My patient was a thoughtful, reasonable woman of 45 who prided herself on keeping a cool head. She had been driving to work one day and realized she was having trouble with her vision. She had no pain, so she wasn't really alarmed. She pulled up to a stop light and put her hand over each eye individually. It was her right eye only that was involved, and it seemed to her that it was as if a curtain had come down over that eye. Just as she was observing this, the "curtain" rose again and her vision returned to normal. The whole episode lasted about 5 minutes. She continued on her way to work, making a mental note that she would tell her doctor about it the next time she saw him.
Several days later she had an episode where she suddenly dropped the papers she was holding in her left hand, and her whole left arm felt funny, like pins and needles. She decided to make that call to her doctor right then and there.
Fortunately, she did just that. She was not given an appointment for next week. She was told to call 911 and to come to the emergency room.
I saw her there shortly after her arrival. Her symptoms had all resolved, but in examining her, I heard a noise when I listened to the right side of her neck. We use the French word for noise, bruit, for this particular finding. Its importance in that it can sometimes indicate a blockage in one of the arteries to the brain. When paired with the symptoms she had experienced- the sudden visual loss in her right eye, and then the loss of strength and sensory problems in her left arm-this bruit was likely a key piece in the neurological puzzle. The artery producing this noise supplies the right eye as well as the part of the brain controlling the left side of the body. My patient was having the warning signs of a stroke. We call this a TIA-transient ischemic attack.
This patient was very fortunate to have come to the hospital in time. She commented afterward that she wishes she hadn't been quite so cool-headed when she had the problem with her vision. Any new neurological symptoms, even brief or painless ones, can be crucial indicators of an impending stroke. She realized how important it is to know these signs, which can include disturbances of vision, speech, sensation, strength or coordination.
This story had a happy ending. Further testing confirmed that there was a partial blockage of the artery in question. My patient underwent an operation called a carotid endarterectomy to actually clean out the blockage. She did well with this and, in the process has reduced her risk of future stroke. She has become a strong advocate for stroke prevention, and a presentation she made at work convinced a coworker not to wait when he developed slurred speech a few months later.
Mildred LaFontaine, M.D., is a neurologist based in Concord, N.H., for 18 years. Prior to that she was in private clinical practice in neurology in Philadelphia and was a clinical assistant professor of neurology at the University of Pennsylvania. She received her M.D. from Duke University School of Medicine in 1977 and completed her residency in neurology at the University of Pennsylvania. Her interests in neurology are varied and include stroke, movement disorders, memory loss and Multiple Sclerosis. Dr. LaFontaine believes that listening to the patient is one of the most important skills a physician can have, and that the doctor-patient relationship is a partnership where both the physician and the patient have important contributions to make in the journey toward enhanced health and well-being.
