The Willis lecture: transient ischemic attacks, scientific method, and new realities

Abstract

First described by Thomas Willis in 1679 and defined in the 1950s, transient ischemic attack is universally agreed to be an episode of focal neurologic deficit in a vascular distribution, sudden in onset and resolving without residual deficit in less than or equal to 24 hours. Transient ischemic attack is diagnosed by characteristic history and absence of residua on neurologic examination. After these criteria had been accepted, regional cerebral blood flow and computed cranial tomography in the 1970s, later positron emission tomography, and even more recently, magnetic resonance imaging reveal prolonged pathophysiologic and metabolic disturbances even in persons with all the definitional characteristics of transient ischemic attack. These persistent abnormalities necessitate reexamination of the validity of the concept of transient ischemic attack. Furthermore, our group suspects that transient ischemic attack is probably only a marker, and not itself the risk factor, for the cerebral infarction which frequently follows transient ischemic attack. Additionally, the surprising frequency with which cerebral infarction, unrecognized by patient or physician, is revealed using neuroimaging techniques has created a need to redefine the categories heretofore used for diagnosis and assessment of therapy and prognosis for transient ischemic attack and cerebral infarction.