May is Stroke Awareness Month. But are transient ischaemic attacks (TIAs), or ‘mini-strokes’ really that transient and are they being overlooked by both clinicians and policy makers?
Over 510,000 people have had a TIA in the UK and incidence is rising. TIA is similar to full stroke; however, loss of blood flow to the brain is transient and symptoms are short-lasting (less than 24 hours).
It is because symptoms resolve rapidly that people who experience TIA are assumed to recover fully and have no ongoing impairments. People who have TIA are known to have an increased risk of a full stroke and, therefore, treatment of TIA is focused on stroke prevention. However, a growing body of evidence suggests that some people have long-term impairments after TIA.
Here at the University of Birmingham, our research team systematically searched the literature on this topic and found some evidence to suggest a relatively high prevalence of cognitive impairment and depression after TIA and minor stroke. However, the evidence was limited and a large study was needed to understand the long-term impact of TIA.
Following this, we conducted a study using general practice medical records of 9,419 TIA patients and 46,511 people of the same age and gender (controls). We looked at people who had consulted their general practitioner for anxiety, depression, fatigue or cognitive impairment and found that TIA patients were more likely to consult for all of these impairments compared to controls.
Our findings are further supported by the results of a survey conducted by the UK’s leading stroke charity, the Stroke Association, in which over 70 per cent of people reported long-term effects after suffering from TIA.
In response, the Stoke Association declared that the long-term impact of TIA should be a priority area for research, and consideration for healthcare professionals treating TIA patients. This message was reiterated by the Parliamentary Under-Secretary of State for Health when the Stroke Association’s TIA campaign findings were debated in Parliament. Ongoing impairments are also described by TIA patients on the website HealthTalk.Org which describes people's experiences of health.
Treatment of TIA was revolutionised upon the realisation that it is a risk factor for a full stroke. Once thought of as a benign condition, TIAs are now considered a medical emergency and dedicated TIA clinics have been set up to enable rapid treatment of patients with a suspected TIA.
However, the short-lasting symptoms are misleading and, until now, ongoing impairments after TIA have not been recognised. There is a need to raise awareness of these impairments among patients, healthcare professionals and policy makers.
Unanswered questions remain and future research should establish best practice in order to detect and treat ongoing impairments after TIA. This may be a case of enabling access to existing services or may require more specialised interventions which could extend beyond healthcare providers, such as media campaigns. The ‘Act F.A.S.T’ (Face Arms Speech Time) media campaign, launched in England in 2009, has shown to be successful in improving identification of stroke symptoms and emergency admissions.
The ‘transient’ characterisation of TIA has been challenged by our research findings. Undetected and untreated impairments post-TIA could reduce quality of life, impact on patients’ return to work/social activities and hinder stroke prevention.
Given the high and increasing prevalence of TIA, the holistic effects of this condition should be considered a high priority for researcher, patients, clinicians and policy makers. The current guidelines for TIA do not extend beyond initial diagnosis and management. There is an urgent need to reassess these guidelines to include the long-term impact of TIA.
Dr Grace Turner
Research Fellow, Institute of Applied Health Research, University of Birmingham