Witnessing a Possible TIA – Case Study

Surreal.  He was surrounded by cardiologists at a Cardiology Congress in Tokyo, Japan.  The speaker, an 80-year-old Caucasian male cardiologist, was giving a presentation when something went wrong. I looked around my seat, and we were all in a state of disbelief. As seconds ticked by, I was impatiently waiting for one of my colleagues to attend to the ailing speaker, but no one did. After speaking with several afterwards, they (cardiologists) did not immediately recognize the symptoms.

The Event:
It was May 2018.  The presenter was speaking in English, an acquired, non-natural language. His English was sharply accented, but intelligible, and he had a deep knowledge of the subject matter. After about 6 minutes into his presentation, the following happened:
  • He was unable to read his monitor, nor the overhead screen it was presented on.

  • His hand/eye coordination with the computer mouse went awry (the cursor went wild).

  • His speech was mumbled, unintelligible.

  • He was incoherent for ~4 minutes.

And then he somehow seemed to understand where he was in his presentation and stumbled through the next few screens until mercifully, the presentation ended. The stunned convention attendees did not ask any questions.

Approximately 4 hours later, this person appeared perfectly normal and actively engaged another presenter with insightful questions and banter.

What Happened? (possible diagnoses)
My guess: a TIA (Transient Ischemic Attack).  Unlike a stroke, TIA symptoms resolve within 24 hours.  Also, unlike a stroke, a TIA does not tend to kill brain tissue or cause permanent disabilities. The worries with a TIA are that it could turn into a stroke, or be an early warning sign for a full-blown stroke. The speaker did have a podium, but I do not recall seeing any left-sided weakness or facial drooping. The speaker’s age also aligns with TIA risk factors (it rarely happens in younger people).  I have no knowledge of his medical history, but given his age, he could have hypertension and possibly diabetes – both risk factors for a TIA.

Other specific symptoms which further indicate that he experienced a TIA include:
  • Weakness, numbness or paralysis in the face, arm or leg (typically on one side of the body)

  • Slurred or garbled speech - or difficulty understanding others

  • Blindness in one or both eyes - or double vision

  • Dizziness or loss of balance or coordination

  • Sudden, severe headache with no known cause

Although these symptoms are nearly identical to those seen in an ischemic stroke, they are experienced in a shorter duration and usually end a few minutes after the blood flow returns in the blocked artery. According to Mayo Clinic, they generally don’t cause any permanent brain damage unlike a true stroke. What’s interesting, is that symptoms can differ depending on what part of the brain was affected from the blockage.

Risk Factors:
Risk factors for ischemic strokes and TIAs both include: family history, age, sex, sickle cell disease and race. Those with family members who have experienced a stroke or TIA are at a much greater risk. Risk also increases with age, especially after 55. Men are more likely to experience them, but women are more likely to die from them. People with sickle-cell anemia are more likely to experience them because their irregular blood cells are more likely to stick together and clot. Black men and women have a higher chance of experiencing a stroke because of their higher predisposition to this disorder, as well as a higher prevalence of high blood pressure and diabetes, which I will dive into now. 

Besides high blood pressure and diabetes, the risk factors mentioned above can’t be controlled.  However, other ones can be by making healthy lifestyle choices. Higher blood pressure (>140/90 mm Hg), higher cholesterol, high levels of homocysteine and a high body mass index (BMI>25) all correlate to a higher risk of stroke or TIA. Also, those with cardiovascular disease, carotid artery disease, peripheral artery disease or diabetes have a higher risk, along with those who are inactive, smoke, drink, use drugs or don’t follow a healthy diet. Everyone should attempt to improve their overall health by minimizing the effects of these conditions, or by eliminating them all together, and by avoiding unhealthy activities. Unfortunately, the alteration of hormone balances that comes with ingesting oral contraceptives also increases the risk of TIA/stroke, so this should be discussed with one’s physician, especially when considering different forms of birth control. 

Other Possible Scenarios (alternative diagnoses):

1. Migraine: Approximately 20% of suspected TIA’s end up being migraines. However, migraines usually have a gradual onset and decline. A TIA usually starts abruptly, and is followed by a gradual offset (typically over minutes). Migraines also usually last 10-30 minutes, but can last several hours. TIA's almost always last under 1 hour.  The migraine time frame did not match the speaker’s episode. Migraines are also characterized by a severe throbbing pain located in the head, and accompanied by extreme sensitivity to light and sound. Attempting to continue the presentation would have been nearly unbearable for him. I never asked him what happened though, as that may have been inappropriate and certainly awkward.

2. Seizure: The normal duration of seizure is up to about 5 minutes.  This would almost perfectly match the episode the speaker had (~4 minutes).  However, there was no complete speech arrest for him, nor were there any involuntary movements. A seizure would have been much more frightening, and he likely would’ve collapsed and lost consciousness - which would have spurred people to help.  So, a seizure can be ruled out.

3. Syncope (temporary loss of consciousness due to reduced blood flow to the brain, or fainting): The normal duration of syncope is a few seconds, which is a lot less time than the speaker’s episode of ~4 minutes.  However, the symptoms do mimic TIA:
  • Dimmed vision

  • Muffled hearing

  • Retinal & cochlear hypoperfusion (possibly caused by postural hypotension)

4. Language Disturbance (an “isolated complete and brief speech arrest”): I can relate to this, as I try to speak Japanese and Spanish when abroad. Also, similar to this is a panic attack brought on by increased anxiety, however these victims are usually aware and able to recover quickly.

Kevin Fitzpatrick, MBA, has authored or co-authored >300 medical and disease-state tools. We specialize in cardio-metabolic tools and have created custom Stroke, CHF, CHD, Diabetes, Hypertension, ASCVD, AAA, PAD, and Arrhythmia risk calculators.

Brock Fitzpatrick is a senior at the University of Wisconsin, College of Letters and Science

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