Consecutive Transient Ischemic Attack Patients Research Articles

Factors impacting D-dimer levels in patients with acute ischemic cerebrovascular events

Background and objectivesA better understanding of the factors influencing D-dimer levels in code stroke patients is needed to guide further investigations of concomitant thrombotic conditions. This study aimed to investigate the impact of time from symptom onset and other factors on D-dimer levels in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). MethodsData on consecutive AIS and TIA patients treated at our tertiary-care stroke center between January 2015 and December 2020 were retrospectively assessed. Patients with available D-dimer levels were evaluated for eligibility. Multivariable non-linear regression analyses were performed. ResultsIn total, 2467 AIS patients and 708 TIA patients were included. The median D-dimer levels differed between the AIS and TIA groups (746 µg/L [interquartile range 381–1468] versus 442 µg/L [interquartile range 244–800], p<0.001). In AIS patients, an early increase in D-dimer levels was demonstrated within the first 6 h (standardized beta coefficient [β] 0.728; 95% confidence interval [CI] 0.324–1.121). This was followed by an immediate decrease (β −13.022; 95% CI −20.401 to −5.643) and then by a second, late increase after 35 h (β 11.750; 95% CI 4.71–18.791). No time-dependent fluctuation in D-dimer levels was observed in TIA patients. ConclusionThe time from symptom onset may affect D-dimer levels in patients with AIS but not those with TIA. Further studies confirming these findings and validating time-specific variations are needed to enable D-dimer levels to be used efficiently as an acute stroke and thrombotic risk biomarker.

Enhancing stroke risk prediction in patients with transient ischemic attack: insights from a prospective cohort study implementing fast-track care.

Fast-track care have been proved to reduce the short-term risk of stroke after transient ischemic attack (TIA). We aimed to investigate stroke risk and to characterize short- and long-term stroke predictors in a large cohort of TIA patients undergoing fast-track management. Prospective study, enrolling consecutive TIA patients admitted to a Northern Italy emergency department from August 2010 to December 2017. All patients underwent fast-track care within 24 h of admission. The primary outcome was defined as the first stroke recurrence at 90 days, 12 and 60 months after TIA. Stroke incidence with 95% confidence interval (CI) at each timepoint was calculated using Poisson regression. Predictors of stroke recurrence were evaluated with Cox regression analysis. The number needed to treat (NNT) of fast-track care in preventing 90-day stroke recurrence in respect to the estimates based on baseline ABCD2 score was also calculated. We enrolled 1,035 patients (54.2% males). Stroke incidence was low throughout the follow-up with rates of 2.2% [95% CI 1.4-3.3%] at 90 days, 2.9% [95% CI 1.9-4.2%] at 12 months and 7.1% [95% CI 5.4-9.0%] at 60 months. Multiple TIA, speech disturbances and presence of ischemic lesion at neuroimaging predicted stroke recurrence at each timepoint. Male sex and increasing age predicted 90-day and 60-month stroke risk, respectively. Hypertension was associated with higher 12-month and 60-month stroke risk. No specific TIA etiology predicted higher stroke risk throughout the follow-up. The NNT for fast-track care in preventing 90-day stroke was 14.5 [95% CI 11.3-20.4] in the overall cohort and 6.8 [95% CI 4.6-13.5] in patients with baseline ABCD2 of 6 to 7. Our findings support the effectiveness of fast-track care in preventing both short- and long-term stroke recurrence after TIA. Particular effort should be made to identify and monitor patients with baseline predictors of higher stroke risk, which may vary according to follow-up duration.

The diagnostic tests and functional outcomes of acute ischemic stroke or transient ischemic attack in young adults: A 4-year hospital-based observational study.

Ischemic strokes in young adults have been a significant concern due to various potential etiologies and had substantial clinical and public health impacts. We aimed to study the diagnostic tests, etiologies, and functional outcomes of acute ischemic stroke (AIS) and transient ischemic attack (TIA) in young adult patients. The data were retrieved from the Chiang Mai University Hospital Stroke Registry between January 2018 and December 2021. Consecutive AIS or TIA patients were included if they were 18-50 years and had no stroke mimics. Study outcomes were proportions of positive diagnostic tests, and 90-day modified Rankin Scale (mRS). Of 244 enrolled patients, 59.0% (n = 144) were male, and 38.1% (n = 93) were aged 18-40, classified as the younger age group. There was a high incidence of diabetes (24.5%) and dyslipidemia (54.3%) among patients aged 41-50, associated with small-vessel occlusion and large-artery atherosclerosis stroke classification in this age group. Patients aged 18-40 years had more other determined etiologies (39.8%), with hypercoagulability (8.2%), arterial dissection (7.8%), and cardiac sources (6.6%) being the first three causes, which were associated with higher anticoagulant treatment. The cerebrovascular study, cardiac evaluation using echocardiography, and antiphospholipid syndrome testing were commonly performed, of which computed tomography angiography provided a high proportion of positive results (80.3%). 76.3% of young adult patients had excellent functional outcomes (mRS 0-1) with a median mRS of 0 (interquartile range 0-1) at 90-day follow-up. Stroke of other determined etiology remained the common cause of stroke in young adults, and most affected individuals had excellent clinical outcomes. Blood tests for arterial hypercoagulability and noninvasive vascular and cardiac evaluations are encouraged in selected patients to determine the stroke etiology and guide for appropriate preventive strategies.

Computed tomographic perfusion abnormalities in acute migraine with aura: Characteristics and comparison with transient ischemic attack.

Migraine with aura (MA) accounts for up to 10% of "stroke mimics" and can present cerebral perfusion abnormalities. We aimed to compare perfusion-CT (PCT) findings in acute-onset MA mimicking an ischemic stroke with those observed in transient ischemic attack (TIA). We retrospectively studied patients admitted to our hospital between 2002 and 2014 with suspicion of acute ischemic stroke, having PCT and receiving a final diagnosis of MA. We visually assessed PCT for the presence and extent of focal hypoperfusion (FHP). MA patients with FHP were compared with consecutive TIA patients showing FHP. We performed both qualitative and quantitative analysis of PCT. Of 47 patients with MA (median age = 33 years, 55% females), 16 (34%) displayed FHP. Compared to MA patients without FHP, MA patients with FHP had similar headaches and aura features, but a less frequent history of MA (p = 0.010). Compared to 74 TIA patients with FHP (median age = 69 years, 43% females), MA patients with FHP showed hypoperfusion that more frequently involved adjacent vascular territories or a whole hemisphere (p < 0.001). In addition, hypoperfusion in MA patients had a less pronounced increase in rMTT (1.2 vs 1.8, p < 0.001) and rTTP (1.1 vs 1.2, p < 0.001), and a lesser decrease in rCBF (0.8 vs 0.6, p < 0.001) compared to hypoperfusion in TIA. rMTT displayed the best discriminative ability to differentiate MA from TIA. Focal perfusion abnormalities in acute MA often involve adjacent vascular territories and hypoperfusion is less pronounced than in TIA. MA can be best differentiated from TIA by a smaller rMTT increase.

Epidemiology of Moyamoya Angiopathy in Eastern India.

IntroductionMoyamoya angiopathy (MMA) is a chronic, progressive intracranial vasculopathy with variation in prevalence and clinical manifestations across different populations. This study was aimed to estimate the frequency of MMA as an etiology of stroke and its epidemiological features in the largest cohort of MMA patients in India.MethodA single-centered cross-sectional observational study over a period of 5 years (2016–2021) was undertaken among consecutive stroke and transient ischemic attack (TIA) patients to look for the presence of MMA angiographically. Each patient with angiographically proven MMA was further evaluated for demographic, clinical, and radiological characteristics.ResultsAmong 10,250 consecutive stroke and TIA patients (ischemic = 78%, hemorrhagic = 22%), frequency of MMA was 1.56% (n = 160); 15.3% among children. Female preponderance (Male:Female = 1:1.4) was noted among 160 MMA patients, with bimodal age distribution, first peak at 3–8 years, and a shorter second peak at 41–47 years. Childhood-onset MMA was seen in 75 (46.9%) with commonest initial neurological symptom of fixed-motor-weakness (44.0%), followed by TIA (26.7%); while 85 (53.1%) had adult-onset MMA with fixed-motor-weakness (50.6%) followed by headache (24.7%) as the predominant initial neurological symptom; seizure significantly higher in children (p < 0.001) and headache in adults (p = 0.012). Transient and fixed neurological manifestations constituted 87.5 and 69.4% respectively, of symptoms throughout the disease course. Cerebral infarction (45.0%) and TIA (21.9%) were the commonest types of MMA. On brain imaging, infarction was noted in 80.6%, hemorrhage in 11.3%, significantly higher among adults (p < 0.001). Cortical infarct and Gyral pattern were commoner in children (p = 0.004), subcortical infarcts in adults (p = 0.018). Frequent Suzuki staging observed was stage 4 (31.3%), followed by stage 3 (30.0%). Involvement of posterior circulation was detected in 55.6%, brain atrophy at the time of diagnosis was seen in 65.0%.ConclusionMMA is an important etiological consideration in patients with stroke, especially in children. It can present with a myriad of transient neurological symptoms, frequently overlooked, leading to delayed diagnosis, and contributing to socio-economic burden. Indian MMA showed aberrations in its gender predisposition, age distribution, frequency of familial cases, disease manifestation, and type of stroke, in comparison to its Japanese and Caucasian counterparts pointing to the inter- and intra-continent differences of MMA phenotype. Future development of the Indian MMA national registry is of essence.

Under Treatment of High-Risk TIA Patients with Clopidogrel-Aspirin in the Emergency Setting

BackgroundTreating high-risk transient ischemic attack (TIA) with dual antiplatelet therapy (DAPT) reduces subsequent ischemic stroke risk yet current rates of clopidogrel-aspirin treatment are uncertain. Materials and MethodsWe conducted a retrospective cohort study of consecutive TIA patients who presented to any of the four emergency departments (ED) of a single urban health system from 1/1/2018-3/1/2020. Medical record review was used to describe the cohort and assess clopidogrel-aspirin treatment. Patient eligibility for clopidogrel-aspirin was determined using relevant criteria from the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial. Comparisons among eligible patients who received versus did not receive clopidogrel-aspirin were conducted using t-test, chi-squared, and Mann-Whitney as indicated. ResultsWe identified 248 TIA patients of whom 95 met eligibility criteria for clopidogrel-aspirin treatment. Among these 95 patients, mean age was 69.5 (SD: 12), 68.4% were women, and median ABCD2 score was 5 (IQR: 4-6). A total of 26/95 (27.4%) eligible patients received clopidogrel-aspirin within 24 hours of symptom onset. Appropriate clopidogrel-aspirin use was associated with having a stroke code called upon ED arrival (88.5% vs. 34.8%; P<0.001), being evaluated by a vascular neurologist (88.5% vs. 21.1%; P<0.001), and not presenting to the community ED site wherein only a single patient received clopidogrel-aspirin. ConclusionsIn a multisite, single health system study, nearly three-fourths of high-risk TIA patients eligible for clopidogrel-aspirin treatment did not receive it. Appropriate clopidogrel-aspirin use was highest among patients seen by vascular neurologists and lowest at the community ED, though under treatment was evident at all sites.

Impact of Platelet Endothelial Aggregation Receptor-1 Genotypes on Long-Term Cerebrovascular Outcomes in Patients With Minor Stroke or Transient Ischemic Attack.

Background: Platelet endothelial aggregation receptor-1 (PEAR1) rs12041331 has been reported to affect agonist-stimulated platelet aggregation, but it remains unclear whether this variant plays a role in recurrent stroke. Here we assess the clinical relevance of PEAR1 rs12041331 in acute minor ischemic stroke (AMIS) and transient ischemic attack (TIA) Chinese patients treated with dual antiplatelet therapy (DAPT).Methods: We recruited 273 consecutive minor stroke and TIA patients, and Cox proportional hazard regression was used to model the relationship between PEAR1 rs12041331 and thrombotic and bleeding events.Results: Genotyping for PEAR1 rs12041331 showed 49 (18.0%) AA homozygotes, 129 (47.3%) GA heterozygotes, and 95 (34.7%) GG homozygotes. No association was observed between PEAR1 rs12041331 genotype and stroke or composite clinical vascular event rates (ischemic stroke, hemorrhagic stroke, TIA, myocardial infarction, or vascular death) or bleeding events regardless if individuals carried one or two copies of the A allele. Our results suggested that rs12041331 genetic polymorphism was not an important contributor to clinical events in AMIS and TIA patients in the setting of secondary prevention.Conclusions: Our data do provide robust evidence that genetic variation in PEAR1 rs12041331 do not contribute to atherothrombotic or bleeding risk in minor stroke and TIA patients treated with DAPT.

Acute in-hospital blood pressure variability predicts early neurological deterioration in acute minor stroke or transient ischemic attack with steno-occlusive arterial disease.

It is generally known that acute minor stroke and transient ischemic attack (TIA) seem to be benign. However, their occurrence in patients with steno-occlusive arterial disease may result in early neurological deterioration (END). We aimed to elucidate the effect of blood pressure variability (BPV) on the development of END. Consecutive acute minor stroke and TIA patients within 24hours of onset were prospectively recruited from the Affiliated Hospital of Yangzhou University between Aug 2015 and Feb 2019. END was defined as an NIHSS score increased ≥1 during the first 72hours compared with the initial NIHSS score. During this period, the mean, maximum (max), the difference between the maximum and minimum (max-min), the SD, and coefficient of variation of BP (BPCV ) were calculated. Of the 160 total patients enrolled in the study (mean age, 68.01±9.33years; 50.6% female), 52 (32.5%) patients occurred END during the first 72h after admission. To express the BPV as a categorical variable, we classified the subjects into one of four groups, representing four quartiles of BPV. In the multivariable analyses, the lowest quartiles were considered as reference groups. The results showed that patients who fell in the fourth quartile (SBPmax-min :OR=3.289, 95% CI 1.147-9.430; SBPSD :OR=3.313, 95% CI 1.041-10.547; SBPCV :OR=3.425, 95% CI 1.164-10.077; DBPSD :OR=3.124, 95% CI 1.065-9.158) had a significantly higher risk of END after adjusting the variables (age, female, diabetes mellitus, atrial fibrillation, and CRP with P values <.1 in univariate analyses). Our study demonstrated that the acute in-hospital BPV was associated with the development of END in acute minor stroke and TIA with steno-occlusive arterial disease.

Essen Risk Score in Prediction of Myocardial Infarction After Transient Ischemic Attack or Ischemic Stroke Without Prior Coronary Artery Disease.

Background and Purpose- More intensive secondary prevention with newer drugs may be cost-effective in patients with coronary artery disease (CAD). Whether some subgroups of patients who had a transient ischemic attack (TIA) or ischemic stroke, but no prior CAD are at similar high risk of myocardial infarction as those with prior CAD remains unclear. We determined whether the Essen score identified a subset of TIA/stroke patients without known prior CAD who, nevertheless, had a high risk of myocardial infarction on current secondary prevention management. Methods- In a population-based cohort (Oxford Vascular Study) of consecutive TIA or ischemic stroke patients recruited from 2002 to 2014, 10-year actuarial risks of myocardial infarction and of recurrent ischemic stroke were determined by face-to-face follow-up in patients with and without prior CAD using Kaplan-Meier analyses. Predictive value of the Essen score was assessed with C statistic. Results- Of 2555 patients with TIA/stroke (13 070 patient-years of follow-up), 10-year risk of myocardial infarction in those without prior CAD (n=2017, 78.9%) ranged from 0.9% (95% CI, 0-1.9) at Essen score ≤1 to 29.8% (95% CI, 7.7-46.6) in those with a score ≥5 (C statistic =0.64 [95% CI, 0.57-0.71]; P<0.001). The score tended to be less predictive (difference: P=0.0460) for the risk of recurrent ischemic stroke (C statistic =0.57 [95% CI, 0.54-0.60]). Compared with patients with prior CAD (n=538, 21.1%), an Essen risk score of ≥4 (n=294, 11.5%) in those without prior CAD identified a subgroup at similar high 10-year risks of myocardial infarction (17.2% [95% CI, 6.9-26.3] versus 16.9% [95% CI, 11.5-22.0]) and of recurrent stroke (40.4% [95% CI, 26.7-51.6] versus 32.4% [95% CI, 25.2-38.8]). Conclusions- The Essen score is a simple clinical score to risk-stratify patients with TIA/stroke without prior CAD and to identify subsets who may be at sufficiently high risk of myocardial infarction and recurrent stroke to justify more intensive treatment or inclusion in trials.

Abstract TP425: Prevalence and Predictors of Cortical Superficial Siderosis Among African Americans with Ischemic Stroke and Transient Ischemic Attack

Background: Cortical Superficial Siderosis (cSS) detected on brain MRI affects 0.7% of the general population. In studies of predominantly White individuals, cSS is considered a sensitive marker of cerebral amyloid angiopathy (CAA) associated with increased risk of intracerebral hemorrhage. However, its prevalence and predictors in ischemic stroke (IS) —particularly in African Americans (AA)—has not been well studied. We sought to characterize the prevalence and vascular risks associated with cSS in AA with IS and transient ischemic attack (TIA). Methods: We included 2001 consecutive (year 2009-2018) IS and TIA patients, wherein 1048 patients (52%) were AA with available T2*gradient-echo MRI sequence. cSS rating was performed according to standardized guidelines. Race was determined by self-report based on U.S. census procedures, categorized as White, AA or Other racial groups (ORG). Vascular risk factors included age, diabetes, hypertension, systolic blood pressure (SBP), dyslipidemia, BMI, smoking, prior stroke, coronary artery disease; and illicit drug use (IDU). Differences in associations with cSS were assessed using univariate analyses. Results: We observed cSS in 1.15% (n=23) of AA, 0.4% (n=9) Whites and 0.6% (n=12) ORG patients. Compared to Whites with cSS, AA were younger (63 vs. 69 years), had higher proportion of men (70 vs 56%), hypertension (83 vs 78%), IDU (22 vs 11%), higher SBP (166±33 vs 162±15mmHg), and lower CAD prevalence (13 vs 33%), although differences did not reach statistical significance. Compared to AA without cSS, AA with cSS had higher proportion of men (69.6 vs 49.7%), prior stroke (39.1 vs 29.7%), IDU (21.7 vs 12.9%), and higher SBP (166±33 vs 153±37mmHg), the latter being the only statistically significant (p=0.038). The remaining vascular risk factors did not differ in patients with and without cSS, or between racial groups. Conclusion: The prevalence of cSS in AA with IS/TIA at our urban center is higher than in the general population and higher than in Whites. The vascular risk factor profile seems to differ between AA and White patients with and without cSS. Our results may be relevant in studies of cSS in AA wtih IS/TIA patients as the underlying angiopathy may not represent CAA, but require replication in larger samples.

1.4 times increase in atrial fibrillation-related ischemic stroke and TIA over 12 years in a stroke center

Background and PurposePrevalence of atrial fibrillation (AF) has quadrupled in the past 50years in the general population. However, there is uncertainty regarding prevalence of AF over time in ischemic stroke patients given the aging population and enhanced surveillance of AF. We aimed to explore the changing prevalence of AF as well as other risk factors, stroke subtypes, investigations and pre-stroke medications among ischemic stroke and transient ischemic attack (TIA) patients. MethodsWe performed a retrospective analysis of data from a prospective database of consecutive patients with acute ischemic stroke and TIA from 2004 to 2015. Trends in risk factors and other variables year by year were analyzed using logistic regression or median regression. ResultsAmong 6275 patients (median age [interquartile range] 74 [62–82] years, 56% males), the prevalence of AF increased 1.4 times over 12years (from 23.3% to 32.7%, P<0.001). The increase in the prevalence of AF remained significant after adjustment for age and the use of Holter monitoring. There was also a significant increase in prevalence of hypertension (67.4% to 77.3%), structural heart disease (9.8% to 10.5%), and previous TIA (10.9% to 13.7%) and a significant decrease in prevalence of dyslipidemia (71.8% to 49.4%). ConclusionsThere was a 1.4 times increase in the prevalence of AF among consecutive ischemic stroke and TIA patients in the past 12years in a hospital-based registry. More active screening of the general population for AF may be warranted in order to decrease the overall stroke burden.

Differences in Clinical Characteristics between Patients with Transient Ischemic Attack Whose Symptoms Do and Do Not Persist on Arrival

Symptoms of transient ischemic attack (TIA) persist on arrival and subsequently resolve in some patients admitted to hospitals early after onset. Differences in clinical characteristics between patients with acute TIA whose symptoms do and do not persist on arrival remain unclear. We retrospectively extracted data of consecutive TIA patients with an onset-to-door time (ODT) of 24 hours or less and without a history of stroke from a multicenter TIA database. Clinical characteristics were compared between patients with and without persisting symptoms on arrival. Two hundred sixty-six patients (158 men, 68.0 ± 12.9 years) were included. Of the total number of patients, 105 (39.5%) had persisting symptoms with a mean National Institutes of Health Stroke Scale score of 2.4 (median, 1.0). Patients with persisting symptoms were more likely to have sensory disorder, ambulance-transported admission, long-duration TIA (≥60 minutes), and shorter ODT than those without. Multivariate analysis showed that sensory disorder (odds ratio [OR] 2.52, 95% confidence interval [CI] 1.35-4.77), ambulance-transported admission (OR 1.80, 95% CI 1.00-3.28), and long-duration TIA (OR 3.96, 95% CI 2.12-7.71) were positively associated and that an ODT of more than 12 hours (OR .18, 95% CI .04-.63) was inversely associated with the presence ofpersisting symptoms. Patients with persisting symptoms were more likely to be examined by a stroke physician at first (69% versus 57%, P = .049) and then hospitalized in a stroke unit (59% versus 43%, P = .010). Clinical manifestations and management after admission might differ between patients with acute TIA whose symptoms do and do not persist on arrival.

Abstract WP216: Stroke Recurrence in Patients With Cryptogenic Stroke

Background &amp; Purpose: In cryptogenic stroke or transient ischemic attack (TIA) patients, aortic arch atheroma or patent foramen ovale (PFO) evaluated by using transesophageal echocardiography (TEE) is well known as possible embolic source. These findings were sometimes associated with stroke recurrence. We investigated predictive factors for stroke recurrence in patients with cryptogenic stroke. Methods: From February 2008 to December 2013, among 1832 consecutive stroke or TIA patients, 315 patients (male, 57.8%; age, 73.3±10.9) who were admitted within 7 days after the symptom onset without both atrial fibrillation and significant stenosis (50% or more in diameter) in the cerebral arteries underwent TEE for evaluating embolic sources; embolism was the probable etiological mechanism for their event. Patients with malignancy, cerebral arterial dissection, or infarcts in the perforating artery territory were excluded. We observed stroke recurrence during one year and investigated predictive factors for stroke recurrence. Results: In TEE, spontaneous echo contrast in the left atrium, aortic arch atheroma of 4.0 mm or more in thickness (mean, 4.65±2.06 mm), PFO, and pulmonary arteriovenous fistula were observed in 24 (7.6%), 223 (70.3%), 26 (8.2%), and 20 (6.3%) patients, respectively. Stroke recurrence was observed in 39 (12.4%) patients. Aortic arch atheroma of 4.0 mm or more, male, and prior hemorrhagic stroke were more frequent, and the initial diastolic blood pressure (DBP) and HbA1c were higher in patients with than without stroke recurrence. On the multivariate analysis using those factors and age, aortic arch atheroma (OR 3.73, 95%CI 1.46–11.7) and the initial DBP (OR 1.03, 95%CI 1.00–1.05) were positive predictors for a stroke recurrence. With regard to the operating characteristic curve analysis, the most accurate cut off values for a stroke recurrence were 4.1mm (AUC 0.59) in aortic arch atheroma thickness and 91mmHg in DBP (AUC 0.58). Conclusions: In acute cryptogenic stroke, aortic arch atheroma was observed frequently. Aortic arch atheroma and DBP were significantly associated with one-year stroke recurrence. TEE was required for evaluating aortic arch atheroma in patients with cryptogenic stroke

Abstract WP210: Urgent Detection of Acute Type A Aortic Dissection in Ischemic Stroke or TIA

Background and purpose: Urgent diagnosis of acute Stanford type A aortic dissection (AAD) in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) is sometimes challenging. Several markers such as systolic blood pressure (SBP) laterality, initial D-dimer level, mediastinal-width to chest-width (M/C) ratio on X-ray, common carotid artery (CCA) dissection on carotid ultrasonography and pericardial effusion on echocardiography are reported to be useful to identify AAD in AIS or TIA. We validated these findings using our prospective stroke registry (ClinicalTrials.gov: NCT02251665). Methods: Consecutive AIS or TIA patients with AAD who were admitted to our institute within 4.5 h of onset from Jan 2007 to Dec 2014 were reviewed. They were compared with AIS or TIA patients without AAD who admitted within 4.5 h of onset from Jan 2014 to Dec 2014. Results: We found 24 AIS/TIA patients with AAD (15 women, 75±12 y.o.), and 245 patients without AAD (86 women, 74±12 y.o.). As compared to patients without AAD, AAD patients had higher SBP laterality (30±20 mmHg vs. 10±9 mmHg, p&lt;0.001), higher initial D-dimer level (median 1.0μg/ml, IQR 0.5-2.4μg/ml vs. median 38.1μg/ml, IQR 8.1-155.1μg/ml; p&lt;0.001), and higher M/C ratio in the recumbent position (0.35±0.05 vs. 0.29±0.05, p&lt;0.001), and more frequently had occlusion or the intimal flap of the proximal CCA (85% vs. 1%, p&lt;0.001) and pericardial effusion (43% vs. 1%, p&lt;0.001). Using receiver operating characteristic curve analysis, the cutoff of SBP laterality, D-dimer level and M/C ratio was 17 mmHg, 4.1μg and 0.32, respectively, with c-statistic of 0.84, 0.96 and 0.82, respectively. Sensitivity, specificity, positive predictive value and negative predictive value to identify AAD were as follows. Conclusions: High D-dimer level can be the most reliable screening test of AAD in AIS or TIA patients. Proximal CCA occlusion or flap appears to be the most disease specific finding with acceptable sensitivity.

Detectability of Ischemic Lesions on Diffusion-Weighted Imaging Is Biphasic after Transient Ischemic Attack

Experimental studies of transient focal ischemia indicate biphasic detectability of lesions by diffusion-weighted imaging (DWI); poorly detectable phase exists at 1-12 hours after reperfusion. The present study aimed to clarify whether poorly detectable phase also exists in DWI of transient ischemic attack (TIA) patients. A retrospective study was conducted in 144 consecutive TIA patients who underwent magnetic resonance imaging (MRI) within 2 weeks after carotid TIA. Patients were classified into 9 groups according to time from disappearance of TIA symptoms to DWI: intraischemic period, 0-1 hour, 1-12 hours, 12-24 hours, 1-2 days, 2-3 days, 3-7 days, 7-10 days, and 10-14 days after the end of TIA. Lesions were detected in 33 of 144 patients (22.9%). The frequency of positive lesions was 20% in the intraischemic period and 30.8% at 0-1 hour after the end of TIA; it markedly decreased to 8.7% at 1-12 hours after end of TIA. Thereafter, it increased to 21.7%, 30.8%, 36.4%, 37.0%, 38.5%, and 30% at 12-24 hours, 1-2 days, 2-3 days, 3-7 days, 7-10 days, and 10-14 days after the end of TIA, respectively. In 7 patients, MRI was repeated twice, at 1-12 hours and then at 5-13 days after the end of TIA. Lesions were never detected on the first MRI but were clearly demonstrated in 4 of 7 patients on the second MRI. The detectability of ischemic lesions may be biphasic after TIA as indicated by experimental studies.

Abstract T P291: Impact of Diastolic Dysfunction for Predicting Mortality in Ischemic Stroke and Transient Ischemic Attack Patients

Background: The aim of this study is to identify whether diastolic dysfunction predicts 90-day mortality and develop and validate a risk score model using information available at hospital presentation in ischemic stroke or transient ischemic attack (TIA) patients Methods: Consecutive ischemic stroke or TIA patients within 48 hours of onset were enrolled. Diastolic filling pressure was estimated as the ratio of early transmitral flow velocity (E) to mitral annular velocity (e’) on transthoracic echocardiography performed within 24 hours of presentation. Plasma brain natriuretic peptide (BNP) and D-dimer were measured on admission. We calculated initial diffusion weighted imaging (DWI) lesion volume. Stroke severity was assessed by the National Institute of Health Stroke Scale (NIHSS) score. Mortality was evaluated at 90-day follow-up. Univariate and multivariate analyses were conducted to identify predictors of 90-day mortality. Results: A total of 265 patients with ischemic stroke or TIA were enrolled. Of these, nineteen (7%) patients deceased at 90-day follow-up. At univariate analysis, higher age (p=0.002), atrial fibrillation (p&lt;0.001), use of antiplatelet agent (p=0.005) and anticoagulant agent (p=0.017), cardioembolic infarction (p&lt;0.001), higher NIHSS score (p&lt;0.001), larger DWI lesion volume (p=0.002), internal carotid artery occlusion (p&lt;0.001), higher E/e’ (p&lt;0.001), PT-INR level (p=0.004), BNP level (p&lt;0.001) and D-dimer level (p&lt;0.001) and lower albumin level (p=0.002) were associated with death. Multivariable predictors of 90-day mortality included higher E/e’ (Odds ratio [OR]=1.176; 95% confidence interval [CI], 1.051 to 1.317), NIHSS score (OR=1.180; 95% CI, 1.067- 1.306) and D-dimer level (OR=1.137; 95% CI, 1.009 to 1.281). The END score (1 point each for E/e’ of &gt;= 18.5, NIHSS score of &gt;= 17 and D-dimer level of &gt;= 2.0) stratified patients with a predicted probability of death rate from 0% to 77.8%. The c statistic was 0.947. Conclusions: Diastolic dysfunction could be one of the most important predictors of 90-day mortality of acute ischemic stroke and TIA. The END score may assist clinicians in estimating stroke mortality at hospital presentation.

Importance of transient neurological attacks (TNAs)

Transient neurological attacks (TNAs) are attacks with temporary (< 24 h) neurological symptoms, and reported in 1975. Ischemic cerebral infarction often occurres after transient neurological symptoms which are not sometimes involved in transient ischemic attack (TIA) criteria. The purpose of this study was to clarity transient neurological symptoms before the onset of ischemic stroke. Consecutive acute stroke and TIA patients within 7 days of onset between July 2011 and December 2012 were studied. Questionnaire survey of transient neurological symptoms was done and we investigated the history of transient neurological symptoms and divided the patients into three groups, TIA group (history of TIA), TNAs group (history of TNAs), and no past history group. We compared clinical characteristics, the rate of posterior circulation lesions, and number of attacks among three groups. 184 patients (male 112 patients, mean 73 years old) were enrolled into the present study. TNAs group had 13 (7%) patients, and TIA had 20 (11%). Neurological symptoms of TNAs group were 5 (38%) transient dizziness, 3 (23%) disturbance of consciousness, 2 (23%) weakness of legs, 1 (8%) sensory disturbance of legs, 1 (8%) gait disturbance, and 1 (8%) sensory disturbance of lips. Five (38%) TNAs group had multiple attacks. In 33 transient neurological symptom patients, 17 (52%) patients did not have hospital visit, and 7 (21%) patient did not have antiplatelet and anticoagulant drug. TNAs group more frequently had hyperlipidemia, diabetes mellitus, and posterior circulation lesions among three groups. 20% posterior circulation lesion patients had TNAs history, and posterior circulation might be examined in TNAs patients.

Correlation between ABCD, ABCD2 Scores and Craniocervical Artery Stenosis in Patients with Transient Ischemic Attack

Background and Purpose: Craniocervical artery stenosis is an important etiology for transient ischemic attack (TIA). We hypothesized ABCD and ABCD2 scores can predict craniocervical artery stenosis in patients with TIA. Methods: ABCD and ABCD2 scores were calculated in a total of 479 consecutive first-ever TIA patients in Nanjing Stroke Registry Program and compared with angiographic imaging derived from MRI or invasive catheter-based angiography. Results: Overall craniocervical artery (O-CA) stenosis was found in 197 (41.1%) patients. Extracranial craniocervical artery (E-CA) and intracranial craniocervical artery (I-CA) stenosis was found in 101 (21.1%) and 110 (23%) cases, respectively. ABCD and ABCD2 scores with similar accuracy for O-CA (AUC_ABCD 0.71, AUC_ABCD2 0.70), E-CA (AUC_ABCD 0.72, AUC_ABCD2 0.72) and I-CA stenosis (AUC_ABCD 0.62, AUC_ABCD2 0.62) were both independent predictors for various categories of artery stenosis after being adjusted for non-ABCD2 parameters. The cut-off points were equally 4 in both predicting rules. For ABCD, sensitivity was 57.4, 65.3 and 52.7% and specificity 77.0, 70.4 and 67.5% for O-CA/E-CA/I-CA, respectively. For ABCD2, sensitivity was 61.9, 69.3 and 58.2% and specificity 72.3, 65.6 and 63.1%. Conclusions: In patients with TIA, despite an association between ABCD and ABCD2 scores and underlying craniocervical artery stenosis, the clinical utility was limited by unsatisfactory sensitivity and specificity.

Features of Patients with Transient Monocular Blindness: A Multicenter Retrospective Study in Japan

Transient monocular blindness (TMB) is associated with a transient ischemic attack (TIA). The purpose of this study was to investigate the features of TMB in the Japanese population using data from a multicenter retrospective study of TIA. The subjects were consecutive TIA patients admitted to 13 stroke centers within 7 days after symptom onset. We compared clinical characteristics of patients with TMB and those without TMB who had other symptoms of cerebral TIA. A total of 464 patients were registered between January 2008 and December 2009, and 444 patients (283 men, mean age: 68.5 years) were included in the analysis. Thirteen patients (2.9%) presented with TMB. Patients with TMB were less likely to arrive at the specialized stroke center quickly than those without TMB (P = .013). Stenotic lesions in the extracranial internal carotid artery were more common in patients with TMB (33.3% versus 9.1%, P = .022). TMB was not common in our TIA inpatients. This study suggests that patients with TMB should immediately undergo a diagnostic workup, including brain and vessel imaging, and cardiac evaluation, as is performed in patients with other cerebral TIA symptoms. A larger, prospective cohort is needed to confirm the risks and outcomes of patients with TMB in the Japanese population.

Abstract WP56: Refinement of imaging predictors of recurrent events following Transient Ischemic Attack and Minor Stroke.

Background: Transient ischemic attack (TIA) and minor stroke have a high risk of recurrent stroke. We recently showed in the CATCH study that predefined radiographic abnormalities on CT/CTA and MRI predicted recurrent events after TIA and minor stroke. Specifically, the study recognized the predictive value of CT/CTA abnormalities that were defined apriori: acute ischemia on CT, intracranial or extracranial occlusion or stenosis &gt; 50% (the CT/CTA positive metric), and diffusion-weighted imaging positivity on MRI. Aims: To improve upon the CT, CTA, MRI and clinical parameters that predict recurrent events after TIA and minor stroke. Our secondary aim was to explore predictors of stroke progression versus recurrence. Methods: 510 consecutive TIA and minor stroke patients (NIHSS score of &lt;4) had CT/CTA and most had MRI. Primary outcome was recurrent events (combined outcome of stroke progression or distinct recurrent stroke) within 90 days. Imaging parameters not included in the original CATCH imaging (CT/CTA and MRI) metrics were assessed for prediction of recurrent events. We also completed an exploratory analysis comparing predictors of symptom progression versus recurrence. Results: There were 36 recurrent events (36/510, 7.1% (95%CI: 5.0-9.6)) including 19 progression and 17 recurrent strokes. On CT/CTA: white matter disease, prior stroke, aortic arch focal plaque≥4mm, or intraluminal thrombus did not predict recurrent events. On MRI: white matter disease, prior stroke, and microbleeds did not predict recurrent events. The only additional clinical predictor was symptom fluctuation (hazard ratio 2.3; 95% CI: 1.05-5.0). Parameters predicting symptom progression included: ongoing symptoms at initial assessment, symptom fluctuation, intracranial occlusion, intracranial occlusion or stenosis, and the CT/CTA metric. No parameter was strongly predictive of recurrent stroke. Conclusions: There was no imaging parameter that could improve upon our original CT/CTA or MRI metrics to predict recurrent events after TIA and minor stroke. Only the addition of symptom fluctuation to the CT/CTA metric improved the prediction of recurrent events. Imaging was more predictive of symptom progression than distinct recurrent events.