tia vs als

i recently have been having episodes of slurred speech, increasin in frequency.  doctors have been doing a work-up for stroke/tia.  mri and mra have been ok except for a question of remote stroke in right frontal area.  i don'tthink my symptoms are vascular, but something like als. what do i do next?

[Neuro Forum]

Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with your doctor.

Without the ability to examine you and obtain a history, I can not tell you what the exact cause of your symptoms is. However I will try to provide you with some useful information.

Regaring the intermittent (off-and-on) occurrence of slurred speech, it is important to make a distinction between speech that is normal in content but abnormal in articulation (what is termed dysarthria) and speech that is abnormal in content (either there is difficulty in saying actual words, or the words come out in gibberish, what is termed aphasia). Either way, one of the first things that should be excluded if the history is fitting is a TIA, or transient ischemic attack, due to reduced blood flow to a part of the brain, whatever be the cause (whether from a narrowed artery in the neck or head, reduced blood flow due to changes in blood pressure or abnormal heart rhythm, or a clot coming from the heart). TIA needs to be thoroughly investigated as this could portend an imminent stroke, which is preventable with certain medication such as asprin and cholesterol medications and blood pressure control and smoking cessation etc. Even if an MRA does not show evidence of diseased blood vessels, an evaluation of the heart with echocardiography, and of the heart rhythym (to look for intermittent episodes of abnormal heart rhythm such as atrial fibrillation) is indicated if there is a concern for TIA.

Other causes of intermittent slurred speech could include seizures, effects of certain medications, drops in blood pressure with changes in posture, and certain disorders such as myasthenia gravis, a disorder at the nerve-muscle interface, which causes slurred speech after prolonged speech (and other symptoms of muscle fatiguability). ALS and other progressive neurologic disorders, typically do not cause intermittent (episodes) of slurred speech but rather constant and progressive slurred speech, in association with other symptoms that include but are not limited to difficulty swallowing, changes in voice, weakness of the head or limbs, and others.

Evaluation by a neurologist is recommended, for both stroke risk factor modifcation (given possible evidence of an old stroke on your imaging, there is risk for further strokes that can be reduced with appropriate therapy) as well of discussion of other possible causes to your symptoms.

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.