Stroke–let us talk about it more

It is the start of the New Year and I want to begin by wishing all the readers of my blog a very happy and healthy New Year 2013. May you all be blessed with not only a healthy brain but also a healthy mind!.

I decided that my first post in the New Year 2013 should be on strokes and more importantly on how to recognize a stroke in a timely fashion and how to prevent it. After all a stroke prevented is a brain saved.

So let us begin without delay. Keeping things simple the best way to describe a stroke is to compare it to a heart attack. A heart attack occurs when one of the main arteries of the heart suddenly gets blocked. The sudden lack of blood flow leads to ischemia of the heart (basically the part of the heart supplied by that blood vessel does not get blood/oxygen and if the blocked artery is not opened/ recanalized in time irreversible death of cardiac muscle/tissue occurs). Something similar happens during a stroke and hence sometimes strokes are referred to as brain attacks. A blood vessel in the brain either gets blocked (ischemic stroke) or ruptures (hemorrhagic stroke) and if not opened in time the part of the brain supplied by that blood vessel perishes. The signs and symptoms of the stroke depend upon which part of the brain is involved.

Warning signs of a stroke:

1. Sudden onset of weakness  in the arm and leg on one side of the body (for example abrupt onset of motor weakness in the right arm and leg usually indicates ischemia/lack of blood flow or hemorrhage involving the left side of the brain). That said strokes may be more subtle or unusual in their presentation–weakness in only one arm or one leg, weakness in one arm and contralateral face and so forth.

2. Sudden onset of numbness (loss of sensation but no marked weakness) on one side of the body. Again presentation may be more unusual–abrupt onset of numbness one side of face or just in one arm.

3. Sudden onset of vision problems–double vision or loss of vision in one eye or loss of vision in one half/part of visual field.

4. Sudden onset of difficulty walking or balance–unable to walk in a straight line, dizziness (not all dizziness is stroke though).

5. Sudden onset of speech difficulty–either unable to speak (words are mumbled, not clear, language difficulty), unable to comprehend speech.

6. Sudden onset of complete loss of hearing in one ear (rare form of stroke).

7. Sudden onset of a combination of the above symptoms-usually this is the case.


One of the major problems with stroke is that frequently the symptoms and signs are very subtle and may be ignored by the patient and his family/friends. By the time the patient seeks medical attention, the stroke is already completed (remember when it comes to stroke–TIME IS BRAIN) and the damage is already done. In the case of a heart attack the signs are hard to ignore–sudden onset of squeezing chest pain along with sweating and a sinking sensation. Patients are forced to go to the hospital and seek attention. On the other hand the brain is far more quieter when it suffers a brain attack–no pain, no sweating just quiet suffering of the ischemia.

So what to do when you or someone close to you is suffering a stroke? The most important thing is not to delay seeking attention. You can only be helped if you reach the hospital in a timely fashion ideally within the first hour to 90 minutes of the stroke.  So seek attention at once. It is better to reach the hospital and be told that you misread your symptoms and did not suffer a stroke rather than reach late when nothing can be done to help you apart from supportive care.

So let us start the New Year 2013 by preventing strokes. Remember your brain is your best friend. Protect him, nourish him, take care of him.


Nitin K Sethi, MD


I had a stroke like episode—what do I do?

I had a stroke like episode—what do I do?


Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065




I frequently see patients admitted to the hospital for evaluation of a suspected stroke like episode. Most of these patients are “normal” with no neurological signs and symptoms (the presenting symptom has invariably resolved by the time of their admission to an acute care facility).

So what are these stroke like episodes which scare patients and doctors alike leading to admission to a hospital and invariably a battery of tests including but not limited to MRI scans of the brain? Well some may be as vague as an episode of sudden dizziness, difficulty walking or weakness in the arms and legs, others are more restricted-an episode of difficulty speaking (I could speak but my words did not come out right or my speech was slurred as if I was drunk), loss of vision in an eye and so on.

When patients present to the ER or a doctor’s office with a history of such symptoms, they are frequently advised admission to rule out a possible stroke. When people think of stroke, they usually think of someone with weakness of the arm and leg but stroke signs and symptoms can be more subtle. Many patients have what we refer to as transient ischemic attacks (TIAs) prior to the stroke. As the name suggests, TIAs are transient (short lived) episodes of ischemia to the brain. Let me try to explain a TIA with the aid of an example. Let us assume a clot (entangled platelets and cholesterol crystals) breaks from the heart and goes up to the brain via the carotid artery (the carotid artery is one of the main arteries carrying blood to the brain). As it goes up further and further, it may get lodged in the ophthalmic artery (the ophthalmic artery is a branch of the carotid artery and supplies the retina of the eye). Now if the ophthalmic artery gets blocked by the clot there is no blood supply to the retina with resulting loss of vision in that eye (patients frequently complain of a black curtain descending in front of their eye). If the clot breaks by itself and dissolves the vision comes back (we call this transient monocular blindess—transient blindness in one eye). There you have suffered a transient ischemic episode.

There can be other types of TIAs which can involve different blood vessels in the brain and present with a myriad of signs and symptoms such as dizziness, double vision and difficulty speaking. So what is so important about TIAs?

Well put in simple language a TIA may be a warning sign of a future stroke (and by future, I mean in the NEAR future). It is a sign that all is NOT well with the blood vessels of the brain or the heart (either the vessels are slowing getting narrowed or the heart is not functioning well and throwing up small blood clots into the brain). TIAs thus should be aggressively and thoroughly investigated.


What are the stroke risk factors?

How can they be modified?

Does the patient need to be on any blood thinners?


As I frequently explain to my patients and their families









Warning signs of an impending stroke

I want to lay stress on the warning signs of a stroke. We all need to be aware of these as a stroke can strike anyone anywhere and with stroke time is brain. The sooner the stroke is recognized and help is sought the better is the outcome.

So let us get to the heart of the topic. The following are some of the warning signs of an impending stroke/ stroke in evolution:

1) Sudden onset of speech difficulty. Either unable to speak or unable to comprehend speech (the patient can speak but cannot understand, so whatever he speaks makes no sense. We call this jargon speech). At times the problem with language can be more subtle: unable to name things (we call this nominal aphasia or anomia), the speech is slurred (we call this dysarthia).

2) Sudden onset of weakness in one arm or leg usually of the same side. For example weakness in right arm and right leg or in the left arm and left leg. This weakness may be prominent and the patient may not be able to move the arm and leg at all or it may be more subtle.

3) Sudden onset of numbness in one arm or leg usually of the same side. Numbness is hard to define and patients may use words like “weakness”, “tightness”, “dead feeling” or “my one side feels as if I slept on it”.

4) Sudden onset of facial weakness. One side of the face usually starts to sag, the smile is crooked when the patient attempts to smile and the patient may drool from the angle of the mouth.

5) Sudden onset of gait problems: the patient is unsteady and falls when attempting to walk. The balance is off. Patient is clumpsy and appears “drunk”.

6) Sudden onset of visual problems: patient may have an episode of transient loss of vision in one eye ( I felt as if a curtain decended in front of my eye). We call this transient monocular blindness and this is a TIA (transient ischemic attack). Patients may also complain of a field cut (unable to see one part of the visual field).

7) Acute loss of hearing in one ear especially in the elderly (this is a rare sign of a stroke).

Nitin Sethi, MD

Transient ischemic attacks or TIA’s

Let us talk about transient ischemic attacks or TIA’s here. What does it mean when your doctor tells you that you had a TIA?

TIA or transient ischemic attack as the name suggests means that one has an episode of transient ischemia to the brain. Kind of like a mini-stroke except that for it to be called a TIA, the neurological deficits should reverse completely. Let me explain this further. Suppose you have an episode of sudden weakness of the right side of the body (arm and leg) and at the same time, your speech is off. This presentation is mostly likely due to ischemia (lack of blood flow) in the left middle cerebral artery of the brain. Now this can act out in 2 ways. One you are recover completely, often within a few minutes to an hour at most. That means the ischemia was transient and that you are not left behind with any neurological deficits (no weakness and speech is back to normal). This would then be called a TIA involving the left middle cerebral artery.

The second possibility is that you do not recover at all, or do recover to some extent (after been treated in the hospital for acute stroke). Here the patient has stroked out. If you do an MRI of the brain, you shall see evidence of acute stroke. In a TIA, the imaging shall be normal as the recovery is complete.

So now that we understand what a TIA means, let us talk about the different types of TIA’s. One of the most common TIA is what we call transient monocular blindess or Amaurosis Fugax. This is a special type of TIA in which there is sudden lack of blood flow into the ophthalmic artery (branch of the internal carotid artery in the neck). As there is lack of blood flow in the artery which supplies the retina, patients notice sudden onset of loss of vision in one eye (remember I said monocular). Ususally they describe it as if a curtain suddenly descended in front of that eye. This monocular blindness lasts for a few seconds to minutes and then goes away.

One can have other types of TIA’s depending upon which blood vessel in the brain has a sudden episode of ischemia. So you have patients who present with history of transient weakness in an arm or leg, transient speech difficulties, transient numbness in an arm or leg, transient episode of dizziness or unsteady gait etc etc.

So are TIA’s important and do they need to be treated is the next question? Usually a TIA shall affect the patient and make him or her visit the ER. Some patients though may ignore the episode, since now they are back to normal and just go on with their lives.

A TIA is a warning sign for stroke. It usually is a sign that a stroke is imminent. The brain has suffered an episode of dysfunction even though transient. Here in lies the importance of recognizing a TIA and seeking medical attention for it. Studies have shown that major strokes may soon follow a TIA.

What to do if you have a TIA?

1) well first things first it is important to recognize a TIA and give it its due importance. If you are having stroke like symptoms call for help and dial 911 and be taken to the nearest hospital for evaluation. You do not know at the onset whether this is going to be a TIA and that you shall recover completely without any intervention or that you are going to stroke out. Remember time is brain, the more time you waste, the more likely you shall suffer damage to the brain from a stroke.

2) If you are having a TIA, it is likely that the symptoms shall have abated by the time you reach the ER. Well and good, as you rather have a TIA than a stroke.  When patient’s present to the ER with a TIA, doctors usually admit them for a thorough stroke evaluation. We have a unique opportunity to try to identify your risk factors for stroke and modify them, so that you do not have a future stroke. Your doctor may run many tests on your brain (MRI, carotid dopplers to look to see if your neck vessels are patent) as well as on your heart ( as some strokes and TIA’s come from the heart. Tests like holter monitor and ECHO).

We can also prescribe you medications to make your blood thin, medications like aspirin which may reduce the risk of a future stroke.

So remember to recognize a TIA and seek help promptly. A stroke prevented is a brain saved.

Dr. Sethi