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Don't ignore signs of a ministroke

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 percent blocked. The doctors did surgery the next day to clear out the fatty blockage, and Yagin, 65, 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 United States 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." 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 nation. 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 ministroke — 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 percent of those patients suffered a far more damaging stroke, about half of these within the first two days after the ministroke.

Johnston says the results show how devastating a misdiagnosis or delay in treatment can be. Referring to the case of Yagin, 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.

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. Hooper, now 56, 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, 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, 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."