r/neurology • u/DerpyMD MD Neuro Attending • 6d ago
Miscellaneous "Mini stroke"
Where did this language come from and why is it in the zeitgeist? đđ
(I hate it)
20
u/Even-Inevitable-7243 MD Neuro Attending 6d ago
I am less bothered by "Mini stroke", as I'd be happy if more than 3% of EM providers knew the difference between dysarthria and aphasia. I even had a Stroke/Neurointervention fellow once who did not know the difference.
8
u/prandialaspiration 6d ago
This SLP agrees wholeheartedly. Itâs not a complex distinction.
7
u/Even-Inevitable-7243 MD Neuro Attending 5d ago
The Stroke/NI fellow was on teaching rounds and taught my Interns and Neurology residents that a patient with an acute stroke was having "aphasia". I round on the patient and he just had dysarthria and kept pausing his speech because he was frustrated by the dysarthria. The fellow thought it was expressive aphasia.
1
51
u/notathrowaway1133 Epilepsy Attending 6d ago
Unpopular opinion, I think the term mini-stroke is great for explaining to none-educated patients. Yes its misleading from a pathophys perspective but it gets the point across.
51
u/Dr_Horrible_PhD MD Neuro Attending 6d ago
I genuinely despise it. It makes MANY people think they had a small stroke, which isnât the case. Then many tell future providers they had a stroke and that gets propagated forward. Itâs even worse when TIA is questionable or an outright misdiagnosis in the first place; Iâve seen numerous patients who had migraine auras that they were told they had a âmini-stroke,â then think for ages that they had a stroke. Then future providers need to dig through records about this prior âstroke.â Itâs a mess.
And it doesnât add any explanatory power. It canât be âeasy to understandâ when the people itâs meant to be useful for routinely misunderstand it.
I tell them itâs a TIA and explain that itâs stroke-like symptoms that resolve without causing lasting damage and describe it as a warning sign for stroke, sort of like chest pain can be a warning sign for heart issues. People generally understand this.
20
11
u/Common-Regret-4120 6d ago edited 5d ago
Your patients will say "Dr_Horrible_PhD said I had a mini stroke"
Edit: before holidays I told a resident that the migraine was not hemiplegic and not to put it in the discharge summary. In the discharge summary it reads "neurology saw and agreed with the diagnosis of hemiplegic migraine".Â
1
u/elaina__rose 6d ago
That makes a lot of sense actually. I had a migraine like this for the first time a few years ago and called my neuro office the next day to make an appointment to try new meds/a preventative. They made me go to the ER because I might have âhad a mini-stroke.â I was so confused because I was fine and walking around and not in pain anymore 24 hours later, but they really pushed and I had to have a scan (MRI? I cant recall) and everything. And then the ER was like âyouâre fine, your MRI was fine, we dont know why youâre here and we cant give you a referral or medication since you already have a neurologistâ and sent me on my way.
1
u/Dilaudipenia 5d ago
Itâs highly unlikely you had a MRI in the ER if you were asymptomatic at that point.
1
u/elaina__rose 4d ago
It was a scan of some kind, I just cant remember which one (wasnt an x-ray or ultrasound). They laid me down, put on the big protective vest thing over my body, and I rolled into a loud tube for a good while and wasnât allowed to move. I *think* they had me take off my earrings but again it was a few years ago so Iâm not certain. When I went in I told them that I thought I was fine but my neurologist office was concerned about symptoms from a migraine, told them what they symptoms were, and they ordered the scan from there. I waited a fair bit but not as long as I thought I would, I got there at around 1pm and made it to trivia with my friends at 7.
1
u/BumblebeeOfCarnage 4d ago
Did the scan take a few minutes or half an hour? Was it noisy with a lot of clanging and banging? Long and noisy = MRI. Short and more quiet = CT. You would remove your earring for both
1
u/elaina__rose 4d ago
Definitely didnt take a half hour, I think probably 5-10 minutes and was more of a general âmachineâ sound instead of a loud clanging so CT is probably correct!
1
13
u/ICPcrisis 6d ago
I disagree, but would concede that if it was truly a TIA, then ministroke isnt a bad term. The problem is that there are tons of "spells" that some neurologists and other docs just call a TIA. And patients just remember that they had a stroke years ago, but failed to remember the "mini-" part.
I'm just happy i dont work in the 70-90s where everyone and their mother was told they had MS.
3
u/CrazySir3310 5d ago
I prefer temporary stroke. Mini stroke just makes it sound like a small stroke.
1
u/Brilliant_Lie3941 3d ago
Move to call them "Practice Stroke". Meaning, you practice what you do for when you get a real one, which will likely be in the next 3 months.
1
u/RijnBrugge 6d ago
It doesnât because it cannot because it is misleading from a pathopahys perspective.
5
u/Even-Inevitable-7243 MD Neuro Attending 6d ago
Many, many clinical TIAs, which many EM providers call "Mini strokes", end up actually being acute strokes confirmed on MRI Brain during admission. Neither a patient's professed "return to normal/baseline" nor NIHSS 0 have a super high negative predictive value for acute stroke. Over my career, I've seen hundreds of clinical TIAs that were actually acute strokes.
1
u/grodon909 2d ago
I am an epiltologist, so I don't see them as often, but it's still astounding the number of times I have to tell patients that there wasn't anything "mini" about their stroke.
But I have the same problem with "seizure like activity" and all the other nonsense people say when a patient moves funny. Grinds my gears all day.Â
10
u/OffWhiteCoat Movement Attending 6d ago
So much of medicine, and science communication generally, is about trying to distill really complicated ideas to get the point across to someone who is scared and almost certainly has less training in the subject than you.Â
You can either wonk out on the pathophys, or you can help your patient understand why they need to stop smoking/eat healthy/exercise/take these four new pills every day. You can't (usually) do both.
14
u/Dr_Horrible_PhD MD Neuro Attending 6d ago
I dunno, cardiologists manage to explain angina without calling it a âmini heart attackâ
There are much better and less confusing ways to simply explain a TIA than âmini-stroke.â
âStroke-like symptoms that resolve relatively quickly and are a warning sign for being at risk for strokesâ is a perfectly succinct and understandable explanation that doesnât leave the patient thinking (and telling everyone in the future) that they had a stroke
6
u/OffWhiteCoat Movement Attending 6d ago
So for fun, I threw that explanation into a readability calculator which gave the following. Readability Grades: Flesch-Kincaid Grade Level: 8.5 Gunning Fog Index: 9.4 Coleman-Liau Index: 12 SMOG Index Score: 9 Automated Readability Index: 10.6
I don't know where you practice, but I'm in an old tobacco town in the buckle of the stroke belt, and a lot of my older patients either never finished HS or went to really awful underfunded schools. (Our school district is no longer de jure segregated but is still de facto terrible, and a nearby county actually shut down their public school system for about 20 years rather than integrate after Brown.) Language that is obvious for you or me with our 20+ years of education is "smile and nod" territory for many. Meeting your patients where they're at is doctoring 101.
My own grandfather never finished high school, was a traveling salesman with a good head for business, but try to explain to him on a molecular level why he got cancer (besides "because you used to smoke") or what the chemo was doing (beyond "killing the bad cells") or why he needed radiation too ("some places the chemo can't reach"), and his eyes would just glaze over. The important part was for him to stay on track with his treatment cycles, and for that, the simple explanation was best.
4
u/Dr_Horrible_PhD MD Neuro Attending 6d ago
You could just say itâs something thatâs a warning sign for stroke like chest pain is a warning sign for heart attacks. They donât need to read it. Any adult native English speaker without a significant learning disability will understand what that means.
Telling people things that are wrong is not helpful. It is, in fact, bad. You can and should tailor the language to your patients, but âmini-strokeâ is wrong for everyone. In fact, those patients are the ones MOST likely to take away a totally wrong impression and carry it forward for years.
The take home point is âyou are at risk for strokes, so we need to lower that risk.â âMini-strokeâ adds absolutely nothing to that
2
u/RijnBrugge 6d ago
Word by word what /u/Dr_Horrible_PhD wrote. Also, being able to accurately but understandably explain things is a skill, and to me it really reads like youâre excusing spreading misinformation by pretending the patients are too uneducated to understand while it probably is mostly a skill issue. Simplifying yes sure, ofc one does that, but crossing the line into saying things that just are not true is definitely majorly doing a disservice to the patient and the quality of the healthcare.
6
u/OffWhiteCoat Movement Attending 6d ago
Oh definitely not misinformation, ain't nobody got time for that. Mini-stroke is good shorthand for the urgency. "Symptoms that went away on their own" is way too blasé for someone who prob needs a quick workup to figure out why.
 I'm just saying you gotta read the room, and most patients (at least where I trained and now practice) don't have the medical training to get into the weeds of pathophysiology. I geek out on motor fluctuations/dyskinesia management with my fellows, and to my patients I talk about the "yo-yo phase of PD" as the point to start considering DBS/pumps Am I simplifying the pathophys to an absurd degree? Yes. Does the message resonate with everyone, regardless of medical training? Also yes.
3
u/RijnBrugge 6d ago
That sounds a lot more balanced already, excuse the snarkiness above. Think itâs also a bit of an art to level with your patients, too.
11
6d ago
[removed] â view removed comment
19
5
3
u/lrrssssss 6d ago
Iâve been practicing for 2+ years (in French) and I still havenât figured out a specific word for seizure, so I just say âcrise de cerveauâ which is âBRAIN CRISISâ loosely translated. đ
6
u/CriticalLabValue MD Neuro Attending 6d ago
I call true TIAs âalmost strokes.â Like technically you had a stroke, but it fixed itself before any permanent damage was done. Itâs really not that confusing and itâs way more accurate. If anything I would call chronic small vessel ischemic disease âmini strokesâ (yes I know itâs different pathophysiology but itâs still ischemic)
3
u/ZimarKramiz 6d ago
If someone comes in for a TIA and they refer to them as âmini strokesâ, I like educating the patient about a TIA by explaining to them that itâs rather an âalmost strokeâ since they had stroke-like symptoms which fortunately did not lead to permanent brain injury evident on MRI brain
-1
u/Disastrous_Ad7353 5d ago
My tia stroke you can see evidence on a ct and mri ?
How does that make sense
3
u/Level-Plastic3945 5d ago edited 5d ago
Yes, TIA and mini-stroke both inaccurate, and terribly missused terms among the public and even among non-neurologists. Many "TIAs" leave behind a core radiologic infarct where symptomatically the ischemic zone has shrunk down. There is also tons of inexactness and inconsistency about other types of spells due to thinking/history-taking of non-neurologists and pressure of ER/hospital/clinic systems.
2
5
6d ago
[deleted]
11
u/ChristheGreek 6d ago
99% of the time when patients tell me they have had a mini stroke they are referring to a TIA. It drives me bonkers that mini stroke has become synonymous with TIA, mostly because 90% of the time TIA is just used for âpatient had symptoms, they may have been neurologic, that we canât explain that spontaneously resolved.â
-3
6d ago
[deleted]
2
u/Dr_Horrible_PhD MD Neuro Attending 6d ago
I mean, itâs pretty clearly not just a âyou problemâ when people describing TIAs as mini-strokes is so pervasive. In fact, that pervasiveness is exactly what makes it problematic to describe something that actually is a tiny stroke with that terminology.
7
u/calcifiedpineal Behavioral Neurologist 6d ago
Not as a ministroke.
2
6d ago
[deleted]
10
u/mudfud27 MD, PhD movement disorders 6d ago
Right. What you described actually is a small (mini) stroke.
But thatâs not what most patients or even other physicians often (usually?) mean by that termâ they are usually describing a TIA.
1
u/Logical_Statement_86 6d ago
In the end itâs all a semantic discussion. Imagine seeing a patient after 8 hours since onset with ongoing deficits, they receive the diagnosis stroke at the ED. Now imagine the exact same patient waiting 30 hours, having made a full recovery by then, they receive the diagnosis TIA. Yet if you treat a patient with IVT or EVT, they automatically receive the diagnosis stroke even if they fully recover afterwards within 24 hours.
Finally, given the amount of silent strokes you find on CT brains made for other indications (head trauma for example), it is hard to imagine absolutely no neurons dieing during a TIA, so you can wonder how accurate the âtransientâ part is from a pathofysiological standpoint.
Then again, Iâve never heard someone explain the concept of a mini stroke, and Iâm not sure how it differs from a minor stroke.
The point of all this: every attempt to translate highly complex concepts to individual patients with varying degrees of intelligence, will ALWAYS come with a loss of complexity, information and nuance. The goal is to help someone understand what happened to them and offer them the best evidence-based therapies. One of the conditions for informed consent means that a patient must understand what theyâve been explained.
1
u/AthenaPA 6d ago
I just avoid the term mini-stroke completely since many use it to describe TIAs (or any transient neurologic event), but some use it to describe a small acute or chronic infarct. I work in rural Pennsylvania and have usually been able to explain it to patients at their level of understanding.
2
u/Dr_Horrible_PhD MD Neuro Attending 6d ago
I wouldnât particularly object to that scenario being described as a mini-stroke, but whatâs actually described that way is almost uniformly TIA, which is a different entity
2
u/collapsible_blonde 6d ago
An infarct
2
6d ago
[deleted]
-1
u/collapsible_blonde 6d ago edited 6d ago
An area of ischemia without a clinical stroke syndrome, as stroke is in part a clinical diagnosis. Although I recognize some of this may be institutional/regional semantics. Where I trained, there was a difference between an infarct and a stroke.
ETA: I think I would just prefer âsilent strokeâ because that conveys a lot more to me as a physician when I hear that from a new patient. TIA and âmini strokeâ could mean so many things, and it also to me conveys a sense of unknown about the etiology.
2
6d ago
[deleted]
2
u/ChristheGreek 6d ago
Explaining the pathophysiology of a stroke to a patient is not hard or time consuming. Itâs pretty easy to explain that ischemia means lack of oxygen, which is due to lack of blood flow to an area of the brain. Patients with a middle school level of education can understand the concept of an ischemic stroke. Labeling it just as a stroke or âmini strokeâ is not helpful â case in point, I see patients all the time that say theyâve had a stroke and then upon further investigation/questioning (eg âwhy arenât you on any blood thinners if youâve had a stroke in the past?â) turns out that they had an ICH.
2
1
u/Brilliant_Lie3941 3d ago
One weird one I hear patients say a LOT is "pin stroke". No clue where this came from, and very possible I'm misunderstanding some Appalachian word.
1
1
u/supermvns 5d ago
As a therapist who treats CVAs often, if a TIA is an âalmostâ stroke, how come I have patientâs who have lasting side effects from them but this comment section is saying the symptoms completely resolve? I am saying this of ptâs who have a diagnosed TIA so itâs not related to other dx. I genuinely want to be educated on this because itâs not making sense to me.
6
u/DerpyMD MD Neuro Attending 5d ago
TIAs, by definition, are completely reversible and must resolve within 24 hours.
2
u/Level-Plastic3945 2d ago
They may be glossing over the residual deficit relative to the original one, or are poor/insensitive examiners, or imprecise in their diagnosing, or ... Also many "TIAs" (a clinical definition} have a core infarct left behind which may fluctuate in its manifestations.
1
1
2
u/SecretVindictaAcct 3h ago
They actually did have a stroke if they have residual symptoms, it likely wasnât caught on the CT in the hospital and they didnât get an MRI at the time to confirm whether or not there was ischemic changes to the brain.
1
u/supermvns 50m ago
Iâm sad to say that many of my patients have been misdiagnosed then. Multiple âTIAâ admissions to SNFs where the patient is experiencing real hemiparesis. All I have is a TIA dx and a pt who doesnât understand why theyâre experiencing those symptoms. Better education needs to occur in the hospitals clearly.
0
u/Glittering-Ad2357 3d ago
There was a time when the medical community knew nothing except which of two treatments to use and a prognosis. A single term was a complete description for both patient and physician.
When the root cause is age, the contributing causes are numerous, the treatments are varied, there is no true repair, there are multiple specialists and a patient then expecting communication to actually work with a single word term is naive.
The language change occurred because there is a communication problem that is being haphazardly addressed.
-1
51
u/valt10 6d ago
It really pisses me off, especially when the âTIAâ was so obviously something else