High Early Risk Of Stroke Research Articles

High risk of early recurrent stroke in patients with near-occlusion with full collapse of the internal carotid artery.

We aimed to validate the prognostic ability and assess interrater reliability of a recently suggested measurement-based definition of near-occlusion with full collapse (distal ICA diameter ≤ 2.0mm and/or ICA ratio ≤ 0.42). 118 consecutive patients with symptomatic near-occlusion were prospectively included and assessed on computed tomography angiography by 2 blinded observers, 26 (22%) had full collapse. At 2days after presenting event, the risk of preoperative stroke was 3% for without full collapse and 16% for with full collapse (p = 0.01). At 28days, this risk was 16% for without full collapse and 22% for with full collapse (p = 0.22). Interrater reliability was perfect (kappa 1.0). Thus, near-occlusion with full collapse should be defined as distal ICA ≤ 2.0mm and/or ICA ratio ≤ 0.42 in order to detect cases with very high risk of early stroke recurrence.

European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack.

The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack.

The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack

Management of transient ischemic attack (TIA) has gained significant attention during the past 25 years after several landmark studies indicated the high incidence of a subsequent stroke. To calculate the pooled event rate of subsequent ischemic stroke within 2, 7, 30, and 90 days of a TIA and compare this incidence among the population with TIA recruited before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C). All published studies of TIA outcomes were obtained by searching PubMed from 1996, to the last update on January 31, 2020, irrespective of the study design, document type, or language. Of 11 516 identified citations, 175 articles were relevant to this review. Both the classic time-based definition of TIA and the new tissue-based definition were accepted. Studies with a combined record of patients with TIA and ischemic stroke, without clinical evaluation for the index TIA, with diagnosis of index TIA event after ischemic stroke occurrence, with low suspicion for TIA, or duplicate reports of the same database were excluded. The study was conducted and reported according to the PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality assessment used the Quality in Prognosis Studies tool. Publication bias was visualized by funnel plots and measured by the Begg-Mazumdar rank correlation Kendall τ2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models. The proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size. Systematic review yielded 68 unique studies with 223 866 unique patients from 1971 to 2019. The meta-analysis included 206 455 patients (58% women) during a span of 4 decades. The overall subsequent ischemic stroke incidence rates were estimated as 2.4% (95% CI, 1.8%-3.2%) within 2 days, 3.8% (95% CI, 2.5%-5.4%) within 7 days, 4.1% (95% CI, 2.4%-6.3%) within 30 days, and 4.7% (95% CI, 3.3%-6.4%) within 90 days. There was a recurrence risk of 3.4% among group A in comparison with 2.1% in group B or 2.1% in group C within 2 days; 5.5% in group A vs 2.9% in group B or 3.2% in group C within 7 days; 6.3% in group A vs 2.9% in group B or 3.4% in group C within 30 days, and 7.4% in group A vs 3.9% in group B or 3.9% in group C within 90 days. These findings suggest that TIA continues to be associated with a high risk of early stroke; however, the rate of post-TIA stroke might have decreased slightly during the past 2 decades.

Risk stratification of patients with suspected TIA or minor stroke in the initial triage: The combat-TIA study

Background: People with transient ischemic attack (TIA) are at high risk of early stroke, which can be as high as 3.5% within 48 hours and 5.2% within 7 days. Urgent assessment and intervention reduces the risk of stroke after TIA. Japan has the highest number of magnetic resonance imaging (MRI) units in the world and citizens can freely access any hospital.

Impact of atrial fibrillation on outcomes of patients treated by transcatheter aortic valve implantation: A systematic review and meta-analysis

Conflicting data have been reported related to the impact of atrial fibrillation (AF) on the outcomes after transcatheter aortic valve implantation (TAVI). We aimed to assess the prognosis of TAVI-treated patients according to the presence of pre-existing or new-onset AF. Studies published between April 2002 and November 2016 and reporting outcomes of pre-existing AF, new-onset AF, or sinus rhythm in patients undergoing TAVI were identified with an electronic search. Pairwise and network meta-analysis were performed. Outcomes of interest were short- and long-term mortality, stroke, and major bleeding. Eleven studies (11,033 individuals) were eligible. Compared to sinus rhythm, short-term and long-term mortality were significantly higher in new-onset AF (short-term OR 2.9, P=.002; long-term OR 2.3, P<.0001) and pre-existing AF groups (short-term OR 2.7, P=.004; long-term OR 2.8, P<.0001). Compared to sinus rhythm, new-onset AF increased the risk of stroke at early (OR 2.1, P<.0001) and late follow-up (OR 1.92, P<.0001), and the risk of early bleedings (OR 1.65, P=.002), while pre-existing AF increased the risk of late stroke (OR 1.3, P=0.03), but not the risk of bleeding. Compared to pre-existing AF, new-onset AF correlated with higher risk of early stroke (OR 1.7, P=.002) and major bleedings (OR 1.7, P=.002). AF is associated with impaired outcomes after TAVI, including mortality, stroke and (limited to new-onset AF) major bleedings. Compared to pre-existing AF, new-onset AF correlates with higher risk of early stroke and major bleedings. Improved management of AF in the TAVI setting, including tailored antithrombotic treatment strategies, remains a relevant need.

Validation and comparison of imaging-based scores for prediction of early stroke risk after transient ischaemic attack: a pooled analysis of individual-patient data from cohort studies

Identification of patients at highest risk of early stroke after transient ischaemic attack has been improved with imaging based scores. We aimed to compare the validity and prognostic utility of imaging-based stroke risk scores in patients after transient ischaemic attack. We did a pooled analysis of published and unpublished individual-patient data from 16 cohort studies of transient ischaemic attack done in Asia, Europe, and the USA, with early brain and vascular imaging and follow up. All patients were assessed by stroke specialists in hospital settings as inpatients, in emergency departments, or in transient ischaemic attack clinics. Inclusion criteria were stroke-specialist confirmed transient ischaemic attack, age of 18 years or older, and MRI done within 7 days of index transient ischaemic attack and before stroke recurrence. Multivariable logistic regression was done to analyse the predictive utility of abnormal diffusion-weighted MRI, carotid stenosis, and transient ischaemic attack within 1 week of index transient ischaemic attack (dual transient ischaemic attack) after adjusting for ABCD2 score. We compared the prognostic utility of the ABCD2, ABCD2-I, and ABCD3-I scores using discrimination, calibration, and risk reclassification. In 2176 patients from 16 cohort studies done between 2005 and 2015, after adjusting for ABCD2 score, positive diffusion-weighted imaging (odds ratio [OR] 3·8, 95% CI 2·1-7·0), dual transient ischaemic attack (OR 3·3, 95% CI 1·8-5·8), and ipsilateral carotid stenosis (OR 4·7, 95% CI 2·6-8·6) were associated with 7 day stroke after index transient ischaemic attack (p<0·001 for all). 7 day stroke risk increased with increasing ABCD2-I and ABCD3-I scores (both p<0·001). Discrimination to identify early stroke risk was improved for ABCD2-I versus ABCD2 (2 day c statistic 0·74 vs 0·64; p=0·006). However, discrimination was further improved by ABCD3-I compared with ABCD2 (2 day c statistic 0·84 vs 0·64; p<0·001) and ABCD2-I (c statistic 0·84 vs 0·74; p<0·001). Early stroke risk reclassification was improved by ABCD3-I compared with ABCD2-I score (clinical net reclassification improvement 33% at 2 days). Although ABCD2-I and ABCD3-I showed validity, the ABCD3-I score reliably identified highest-risk patients at highest risk of a stroke after transient ischaemic attack with improved risk prediction compared with ABCD2-I. Transient ischaemic attack management guided by ABCD3-I with immediate stroke-specialist assessment, urgent MRI, and vascular imaging should now be considered, with monitoring of safety and cost-effectiveness. Health Research Board of Ireland, Irish Heart Foundation, Irish Health Service Executive, Irish National Lottery, National Medical Research Council of Singapore, Swiss National Science Foundation, Bangerter-Rhyner Foundation, Swiss National Science Foundation, Swisslife Jubiläumsstiftung for Medical Research, Swiss Neurological Society, Fondazione Dr Ettore Balli (Switzerland), Clinical Trial Unit of University of Bern, South Korea's Ministry for Health, Welfare, and Family Affairs, UK Wellcome Trust, Wolfson Foundation, UK Stroke Association, British Heart Foundation, Dunhill Medical Trust, National Institute of Health Research (NIHR), Medical Research Council, and the NIHR Oxford Biomedical Research Centre.

Statin pretreatment is associated with better outcomes in large artery atherosclerotic stroke.

Even though statin pretreatment is associated with better functional outcomes and lower risk of mortality in acute ischemic stroke, there are limited data evaluating this association in acute ischemic stroke due to large artery atherosclerosis (LAA), which carries the highest risk of early stroke recurrence. Consecutive patients with acute LAA were prospectively evaluated from 7 tertiary-care stroke centers during a 3-year period. Statin pretreatment, demographics, vascular risk factors, and admission and discharge stroke severity were recorded. The outcome events of interest were neurologic improvement during hospitalization (quantified as the relative decrease in NIH Stroke Scale score at discharge in comparison to hospital admission), favorable functional outcome (FFO) (defined as modified Rankin Scale score of 0-1), recurrent stroke, and death at 1 month. Statistical analyses were performed using univariable and multivariable Cox regression models adjusting for potential confounders. All analyses were repeated following propensity score matching. Statin pretreatment was documented in 192 (37.2%) of 516 consecutive patients with LAA (mean age: 65 ± 13 years; 60.8% men; median NIH Stroke Scale score: 9 points, interquartile range: 5-18). Statin pretreatment was associated with greater neurologic improvement during hospitalization and higher rates of 30-day FFO in unmatched and matched (odds ratio for FFO: 2.44; 95% confidence interval [CI]: 1.07-5.53) analyses. It was also related to lower risk of 1-month mortality and stroke recurrence in unmatched and matched analyses (hazard ratio for recurrent stroke: 0.11, 95% CI: 0.02-0.46; hazard ratio for death: 0.24, 95% CI: 0.08-0.75). Statin pretreatment in patients with acute LAA appears to be associated with better early outcomes regarding neurologic improvement, disability, survival, and stroke recurrence.

ABCD score to identify individuals at high early risk of stroke after transient ischemic attack

ABCD score to identify individuals at high early risk of stroke after transient ischemic attack

Abstract T P193: Impact of Observing TIA Patients in a Clinical Decision Unit

Background: TIA carries a high risk of early stroke. National guidelines recommend that TIA cases should have rapid work up, ideally within 24 hours. Hospitalization is recommended when rapid outpatient work-up is not possible. As a result, most TIA patients are managed in the hospital. However, recent literature supports the use of observation in the Emergency Department for testing and monitoring of TIA patients. Here, we review the effects of our protocol for the observation of TIA cases in a Clinical Decision Unit (CDU) at our Comprehensive Stroke Center (CSC). Methods: Retrospectively, we reviewed the charts of all TIA cases, from one year prior to the use of a CDU protocol, to one year after its use. Patients were identified by billing codes, using our informatics system. Data on location of care, final diagnosis, cost of care, contribution margin, admission rate, and imaging test was collected and analyzed. Descriptive and analytical statistics were used to compare groups. Results: From May 2011 to May 2013, 400 suspected TIA cases were seen. Prior to the initiation of our protocol, 209 TIA patients were hospitalized. After the protocol, 191 patients were seen, with 85 patients seen in the CDU and 106 patients being admitted. The inpatients were mostly cases transferred to our CSC from regional facilities. Of the 85 CDU cases, 51 had a final diagnosis of TIA, 7 had confirmed strokes, 25 were non-cerebrovascular, and 2 were transient global amnesia. From the CDU, 20 patients were admitted, due to confirmation of stroke, recurrence of symptoms, or need for urgent intervention. Over two thirds of all patients underwent MRI/MRA for neuroimaging; the rest had non-contrast CT and carotid ultrasound. Since the start of the TIA protocol, the direct cost of care per case was $453.65 less (p=0.02) in the CDU cases. During the same time period, there was no significant difference in the contribution margin between the CDU and inpatient groups. Conclusion: Given the high risk for early stroke after TIA, early evaluation and monitoring remains imperative. Our results are similar to recent literature, showing that similar management can be provided for less cost and similar clinical outcomes. Larger studies are necessary to determine the overall financial impact of such programs.

The Epidemiology of Delirium: Challenges and Opportunities for Population Studies

Delirium is a serious and common acute neuropsychiatric syndrome that is associated with short- and long-term adverse health outcomes. However, relatively little delirium research has been conducted in unselected populations. Epidemiologic research in such populations has the potential to resolve several questions of clinical significance in delirium. Part 1 of this article explores the importance of population selection, case-ascertainment, attrition, and confounding. Part 2 examines a specific question in delirium epidemiology: What is the relationship between delirium and trajectories of cognitive decline? This section assesses previous work through two systematic reviews and proposes a design for investigating delirium in the context of longitudinal cohort studies. Such a design requires robust links between community and hospital settings. Practical considerations for case-ascertainment in the hospital, as well as the necessary quality control of these programs, are outlined. We argue that attention to these factors is important if delirium research is to benefit fully from a population perspective.

Recent advances in the management of transient ischaemic attack: a clinical review

Transient ischaemic attack (TIA) if untreated carries a high risk of early stroke and is associated with poorer long-term survival. There have been recent advances in the understanding of TIA, its investigations, management and organisation of services for patient care. Clinically, patients are diagnosed TIA if they have transient sudden-onset focal neurological symptoms which usually completely and rapidly resolve by presentation. Patients with residual symptoms should be evaluated as potentially having stroke, if they present within 4.5 h of onset, should be urgently evaluated for their potential eligibility for thrombolysis. TIA patients should receive rapid attention with essential investigations, including brain imaging, electrocardiograph and carotid ultrasound. Immediate administration of an antiplatelet agent is recommended after brain imaging, with subsequent attention to preventing or treating other mechanistic factors. There is emerging evidence that TIA patients can be managed safely in the outpatient setting after initial rapid management in emergency departments as part of a structured clinical pathway supervised by stroke specialists. Clinical systems of management may require approaches individualised to the healthcare setting, while adopting the central aspects of rapid management.

Stroke Risk After Posterior Circulation Stroke/Transient Ischemic Attack and its Relationship to Site of Vertebrobasilar Stenosis

Recent prospective studies have shown vertebrobasilar (VB) stenosis predicts stroke risk in posterior circulation stroke and transient ischemic attack. It is unclear whether this association is independent of other risk factors, and whether intracranial or extracranial stenosis confers different risks. A pooled individual patient analysis of data from 2 prospective studies was performed in 359 patients presenting with VB transient ischemic attack or stroke. Contrast-enhanced magnetic resonance angiography, or computed tomography angiogram, and clinical follow-up were available in 323 patients. Risk of stroke was calculated from any VB transient ischemic attack/stroke in the month before the presenting episode (first event) and from the presenting event. A systematic review of similar prospective studies was performed. Ninety-day risk of stroke from the first event was 24.6% in patients with VB stenosis versus 7.2% in those without (odds ratio, 4.2; 95% confidence interval, 2.1-8.6; P<0.0001). Risk was higher (33%) with intracranial (odds ratio, 6.5; 2.8-15.0; P<0.0001) than extracranial stenosis (16.2%; odds ratio, 2.5; 0.9-6.8; P=0.06). Risk from the presenting event was 9.6% in patients with stenosis versus 2.8% in those without (odds ratio, 3.7; 1.2-11.0; P=0.012), and again the risk was higher with intracranial stenosis. Cox regression showed the risk associated with VB stenosis was independent of other cardiovascular risk factors. The systematic review identified only 1 other report, which included only 6 patients. Symptomatic VB stenosis, particularly intracranial stenosis, is a strong independent predictor of stroke recurrence. The high early risk of stroke provides a strong rationale for randomized trials to determine whether stenting can reduce risk.

Abstract TP231: Clinical Characteristics of TIA with Atrial Fibrillation

Objectives: Patients with transient ischemic attack (TIA) are at high risk of early stroke, indicating a need for urgent diagnostic workup and treatment. Atrial fibrillation (AF) is one of important causes for TIA. The purpose of this study was to investigate characteristics of TIA patients with AF, using data of a multicenter retrospective study. Methods: The subjects of this study were TIA patients admitted to 13 stroke centers within 7 days after onset between 2008 and 2009. The definition of TIA used in this study was that of clinical symptoms lasting less than 24 hours, regardless of imaging findings. We compared baseline characteristics and diffusion weighted-MRI (DWI) findings between patients with AF and those without AF. Results: A total of 464 patients (69 ± 13 years in age, 172 women) were enrolled. We diagnosed 79 patients (17%) as having AF. TIA patients with AF were older (74 ± 9 vs. 67 ± 14 years old, P = 0.0001) and more likely to have a longer length of hospital stay (15 ± 9 vs. 14 ± 20 days, P = 0.046) than those without AF. Of 464 TIA patients, 458 patients (99%) underwent head MRI. DWI lesion was detected in 96 (21%) patients. There was no difference of DWI positivity rate between patients with or without AF (28% vs. 20%, P = 0.10). Compared to patients without AF, patients with AF were more likely to have a single lesion on DWI (86% vs. 51%, P = 0.005). DWI lesion of ≥15 mm was found more frequently in TIA patients with AF than in those without AF (45% vs. 22%, P = 0.04). Conclusions: This study demonstrated that TIA patients with AF were older and had a longer length of hospital stay than those without AF. In addition, characteristics of DWI findings differed between TIA patient with AF and those without AF; TIA patients with AF were more likely to have a single lesion with a size of ≥15 mm.

Journal Club: Early stroke risk and ABCD2 score performance in tissue vs time-defined TIA

In this journal club article, we evaluate a study by Giles and colleagues1 that reports stroke risk in patients with classically defined TIA subcategorized by presence or absence of radiologic brain infarction. The concept of a TIA is evolving in parallel with better understanding of brain ischemia and insights gained from neuroimaging studies. TIAs were classically defined as a sudden focal neurologic deficit resulting from brain or retinal ischemia lasting less than 24 hours.2,3 The time threshold of 24 hours was arbitrarily chosen, and given that there is no evidence to support any single time criterion associated with infarction, this has appropriately been questioned. A newer and well-received definition of TIA is “a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.”4 This definition communicates the important concept that transient symptoms can nonetheless be associated with permanent brain injury, encourages the use of neuroimaging studies, and may promote rapid interventions for acute brain ischemia. The ABCD2 score, a risk-stratifying score for patients with TIA, is derived from the patient's age, blood pressure, clinical features, TIA duration, and history of diabetes. This simple, validated score identifies patients at highest risk of early stroke after TIA.5 Scores are commonly divided into low risk (0–3), intermediate risk (4–5), and high risk.6,7 The clinical ABCD2 scale is integrated in this study with results from acute brain imaging to assess how the new tissue-based definition of TIA further assists with risk stratification of patients with transient neurologic symptoms. In this analysis of data pooled from 12 medical centers which included 4,574 patients, Giles and colleagues subcategorized TIA as “tissue positive” or “tissue negative,” depending on the presence or absence of radiographic brain infarction seen on MRI or CT …

Abstract 2967: Recurrent TIA and Early Risk of Stroke

Background: Many guidelines recommend urgent intervention for TIA patients with 2 or episodes within 7-days to reduce the early risk of stroke. However, whether all patients with multiple TIAs are at high early risk of stroke is unknown. Methods: Between April 2008 and December 2009, we included 1255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). We prospectively recorded clinical characteristics. We also determined the early short-term risk of stroke (at seven and ninety days). Aetiology of TIA was categorised using the SSS-TOAST classification Results: Enough information was assessed in 1137 patients (90.6%). 7-day and 90-day stroke risk were 2.6% and 3.8% respectively. Atherosclerotic etiology (AE) was confirmed in 190 (16.7%) patients. Recurrent TIA was observed in 274 (24,1%) patients. Duration&lt;1 hour (OR 2.94, 95% CI 2.18-3.96, p&lt;0.001), AE (OR 1.97, 95% CI 1.39-2.78, p&lt;0.001) and motor weakness (OR 1.37, 95% CI 1.03-1.82, p&lt;0.029) were independent predictors of recurrent TIA. The subsequent risks of stroke in these patients at 7, and 90 days were significantly higher than those after a single TIA (5.8% versus 1.5%, p&lt;0.001 and 6.8% versus 3.0%, respectively. HR 2.35, 95% CI 1.28-4.31 p=0.006). In the Cox logistic regression model, among patients with recurrent TIA, no variable remained remained as independent predictors of stroke recurrence at 90-day Conclusion: According to our results, recurrent TIA within 7-days is associated with a greater subsequent stroke risk than after a single TIA. Nevertheless, we were not able to find any independent predictor of stroke recurrence among these patients.

Diffusion–perfusion MRI for triaging transient ischemic attack and acute cerebrovascular syndromes

Time from symptom onset to treatment is considered to be the key variable that influences the indication of recanalization therapy for treatment of acute brain infarction. Symptom duration less than 24 h defines transient ischemic attack (TIA). The evolution of multimodal brain MRI demonstrates that neuroimaging findings of tissue injury may be more important predictors of clinical outcomes than arbitrary time thresholds. Preliminaries studies suggest that stroke victims with a significant penumbra estimated by the diffusion/perfusion mismatch on MRI benefit from thrombolysis beyond the currently recommended time window of 4.5 h. New software programs can automatically produce reliable perfusion and diffusion maps for use in clinical practice. Combined diffusion and perfusion MRI reveals an acute ischemic lesion in about 60% of TIA patients. Patients with transient symptoms and a restricted diffusion lesion on MRI are considered by the American Heart Association (AHA) scientific committee to have suffered a brain infarction and have a very high risk of early stroke recurrence. Multimodal MRI provides critical real-time information about ongoing tissue injury as well as the risk of additional ischemic damage. It is becoming an essential tool for the diagnosis, management and triage of acute TIA and brain infarction.

ABCD2 score to identify individuals on admission at high early risk of stroke after transient ischemic attack

脳卒中急性期病院におけるTIA入院例のリスクと転帰との関連を明らかにする目的で，発症48時間以内のTIA入院例連続160例を解析した．TIAの定義は24時間以内の神経症状消失かつ画像上脳梗塞巣が認められないものとし，発症後90日以内の脳梗塞発症率およびリスク因子と転帰の関連をABCD2スコアで検討した．脳梗塞発症を8例(5%)に認め(全例7日以内の発症，中央値2.5日)，50%はラクナ梗塞であった．脳梗塞発症群で入院時血圧が有意に高かった．ABCD2スコアの各項目(年齢≥60 歳，血圧≥140/90 mmHg，臨床症候，症状持続時間，糖尿病)単独では有意な関連は認めないが，脳梗塞発症群のABCD2スコア中央値は5.5(非発症群中央値4，p=0.065)と高い傾向にあった．また，ABCD2スコア以外の要素では，心房細動合併例と主幹動脈病変合併例ではそれぞれ有意差を認めなかったが，両者の合併例では脳梗塞発症を高率(25%)に認めた．TIAではABCD2スコア高値に加えて心房細動と主幹動脈合併例が急性期脳梗塞発症と関連すると考えられた．

Pro: Intravenous Tissue Plasminogen Activator in Stroke Patients With Rapid, Complete Recovery During Evaluation (Transient Ischemic Attack) and Evidence of Middle Cerebral Artery Occlusion

Carlos A. Molina MD, PhD Magdy H. Selim MD, PhD Section Editors: The Case: A patient presents within 3 hours of acute onset of left-sided weakness. Symptoms rapidly resolve spontaneously. Vascular imaging reveals evidence of right middle cerebral artery (MCA) occlusion. The Questions: (1) Should treatment decision be based on clinical or vascular status? (2) Would treatment with t-PA prevent clinical worsening or early stroke recurrence in this patient? (3) Is increased collateral flow good enough to maintain perfusion? The Controversy: Role of Thrombolysis in Patients with Rapid Recovery during Evaluation and Evidence of Arterial Occlusion on Vascular Imaging. There are some points on which to agree at the beginning of this controversy. The middle cerebral artery (MCA) supplies a large and important proportion of the brain, which is not meant to be perfused through small collaterals. Acute occlusion of the MCA in most cases leads to devastating strokes. Thus, a patent MCA is probably better than an occluded one. Would we really consider a spontaneously recovering stroke patient with a proven, persistent occlusion of the MCA to have a “transient ischemic attack” (TIA) not necessitating thrombolysis? The …

PAW17 Recurrent transient ischaemic attack, capsular warning syndrome, ABCD2 score and early risk of stroke: a population-based study

BackgroundMany guidelines recommend urgent intervention for patients with 2 or more transient ischaemic attacks (TIAs) within 7 days irrespective of ABCD2 score, perhaps in recognition of capsular warning syndrome (CWS)....