How many mini strokes can a person have?

Preventing stroke after transient ischemic attack

From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Foothills Medical Centre, Calgary, Alta.

Correspondence to: Dr. Michael Hill, ac.yraglacu@dmllih
Copyright © 1995-2011, Canadian Medical Association

Stroke is a syndrome that can have either an ischemic or hemorrhagic cause. It is now clear that transient ischemic attack and minor ischemic stroke are highly predictive of a subsequent disabling ischemic stroke within hours or days. The critical clinical problems for physicians and nurse practitioners who evaluate these patients are to identify that the patient has had a stroke or transient ischemic attack and to stratify risk to determine if the patient requires rapid intervention to prevent recurrent stroke.

Diagnosing transient ischemic attack and minor ischemic stroke is not easy. Transient ischemic attacks are sudden. Although maximal symptoms occur at onset, it is a historical diagnosis since patients usually have no clinical signs by the time they are evaluated. Most transient ischemic attacks last 15 minutes or less. 1 Persistent symptoms or signs, however minor, imply a diagnosis of minor stroke. However, this technical distinction is rarely made by clinicians in routine practice or in the current stroke literature.

Common mimics of minor stroke or transient ischemic attack include migrainous aura, simple partial seizures and somatization. Stroke is the most common sudden neurologic event affecting adults; ischemia should be the default diagnosis when there is uncertainty. Symptoms are related to the area of the brain that is dysfunctional rather than to the cause of the dysfunction, making diagnostic inference difficult. Imaging is helpful, particularly diffusion-weighted magnetic resonance imaging, in which a positive result rules in the diagnosis of ischemia. A fast magnetic resonance protocol for stroke consisting of an axial diffusion-weighted image, axial fluid-attenuated inversion recovery imaging and axial gradient-recalled echo imaging (to detect hemorrhage) takes less than 10 minutes of imaging time and could be made available in all large hospitals in Canada. A normal magnetic resonance image does not rule out a diagnosis of ischemia, but provides confidence that the immediate risk of stroke is low. 2 , 3

Diagnosing transient ischemic attack identifies a patient who is at risk for subsequent stroke. The risk of stroke after transient ischemic attack is somewhere between 2% and 17% within the first 90 days. Among patients with transient ischemic attack, one in five will have a subsequent stroke (the most common outcome), a heart attack or die within one year. 4 , 5 Recurrent stroke can occur in one of two ways: 1 the initial stroke or transient ischemic attack progresses and worsens, 2 with ischemia evolving in the initial vascular territory; or a subsequent ischemic event occurs (e.g., a new embolic event) in the same or new vascular territory. Each situation depends on the mechanism of the initial event and the residual vascular patency.

A high proportion of strokes are due to embolic (arteroembolic or cardioembolic) occlusion of intracranial arteries. Early assessment of intracranial and extracranial vessels is critical to assessing risk. Patients with persistent intracranial occlusions have a four-fold increase in risk of developing recurrent stroke. 6 Stroke caused by arteroemboli from large atherosclerotic arteries (e.g., extracranial carotid or vertebral artery) can recur early after the initial event. These causes can be quickly identified with imaging of the intracranial and extracranial arteries. Lacunar syndromes are more challenging because the small penetrating arteries are too small to see using current imaging technology.

Cardioembolic stroke events tend not to recur early, and there is no clear evidence that anticoagulation prevents recurrence within the first two weeks post-event; therefore, the cardiac work up can be done as an outpatient.

Understanding the mechanism and vascular diagnosis involved in transient ischemic attack and stroke allows a rational approach to early intervention. This is not afforded by the ABCD2 score (age, blood pressure, clinical features, duration of symptoms and diabetes), which relies on clinical risk factors, and explains why the ABCD2 is largely an ineffective screening tool. The ABCD2 score was never designed to be used as a screening tool. Indeed, the initial studies used to develop and validate the ABCD2 score showed that it had only moderate discriminative value. 7 In this issue of the CMAJ, Perry and colleagues show that the score has insufficient sensitivity and specificity to be of use in the urgent evaluation of patients. 8

It is possible that the failure to show a reasonable discriminative value for the ABCD2 score is due to improvements in stroke care; 9 , 10 transient ischemic attack and minor stroke are being treated more aggressively. The ABCD2 score was developed using data from populations that did not receive hyperacute stroke prevention. Because outcomes have improved with early treatment, any tool for identifying risk will need to adapt to the changing prevalence of poor outcomes.

The ABCD2 score has raised awareness about the importance of identifying transient ischemic attack and minor stroke as a medical urgency requiring same-day assessment and management. The most important prognostic component of the ABCD2 score is the “C” for clinical symptoms. 11 Motor and speech symptoms, when present, increase the probability that the patient has truly had brain ischemia. Isolated sensory events are more likely to be due to alternate causes of acute symptoms, such as migrainous aura, a simple partial seizure or somatization. 12

The approach to caring for the patient with acute, sudden, neurologic symptoms that have resolved is first to make the correct diagnosis and then to stratify risk so that appropriate decisions regarding triage and treatment can be made.

Imaging of the brain and extracranial and intracranial blood vessels (aortic arch to vertex) can be done with magnetic resonance angiography, but higher resolution imaging is available with computed tomography angiographs. 13 Persistent arterial occlusions (partial or complete), protruding thrombus in the artery, lacunar syndromes, significant carotid artery disease, all appropriate to the predicted relevant ischemic region of the brain, warrant admission to a hospital or clinic for same-day urgent assessment.

Treatment follows diagnosis. All patients should receive a loading dose of antiplatelet medication. Low-dose acetylsalicylic acid is the usual course of treatment. Patients with new onset of atrial fibrillation without a persisting vascular occlusion can be given treatment with anticoagulant medications and sent home. In Calgary, our approach to treatment is based on the mechanism of the event and vascular patency, but there are many patients for whom treatment remains generic because there is no specific vascular diagnosis, the diagnosis of transient ischemic attack is uncertain, or the immediate diagnostic work-up is inadequate. There is a great need for therapeutic trials in this area. The FASTER trial 14 suggested that double-antiplatelet therapy might be helpful, and the POINT trial (clinical trial number > NCT00991029) may definitively answer whether such an approach is useful. However, several questions remain. For example, we do not know how to manage blood pressure acutely or how quickly carotid intervention should be done.

Stroke management is becoming more complex and clinical rules are no longer sufficient. The diagnosis of a stroke syndrome, once made, implies the need to investigate the vascular mechanism that caused it. The ABCD2 score has raised awareness. Imaging has elevated understanding. Therapeutic trials are next.

Key points

Transient ischemic attack and minor stroke are highly predictive of a subsequent disabling stroke within hours or days of the first event.

The risk of subsequent stroke after a transient ischemic attack is between 2% and 17% within the first 90 days after the initial event.

How many strokes can a person survive?

There is no exact answer as to how many strokes someone can have and survive. However, the more strokes a person has, the higher the risk of damage to the brain. Brain damage affects someone’s chances of survival.

However, many other factors can also influence a person’s chances of surviving a stroke, including how soon they receive treatment.

Stroke is a leading cause of death in the United States, but it is not always fatal. Around 795,000 people in the U.S. have a stroke each year.

In 610,000 of these cases, it is a person’s first stroke, while the remaining 185,000 have had a previous stroke. Of these total stroke cases, 137,000 people die each year.

Read on to learn more about stroke and survival rates.

There is no defined limit to the number of strokes a person can have without dying. However, each stroke injures the brain, which can cause lasting damage.

Brain cells need a constant supply of blood and oxygen to stay alive. Therefore, when something causes a blockage, the cells begin to die within minutes . This may result in disability, depending on the part of the brain it affects.

If the brain tissue cannot get enough blood and oxygen for too long, a person can die. The more strokes someone has, the greater the risk for this to occur. However, with early treatment, the chances of survival improve.

The Centers for Disease Control and Prevention (CDC) say that people who get to the hospital within 3 hours of the first symptoms of stroke often experience less disability after 3 months than those who receive delayed medical attention.

Having multiple strokes appears to elevate a person’s risk of having another stroke. It also reduces their likelihood of survival.

A 2022 study analyzed data from 313,162 people in Australia and New Zealand. The participants had an average age of 73 years. The researchers found the following survival rates after an initial stroke:

The risks of having another stroke are different for people who have had a ministroke, or transient ischemic attack (TIA).

A 2016 study found the following rates of stroke in people who had recently had a TIA:

• 1.5% within 2 days
• 2.1% within 7 days
• 2.8% within 30 days
• 5.1% within 1 year

Overall, around one in four stroke survivors will go on to have another stroke.

There are two broad types of stroke, and they each carry a different level of risk.

A hemorrhagic stroke occurs when blood leaks from an artery in the brain. In contrast, ischemic strokes occur when blood clots or other particles block a blood vessel, depriving part of the brain of oxygen.

The 2022 study found that having a hemorrhagic stroke carried a greater risk of death and having another stroke than having an ischemic stroke.

Additionally, a 2018 study found that, 5 years after having a stroke, 70.6% of people who had had an ischemic stroke had died or become completely dependent on caregivers. In the case of intracerebral hemorrhage, this figure increased to 79%.

The CDC says that a person’s risk of having a stroke doubles every 10 years from the age of 55. That said, one in seven strokes occur in people aged 15–49 years.

The 2022 study also found that people aged at least 85 years were over seven times more likely to die from a stroke than those aged 18–54 years.

However, one 2019 study from the Netherlands involved 18–49-year-olds who had had their first stroke. Their risk of survival compared with the general population stayed low for up to 15 years after the stroke.

The U.S. has significant health disparities between racial and ethnic groups, including healthcare for stroke. Even though many strokes are preventable, the following groups have higher mortality rates than white people:

• Black
• Hispanic
• Native American
• Native Alaskan
• Hawaiian Natives
• Pacific Islander

Several factors contribute to this, but unequal healthcare is a key cause. This includes:

• difficulty accessing healthcare
• receiving lower-quality healthcare
• lower levels of health insurance coverage

Several factors can increase a person’s risk of dying from stroke or having another stroke.

The CDC says that more females than males experience stroke and that females of all ages are more likely to die from stroke than males. Pregnancy and hormonal birth control can influence the risk.

A person is also more likely to die from stroke or have another stroke if they have certain health conditions. These include:

• atherosclerosis
• irregular heartbeat
• diabetes

A 2022 study analyzed stroke data from Denmark. The researchers found that 13.7% of people with atrial fibrillation had very severe strokes in comparison with only 7.9% of people without atrial fibrillation.

There is no safe number of strokes a person can have, and no set limit on how many someone can have before a stroke is fatal. The more strokes an individual has, the higher the likelihood of lasting damage or death.

One in four people who have had a stroke will have another. However, many factors influence the risk, and 80% of strokes could be preventable. If a person has concerns about having multiple strokes, they can speak with a doctor about what they can do to lower the risk.

Last medically reviewed on January 31, 2023

• Stroke
• Vascular
• Cardiovascular / Cardiology
• Neurology / Neuroscience

How we reviewed this article:

Medical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations. We avoid using tertiary references. We link primary sources — including studies, scientific references, and statistics — within each article and also list them in the resources section at the bottom of our articles. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

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• Ekker, M. S., et al. (2019). Association of stroke among adults aged 18 to 49 years with long-term mortality.
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Why You Need to Call 911 in the Event of a Mini-stroke

Mini-stroke, also known medically as a transient ischemic attack (TIA), is a warning sign that a person is at risk for a more serious and debilitating stroke. The risk of stroke after transient ischemic attack is somewhere between 2% and 17% within the first 90 days. About a third of people who experience a mini-stroke go on to have a major stroke within a year*. Mini-stroke is a medical emergency and you need to call 911 immediately. If you had a mini-stroke, talk to your doctor about a stroke prevention plan to make this mini-stroke your last.

What is a mini-stroke?

Mini-stroke occurs when there is a temporary lack of blood flow to the part of the brain, causing stroke-like symptoms that usually resolve within 24 hours. This condition is also known as a transient ischemic attack (TIA).

Blood clots forming in the brain are the leading cause of a mini-stroke. However, mini-stroke can also be caused by high blood pressure, atherosclerosis, carotid artery disease, diabetes, or high cholesterol.

What are the symptoms of a mini-stroke?

Mini-strokes can be difficult to identify, and their symptoms might not last very long. However, the signs of a mini-stroke are very much like those of a stroke, such as:

• Dysphasia, a condition that affects your ability to speak or understand what someone is telling you
• Dysarthria, a motor speech disorder that refers to when the muscles of the mouth, face, or respiratory system weaken or become difficult to move
• Vision changes, such as total or partial blindness, blurred vision, or double vision
• Not being able to think clearly, or becoming confused
• Becoming disoriented as to who you are, where you are, where you live, etc.
• Weakness/numbness on just the right or left side of the face or body, which is determined by the blood clot’s location in the brain
• A dizzy sensation that can cause balance issues or falling down
• An abnormal tingling sensation under the skin
• Fainting or passing out due to a lack of oxygen in the brain
• A sudden, severe headache
• Sudden changes to taste or smell

FACE: Is it drooping?

ARMS: Can you raise both?

SPEECH: Is it slurred or jumbled?

TIME: To call 911 or your local emergency number right away

Mini-stroke symptoms can last as briefly as one minute or as long as 24 hours. They might even disappear by the time medical help arrives, but it is a medical emergency and should seek immediate medical help.

When you first notice symptoms of a mini-stroke, seek help immediately – call 911 or go to your nearest emergency ward.

What do you do if someone is having a mini stroke?

If you witness someone having a mini-stroke, fast action is needed to increase the person’s chances of recovery. Here’s what you can do to help:

• Call 911
• Stay calm
• Encourage the person to lie down, which will promote blood flow to the brain
• Speak reassuringly to the person
• Wait with them until medical help arrives

What to do after a mini-stroke

Although many people recover from their symptoms of a mini-stroke within 24 hours, mini-strokes should be considered as a serious warning sign.

Studies have shown that chances of having a major stroke doubles for the following five years after a mini-stroke. It’s imperative to make changes as soon as possible to cut your risk of a second and possibly worse stroke.

The best way to prevent a second stroke is to get the underlying conditions such as diabetes, cholesterol, and blood pressure under control. Some other proactive steps you can take include:

• Consulting with your doctor
• Eating a balanced diet with lots of fruits and vegetables
• Getting moderate exercise regularly
• If you smoke, quit
• Limiting your alcohol intake
• Reducing the amount of stress in your life

At CareHop, we specialize in elder care, especially when injury or illness rehab is needed. Our professional, supportive healthcare workers are available for comprehensive ongoing care, or on-demand when families aren’t available or need a break.

Our entire team of eldercare professionals is committed to delivering quality, compassionate, and respectful care designed to bring joy and sunshine into their lives. Our goals are to help your loved ones live at home for as long as possible and ensure that all of their healthcare needs are met.

If you have any questions about our customized elder care services, please reach out to us anytime. *Wu CM, McLaughlin K, Lorenzetti DL, et al. Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med 2007;167:2417–22 Harvard Health Publishing.

About the Author

Amanda Lomat has been a Community Nurse for 5 years now, she is passionate about developing client relationships and helping them with the care they deserve at home.