possible TIA?

Bones, joints and muscles
1

My dad has had temporal arteritis for more than 10yrs now. He has been treated with prednisolone and latterly also methotrexate too. He has never been able to reduce to less than 12mg steroid daily.

On thursday morning he had an event that occured within 2hrs of being fine whereby my mum found hin collapsed and shaking, totally unresponsive verbally though not unconcious.

He was transferred to local hospital by emergency ambulance.

There he continued to be unresponsive to all stimulus, non verbal and vague.

He was also incontinent, pyrexial and chesty.

Immediate treatment with iv fluids and paracetamol then work up of bloods and ct brain are allegedly negative.

We are awaiting an urgent MRI now but two days on he has become gradually more alert and coherent but with tremor and headache. The headache was prevalent on becoming awake as he was post ictal following the event.

His only active treatment now has been with 30mg pred now and he states that the headache and tremor and weakness begin to recur as they wear off after approx 5-6hrs.

Docs on the ward today were going to discharge him but as he has not had the promised MRI or had definitive diagnosis we declined to take him home.

The only suggested diagnosis has been possible TIA?

They havent even asked his neurology team to be involved.

Do you out there think there is

Any other diagnosis to consider?

We are right to insist he is scanned before discharge?

Should see his neurologist?

Being too precious?

Should i be doing anything else?

2

Hello Angela, what a couple of scarey days you've all been going through. I am not medically qualified and do no suffer from TA so what I say is mere observation.

you say that he has recently started mtx. Could this episode be a side effect of that?

i have just looked up Tia and from what I read it doesn't sound as if that is what he suffered from but to be honest we all have different symptoms to one given condition so maybe it was a Tia.

has he as yet actually seen a specialist? Because I think a specialist is who he should be seeing and you say that he is at a local hospital and very often these hospitals do not have the specialists, so perhaps he should be transferred to a larger hospital.

but I am glad you refused to take in home. They haven't even given him a definitive diagnosis or a proper treatment plan and they wanted to send him home? What next?

i can't help you with any other diagnosis as I am not medically trained. I think you should insist on a specialist and also the Mri scan.

you are definately not being too precious, this is your father you're talking about here and therefore he is very precious. he has a chronic medical condition that has over the ten years could be described as atypical as he has not been able to reduce the medication by any real significance. There is quite clearly a new development either to the existing condition or a new condition. 

Hopefully a member will be along soon to offer some better advise, but please hang on in there and do not allow them to push either your father or you about. All the best, christina 

3

I am so sorry angela.  I would definitly get an MRI of head.  I am only thinking it might be an annerysem????  I am only saying that , because I have had one!!!

  I can't beleive they haven't done it already!  I had  mine clipped  with tantanium in 2001.  I beleive the symptoms are worse than the surgery.  I was fine a couple months later.

  I hope  everthing turns out fine, hang in there!

4

I also have temporaal artiritis and suffer headaches when prednisolone tails off. But it certainly sounds as if your Dad has had a TIA. stick to your guns and insist on further investigation.

5

When I had a query TIA - that had been diagnosed correctly in A&E as a global transient amnesia - the consultant said I wouldn't be allowed out until certain tests had been done: MRI, echocardiogram and carotid scan and that would be days. They were in fact done the same day as my husband worked in one of the departments and called in favours from the others so I got out of the hands of that consultant. I'd had a CT earlier.

If he still isn't well then I would also refuse to take him home until he'd had an MRI and the neurologist had assessed him if he is already under them. But more than that I don't think anyone here can say. If you are in the UK he will have an early appointment with the TIA team - it should be within a week. A TIA is taken as a warning of an increased risk of stroke in the next few years so they investigate to see if there is evading action that could taken. However - Im not sure I'd accept TIA as a diagnosis at the moment because I have always been led to believe the criterion is full resolution of symptoms within 24 hours and it doesn't sound as if that has happened. The stroke lead consulant I saw insisted on ruling out an epileptic episode and what you describe could be that. 

Above all - since it is the weekend I would want to know what qualifications in neurology the doctors wanting to discharge him have. My daughter was in last week after a very severe asthma attack and on the ward round the "consultant of the day" from AMAU (medical assessment unit), a gastroenterologist, told her that her breathlessness was probably due to being overweight. Er - no! The respiratory consultant was a bit more informed. 

6

Thank you all for your suggestions and support.

The consultant on call over the weekend is endocrinology speciality so that is why i challenged her decisions to discharge my dad home.

Certainly I feel the discharge is premature and unsafe.

I would want at least the MRI as was promised done prior to him coming home incase it then is further delayed in the ether.

I also would want to have his consultant consultant neurologist made aware of his collapse and admission let alone the dose increase if his steroids.

I shall keep you posted as to the outcome and once again thank you xx

7

By the way - I assume they have done a urinary culture? They won't have a result after a couple of days but the primary cause of confusion in the elderly is a urinary tract infection. It should have been automatic under the circumstances but as you know, that doesn't mean a lot...

8

Exactly Eileen!

They took a battery of samples, blood, urine, sputum.

His raised crp was most abnormal result thus far from bloods and had risen from 25on admission to 90 yesterday.

We are still waiting on culture from sputum n urine.

9

That suggests there is definitely some inflammation going on if it is still rising on a high dose of pred - if he goes home now you may be dialling 999 again. You haven't said how old your dad is and I realise he could well be my age (though I doubt it) but however much they want his bed - he needs it for the moment. 

10

Hes 81.

Considering hes usually pretty good for his age and has had TA fir ten years!

I feel sure that if we had brought him home yesterday that would def happen!

He hadnt even been mobile for more than 4hrs when the consultant saw him yesterday.

The trouble is with hospitals, all comes to a juddering halt at weekends and communication plus continuity is lost.

(and i work for the nhs:-!).

11

It hurts me to say it - having worked in the NHS myself and been married to/mother of NHS staff all my life - it is all coming to a juddering halt in places. My daughter, who is asthmatic, has been ill on and off since October, her GPs (different one every time) said "it's the time of year". No, it was an unidentified chest infection and it finally culminated in her being blue-lighted to the hospital 35min drive away after collapsing with a severe attack in the doctor's surgery. The paramedic they eventually called took one look and asked had she been given drug x - no, and they didn't even know the dose though they did have some. My daughter is a paramedic herself and she told me if she had been sent to her right at the start of the attack she'd have been moving towards hospital immediately, not waiting for half an hour messing about with nebs they couldn't find the equipment for while she was deteriorating. She admits, it scared the hell out of her. Some GPs terrify me, and so do some consultants. OTOH - she may get sorted out properly now and I doubt the GPs will dismiss her so lightly again.

Do let us know how your dad gets on. That CRP seems a bit high even for a chest infection though - but untreated I imagine anything can happen.

12

Thank you,

Sadly this is not an isolated incident nowadays and sorry to hear your experience is the same as ours.

In fact my 15yr old neice has been terribly ill since last oct with numerous visits to gp and hospital due to tonsillitis and now glandular fever. Her crp three days ago was 239!!! And a consultant paed asked why she wasnt attending school or eating properly!

He then asked if my sister had been reported to social services because of the absenteeism!

For g sake, shed be in school if fit!

So as you can tell as a family its not a good time.

13

I didn't mention the 15 year old granddaughter with severe brittle asthma. On one occasion the paramedic refused to transport until her aunt rushed her to the OOH unit at the small hospital and the same paramedic was told by the doctor there to bluelight her to the big hospital. Said paramedic denied having refused. Subsequently the consultant paed drew up a treatment plan that had her in resus circling the drain on 2 or 3 occasions - he maintained she is non-compliant, hardly, mum  is a nurse and used to work on the resp ward. She is an awful lot better now they have her on an adult dose - not one for a 6 or 10 year old respectively. She's 15 and weighs 85kg due to the massive doses of pred she's needed. What does a 6 year old weigh?

If your niece didn't have glandular fever I'd say we should get them together but that's the last thing she needs!

Never used to be like this did it?

14

It seems we are so similar in our experience of our modern nhs. I have been a nurse for 35yrs this year and it pains me to see how poor treatment has become, when communication, continuity and compassion are all the under pinning skills that would make a massive difference and best of all....cost nowt!

Dad was a bit brighter today and eating a bit more but then who wont on 30mg pred lol :-)

15

It seems so - I started in the NHS 43 years ago after deciding medical school was not for me (I didn't want to starve for 5 years) and looking at my peers, in retrospect it was not a bad decision. My husband took early retirement in despair. My daughters are still fighting the fight. They love their work - but I couldn't do what they have to do to stay employed.

Now as soon as I started on 15mg pred the cravings for carbs every afternoon just WENT! Older daughter is the same! I DO know people who lost weight on higher doses of pred...

16

It sounds to me more than a TIA and should be under a CVA specialist. Did he never have a stroke assessment done in the past? Temporal Arteritis increases normal all the usual risks.

17

Our NHS is very worrying, you can see why people are frightened to go into hospital....it`s such a shame,  because there are some wonderful stories we hear as well, but they are few and far between....I fear it will get worse.  I expect you do not recognise what`s happening, compare to when you/husband worked there.  Don`t know what the answer is...only that they have more people to treat now, and can`t cope!

18

Latest update,

Had Mri today and was informed that has had small stroke, been discharged home on aspirin 300mg for two weeks then to start clopidogrel.

Mentioned his neurologist but was told he would get to know eventually!

Steroids at 30mg to start reducing back to 15mg.

Also on abx for chest infection and sputum been sent for further testing....unsure exactly what as yet? Pneumonia.

Has been referred to TIA clinic and to expect an apt within 2weeks.

Not sure if stroke is new or related to the Gca.

19

Well gosh - there's a surprise. TGIM!!!! Keep an eye out for that appointment though - don't let the fast track slow to a crawl.

Hope you are all feeling somewhat relieved at the conformation of what I'm sure you knew.

All the best.

20

Hello Angela, I know that not all your questions have been answered but at least he's had an Mri scan and he's had a care pathway of sorts established. GCA sufferers are at higher risk of strokes but as you say this stroke could be unrelated. I hope that each day his health improves and that it won't be long before he is back to his normal self. Be determined that he receives the best care because I'm afraid often it's the families that have to fight for it otherwise patients are simply fobbed off with second rate care. Regards christina