the Reding three-factor approach [125] are in wide clinical use.

The OPS includes assessments of arm motor function, proprioception, balance, and cognition, making it
easier to perform than the NIHSS. The OPS is better at predicting return of function than NIHSS in those with
mild to moderate stroke [123], possibly because balance is so critical to carrying out activities of daily living.

The Reding three-factor approach provides a useful way to gauge the speed and degree of recovery for an
individual patient [125]. Patients are divided into one of three groups:

Motor deficit only

Motor deficit plus somatic sensory deficit

Motor deficit plus somatic sensory deficit plus homonymous visual field deficit

Once the group is determined for the individual patient, their recovery can be compared with a cohort of similar
patients to estimate the probability of return to Barthel Index (table 3) score of 60. This level of function is a
useful benchmark because most patients with a Barthel Index score 60 are able to walk with assistance and
contribute to their activities of daily living; in addition, the likelihood of a supported discharge to the community
rises substantially. With a Barthel Index score of 100, a discharge to the community at a level of independence
becomes plausible, but requires adequate cognitive function.

A number of other prognostic models may be useful for predicting global outcome from acute ischemic stroke;
however, none of the current models is established as generally valid, and none is widely used in clinical
practice. These models include the ASTRAL score [126,127], DRAGON score [128], iScore [129,130], and
PLAN score [54]. These stroke prognostic models are intended to be easy to calculate from data available on
admission. However, they disregard information available from follow-up and testing, such as stroke etiology,
treatment, and complications, that has an important impact on outcome [62,131]. The course of stroke often
changes in the first days after onset, and assessment at later times (eg, from 1 to 10 days after stroke onset) is
likely to provide a more reliable prognosis [9].

Although prognosis among mechanically ventilated stroke patients is generally poor, a minority do
survive without severe disability. Prognosis can be assessed according to clinical presentation and
patient characteristics. There is an urgent need to better understand the marked variation in the care
of these patients and to reliably measure and improve the patient-centeredness of such decisions.