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Neurology (Expert Forum)
TIA
Answered by
CCFNeuroMD JT, MD - Neurology/Epilepsy, Neurology/General
Cleveland - OH
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TIA
by SL345, Feb 19, 2008 08:40AM
54 years old with h/o hyperlipidemia. Very scary incident of transient loss of left-sided peripheral vision x 1.5 hours. No other neurologic symptoms. CT scan and MRI (x 2 over 6 month period), MRA, transcranial and carotid ultrasounds all wnl. Currently on Lipitor 10 MG and ASA 81 MG. What do you think happened? How concerned should I be? Any further recommendations, please. Thank you.
Doctor's Answer
by CCFNeuroMD JT, MD, Feb 27, 2008 10:01AM
, Feb 27, 2008 10:01AM
To: SL345
Dear SL345,
Thank you very much for your question. I am happy to address the issues that you pose, although it is important that you recognize that my impression is based entirely on the information you have provided in your posting and is by no means a replacement for an office visit with a neurologist. Diagnosis is contingent on detailed history and physical exam and as such, the following information should be considered solely for educational purposes.
The episode you described in which you had a temporary loss of your left peripheral visual field indeed sounds very much like it could have been a TIA. I am assuming that in your ophthalmologic evaluation, they did in fact confirm that you have not sustained any permanent damage to the optic nerve head as optic nerve damage can also produce visual field deficits. It would be important to clarify whether the left visual field was absent in both eyes vs. just one. If present in both eyes, this is suspicious for a process affecting the occipital cortex on the right side, the part of the brain responsible for the left visual field. If the visual defect only was present in one eye, then the problem is more likely involving the optic nerve.
Assuming that this is what we would call a "left homonymous hemianopsia", that is, a left visual field deficit involving both eyes, this implicates the right occipital cortex (at the back of the brain) as the culprit. The blood vessels most likely to produce visual symptoms include those constituting the posterior circulation: posterior cerebral artery, basilar artery, and vertebral artery. Atherosclerotic disease ("hardening of the arteries") may sometimes lead to buildup of plaque which can break of and embolize to the brain, although it sounds like you have looked at these vessels with an MRA and transcranial dopplers (TCD's).
One other common source for emboli/clots is the heart. A blood clot in the heart can propogate to the blood vessels in the brain and produce a stroke or TIA. You did not mention above that you had an echocardiogram which is a test that looks for such clots. I would recommend a transesophageal echocardiogram (TEE) which involves placement on a small probe down the esophagus where it can be placed just adjacent to the heart for an optimal view. This test is not only good for looking at blood clots on the heart valves or within the heart, but can also detect something called a patent foramen ovale (PFO). The foramen ovale is a communication between the right and left heart which is present normally during embryologic development but should close up. About 20% of the population is estimated to have a PFO where that communnication remains open; in most, this is asymptomatic but in younger patients with stroke, it provides a route for blood clots to travel from the right to the left side of the heart. During a TEE, the technologists are able to look for blood flow between the right and left heart suggesting a shunt through a PFO. Should a PFO be present, there are procedures available for closure.
Indeed, the symptoms you describe, while suggestive for TIA, are non-diagnostic. As one of the other forum readers suggested, there is a chance that this was an atypical form of migraine. Another possibility is severe hypertension producing a hypertensive emergency, although you do not convey a history of hypertension.
In young individuals such as yourself with few risk factors for stroke (only hyperlipidemia), one thing we would look for is a tendency to form blood clots. At the Cleveland Clinic, we have something called a hypercoaguable panel that looks at various indices linked with increased risk for blood clots. In addition, if you had the described event while on aspirin 81mg and lipitor 10mg, most stroke doctors would choose to escalate antiplatelet and cholesterol therapy to Aspirin 325mg and a higher dose of lipitor- these doses vary quite a bit between practitioners.
Again, without having the ability to conduct an exam or review your records and MRI, it is difficult for me to give you any definitive answers. I hope the above information was helpful to you. Thank you for your inquiry!
Sincerely,
JBT, MD
Thank you very much for your question. I am happy to address the issues that you pose, although it is important that you recognize that my impression is based entirely on the information you have provided in your posting and is by no means a replacement for an office visit with a neurologist. Diagnosis is contingent on detailed history and physical exam and as such, the following information should be considered solely for educational purposes.
The episode you described in which you had a temporary loss of your left peripheral visual field indeed sounds very much like it could have been a TIA. I am assuming that in your ophthalmologic evaluation, they did in fact confirm that you have not sustained any permanent damage to the optic nerve head as optic nerve damage can also produce visual field deficits. It would be important to clarify whether the left visual field was absent in both eyes vs. just one. If present in both eyes, this is suspicious for a process affecting the occipital cortex on the right side, the part of the brain responsible for the left visual field. If the visual defect only was present in one eye, then the problem is more likely involving the optic nerve.
Assuming that this is what we would call a "left homonymous hemianopsia", that is, a left visual field deficit involving both eyes, this implicates the right occipital cortex (at the back of the brain) as the culprit. The blood vessels most likely to produce visual symptoms include those constituting the posterior circulation: posterior cerebral artery, basilar artery, and vertebral artery. Atherosclerotic disease ("hardening of the arteries") may sometimes lead to buildup of plaque which can break of and embolize to the brain, although it sounds like you have looked at these vessels with an MRA and transcranial dopplers (TCD's).
One other common source for emboli/clots is the heart. A blood clot in the heart can propogate to the blood vessels in the brain and produce a stroke or TIA. You did not mention above that you had an echocardiogram which is a test that looks for such clots. I would recommend a transesophageal echocardiogram (TEE) which involves placement on a small probe down the esophagus where it can be placed just adjacent to the heart for an optimal view. This test is not only good for looking at blood clots on the heart valves or within the heart, but can also detect something called a patent foramen ovale (PFO). The foramen ovale is a communication between the right and left heart which is present normally during embryologic development but should close up. About 20% of the population is estimated to have a PFO where that communnication remains open; in most, this is asymptomatic but in younger patients with stroke, it provides a route for blood clots to travel from the right to the left side of the heart. During a TEE, the technologists are able to look for blood flow between the right and left heart suggesting a shunt through a PFO. Should a PFO be present, there are procedures available for closure.
Indeed, the symptoms you describe, while suggestive for TIA, are non-diagnostic. As one of the other forum readers suggested, there is a chance that this was an atypical form of migraine. Another possibility is severe hypertension producing a hypertensive emergency, although you do not convey a history of hypertension.
In young individuals such as yourself with few risk factors for stroke (only hyperlipidemia), one thing we would look for is a tendency to form blood clots. At the Cleveland Clinic, we have something called a hypercoaguable panel that looks at various indices linked with increased risk for blood clots. In addition, if you had the described event while on aspirin 81mg and lipitor 10mg, most stroke doctors would choose to escalate antiplatelet and cholesterol therapy to Aspirin 325mg and a higher dose of lipitor- these doses vary quite a bit between practitioners.
Again, without having the ability to conduct an exam or review your records and MRI, it is difficult for me to give you any definitive answers. I hope the above information was helpful to you. Thank you for your inquiry!
Sincerely,
JBT, MD
I had an episode several months ago that included (all one sided symtoms) of loss of peripheral vision, facial numness, tingling/numbness/weakness in arm and difficulty speaking. My neurologist says it is either a TIA or migraine w/o headache. (I had scans to rule out aneurysm, etc) I like to think migraine without headache because I'm only in my 30's , but who knows?
Did the opthamalogist rule out problems with your retina as well? How was an ocular migraine ruled out? Isn't it caused by a spasm