Nonfocal Symptoms in Patients with Transient Ischemic Attack or Ischemic Stroke: Occurrence, Clinical Determinants, and Association with Cardiac History

Abstract

Background: Transient ischemic attacks (TIAs) accompanied by nonfocal symptoms are associated with a higher risk of cardiovascular events, in particular cardiac events. Reported frequencies of TIAs accompanied by nonfocal symptoms range from 18 to 53%. We assessed the occurrence of nonfocal symptoms in patients with TIA or minor ischemic stroke in a neurological outpatient clinic in terms of clinical determinants, cardiac history, and atrial fibrillation (AF). Methods: We included 1,265 consecutive patients with TIA or minor stroke who visited the outpatient clinic. During these visits, we systematically asked for nonfocal symptoms. Nonfocal symptoms included decreased consciousness, amnesia, positive visual phenomena, non-rotatory dizziness, and paresthesias. Relative risks for the presence of nonfocal symptoms in relation to clinical determinants, AF, and cardiac history were calculated. Results: In 243 (19%) of 1,265 patients, TIA or minor ischemic stroke was accompanied by one or more nonfocal symptoms. Non-rotatory dizziness, paresthesia, and amnesia were the most common nonfocal symptoms. In patients with an event of the posterior circulation or obesity, the qualifying TIA or minor stroke was more frequently accompanied by nonfocal symptoms, and in patients with significant carotid stenosis, nonfocal symptoms occurred less frequently. AF was related only with amnesia. Conclusion: Nonfocal symptoms are present in one out of 5 patients with TIA or ischemic stroke, in particular when located in the posterior circulation. A cardiac history or AF was not directly related to nonfocal symptoms. A heterogeneous etiology is suggested.

Unconsciousness as the main nonfocal symptom of anterior circulation transient ischemic attack: A case report

“…Notably, unconsciousness as a nonfocal symptom of TIA is more frequent in cases of posterior circulation occlusion and less frequent in anterior circulation occlusion (e.g., internal carotid artery or MCA), and it is often associated with poor outcomes. [ 7 ] This association between nonfocal symptoms and the posterior circulation could be because some nonfocal symptoms defined in previous studies may be manifestations of ischemia in the posterior circulation. A single-center study focusing on posterior circulation found that symptoms such as dizziness, nausea, vomiting, LOC, bilateral limb weakness, and hearing loss were frequently observed in patients with ischemia in the vertebrobasilar artery territory.…”

“…Since the highest risk for stroke is in the first 48 hours following TIA symptom onset, it is critical to identify the mechanisms of TIA and initiate appropriate treatment at the earliest. [ 7 ] Notably, almost one-third of TIA patients also experience nonfocal symptoms, including reduced consciousness, confusion, nonrotatory dizziness, and unsteadiness; however, TIA diagnosis primarily hinges on the sudden onset of focal neurological symptoms, such as aphasia, dysarthria, hemiparesis/hemiplegia, and facial paralysis. [ 4 , 5 ] Moreover, non-rotatory dizziness, paresthesia, and amnesia are the most commonly seen nonfocal symptoms of TIA.…”

“…[ 4 , 5 ] Moreover, non-rotatory dizziness, paresthesia, and amnesia are the most commonly seen nonfocal symptoms of TIA. [ 7 ] Transient LOC (TLOC) is defined as a state of real or apparent LOC with loss of awareness, characterized by amnesia for the period of unconsciousness, abnormal motor control, loss of responsiveness, and a short duration. [ 8 ] In cases of insufficient cerebral blood flow (CBF), the brain can maintain its function only for a few seconds.…”

Managing Patients With Transient Ischemic Attack

“…21 Nonrotatory dizziness is the most common nonfocal symptom. 22 In another study of 1,850 patients with probable or definite transient ischemic attack, 177 (9.6%) had isolated atypical symptoms (eg, isolated diplopia, dysarthria, dizziness, sensory symptoms in a single limb or one side of the face). 23 Of the 177 patients, 18.1% had a major embolic source and 5.6% had high-grade arterial stenosis.…”

Application of neutrophil to lymphocyte ratio to identify CT-negative cerebral infarction with nonfocal symptoms

“…From January 1, 2018, to December 31, 2018, adult patients ≥40 years old with nonfocal stroke symptoms presenting to the Emergency Department (ED) and having a head CT were included (Figure 1). Nonfocal stroke symptoms were defined as common stroke confusing symptoms including altered consciousness, dizziness, headache, and memory loss, as reported in previous studies (18)(19)(20). In our hospital, patients with nonfocal stroke symptoms were firstly evaluated by an ED neurologist.…”