Incidence Of TIA Research Articles

Possible Subclinical Leaflet Thrombosis in Bioprosthetic Aortic Valves

BackgroundA finding of reduced aortic-valve leaflet motion was noted on computed tomography (CT) in a patient who had a stroke after transcatheter aortic-valve replacement (TAVR) during an ongoing clinical trial. This finding raised a concern about possible subclinical leaflet thrombosis and prompted further investigation.MethodsWe analyzed data obtained from 55 patients in a clinical trial of TAVR and from two single-center registries that included 132 patients who were undergoing either TAVR or surgical aortic-valve bioprosthesis implantation. We obtained four-dimensional, volume-rendered CT scans along with data on anticoagulation and clinical outcomes (including strokes and transient ischemic attacks [TIAs]).ResultsReduced leaflet motion was noted on CT in 22 of 55 patients (40%) in the clinical trial and in 17 of 132 patients (13%) in the two registries. Reduced leaflet motion was detected among patients with multiple bioprosthesis types, including transcatheter and surgical bioprostheses. Therapeutic anticoagulation with warfarin, as compared with dual antiplatelet therapy, was associated with a decreased incidence of reduced leaflet motion (0% and 55%, respectively, P=0.01 in the clinical trial; and 0% and 29%, respectively, P=0.04 in the pooled registries). In patients who were reevaluated with follow-up CT, restoration of leaflet motion was noted in all 11 patients who were receiving anticoagulation and in 1 of 10 patients who were not receiving anticoagulation (P<0.001). There was no significant difference in the incidence of stroke or TIA between patients with reduced leaflet motion and those with normal leaflet motion in the clinical trial (2 of 22 patients and 0 of 33 patients, respectively; P=0.16), although in the pooled registries, a significant difference was detected (3 of 17 patients and 1 of 115 patients, respectively; P=0.007).ConclusionsReduced aortic-valve leaflet motion was shown in patients with bioprosthetic aortic valves. The condition resolved with therapeutic anticoagulation. The effect of this finding on clinical outcomes including stroke needs further investigation. (Funded by St. Jude Medical and Cedars–Sinai Heart Institute; Portico-IDE ClinicalTrials.gov number, NCT02000115; SAVORY registry, NCT02426307; and RESOLVE registry, NCT02318342.)

Abstract 12536: Lower Thromboembolic and Bleeding Events With Uninterrupted Warfarin Compared to Interrupted Warfarin and Heparin Bridging in Atrial Fibrillation Ablation. Evidence From a Meta-Analysis

Introduction: Optimal anticoagulation strategy in patients undergoing atrial fibrillation ablation (AFA) is controversial. Trials comparing uninterrupted warfarin (UW) with interrupted warfarin and heparin bridging (IW) peri-procedural in AFA are inconsistent in showing decreased thromboembolic and bleeding events with UW. We sought to perform a meta-analysis comparing both strategies in AFA. Methods: We searched online databases till May 2014 for case-control studies that compared patients undergoing AFA with UW versus IW. Studies without a control arm, and those that included patients not on anticoagulation peri-procedural were excluded. We used odds ratio and random effects model. When event rates were less than 1% we used Peto Odds ratio. We explored the hypothesis that UW decreased thromboembolic events with equal bleeding rates compared to IW therapy in patients undergoing AFA. Results: Our search yielded 13 observational and 1 randomized trial. A total of 17628 patients were included, of those 7964 on UW vs 9664 on IW. Patients on UW had lower combined Stroke and TIA compared with IW (Odds ratio (OR) 0.29, 95% confidence interval (CI) [0.12, 0.72]; p=0.007). Consistently Stroke were lower with UW (Peto OR 0.21, 95% CI [0.13, 0.33]; p&lt;0.0001) and TIA (Peto OR 0.25, 95% CI [0.13, 0.51]; p=0.0001). Major bleeding events were also lower with UW (OR 0.73, 95% CI [0.57, 0.94]; p=0.02) as well as minor bleeding (OR 0.36, 95% CI [0.23, 0.56]; p&lt;0.0001) compared to IW. Cardiac tamponade were equal with both strategies (POR 0.84, 95% CI [0.61, 1.16]; p=0.3). Conclusion: In AFA, UW decreases the incidence of stroke and TIA with lower major and minor bleeding events compared to IW. These results recommend use of UW rather than IW strategy in AFA.

Dolichocarotids: Echo-Color Doppler Evaluation and Clinical Role

Dolichocarotids(DCs) represent a rare(2-6%) carotid imaging finding in the general population that may be free of clinical significance or be associated with cerebrovascular events. Their detection is traditionally assigned to carotid echo-color Doppler(ECD) and selective angiography(the standard method). The primary aim of this study was to estimate the sensitivity, specificity and accuracy of ECD in detecting DCs. Moreover, we monitored the DC curvature angle and the incidence of TIA, ischemic stroke, myocardial infarction and cardiovascular death over a five-year followup period. A total of 112 consecutive patients with DCs(80 men, mean age: 61±7 years) were recruited for carotid ECD and carotid angiography due to the persistence of neurological symptoms not well explained on ultrasound evaluations, according to the current guidelines. ECD proved to have 100% sensitivity in detecting tortuosity and coiling and 96% sensitivity in detecting kinking, with an overall accuracy ranging from 92% to 100%. The specificity was 75% for tortuosity, 91% for kinking and 100% for coiling. During the five-year follow-up period, there was a statistically significant increase in tortuosity(61±11° at baseline versus 81±11° after five years, p＜0.001) and the kinking curvature angle(97±3° at baseline versus 100±3° at five years, p＜0.001), whilst no differences were observed with respect to coiling(136±10° at baseline versus 138±11° at five years, p=ns). Moreover, kinking was found to be more frequently statistically associated with cardiovascular death than tortuosity(p=0.005). DCs predispose patients to potentially disabling and fatal events. ECD plays a primary role in the detection of DCs and therefore should be considered to be a secure and reproducible technique.

Methodology of a Population-Based Stroke and TIA Incidence and Outcomes Study: The Auckland Regional Community Stroke Study (ARCOS IV) 2011–2012

Stroke is a leading cause of death and disability worldwide. Stroke burden is immense as it leads to premature deaths, leaves survivors with ongoing disabilities, and has a major financial impact on the individual, their families, and the community. Reliable, high-quality evidence is needed on stroke risk factors, incidence, and outcomes to provide information on how best to reduce this burden. Population-based studies are regarded as the 'gold-standard' of measuring disease burden but are not common due to the logistical and financial challenges they present. The Auckland Regional Community Stroke Studies are among a few in the world that have been carried out at a population level and at regular intervals. The aim of the fourth Auckland Regional Community Stroke Studies IV is to examine the current measures of stroke incidence, prevalence, and outcomes as well the trends over four decades. This article describes the methodology of the Auckland Regional Community Stroke Studies IV with stroke and transient ischemic attacks cases registered over a 12-month period from March 1, 2011 to February 29, 2012. The methodology described may be used as a guide in order to design similar population-based stroke incidence and outcome studies in other countries and populations, thus facilitating the collection of most consistent and accurate stroke epidemiological data.

Transient neurological symptoms in the older population: report of a prospective cohort study—the Medical Research Council Cognitive Function and Ageing Study (CFAS)

ObjectiveTransient ischaemic attack (TIA) is a recognised risk factor for stroke in the older population requiring timely assessment and treatment by a specialist. The need for such TIA services is...

Abstract 19579: The Incidence of Stroke and Pericardial Effusion after Pericardial Suture Ligation of the Left Atrial Appendage

Introduction: Left atrial appendage closure (LAAC) is an effective alternative to warfarin in nonvalvular AF patients who are intolerant to oral anticoagulation. Our aim was to determine the incidence of stroke and pericardial effusion following pericardial suture ligation of the left atrial appendage. Methods: Retropspective analysis of 16 patients who underwent LAAC with an epicardial suture delivery system (LARIAT) at single center. Pericardial access was obtained using an anterior approach, followed by transeptal puncture. Epicardial and endovascular magnetic-tipped guidewires were then aligned, and the epicardial snare and suture were advanced over the left atrial appendage. After snare closure and suture deployment, TEE and fluoroscopy were used to confirm left atrial appendage exclusion. Patients were discharged on aspirin. Reported stroke or TIA events were confirmed by CT or MRI. Results: Of the 16 patients included, the mean age was 74.2 ±9.1, 56% of patients (9/16) were male, and the mean CHADS2 score was 3.6 ± 1.2; 11 patients (69%) had a prior stroke or TIA. These patients accumulated a total of 9.6 person-years of follow up (5.3 months ±7.7). LAAC was confirmed by repeat TEE at 1.95 ± 3.0 months, and 7/16 patients (44%, 95% CI 10-77%) experienced any size left atrial appendage leak, and 1/16 (6%, 95% CI 0-20%) experienced a large leak (≥3mm). After LAAC, 1/16 patients experienced a stroke. A 71 year old male (CHADS2 = 3) who was not on anticoagulation developed a central retinal artery occlusion 5 months post-procedure. The overall incidence of stroke or TIA was 6%, (95% CI 0-20%). After LAAC, 3/16 patients developed a pericardial effusion (19%, 95% CI 0-40%), of which 2 required pericardiocentesis. Conclusion: We observed a significant rate of pericardial effusion and symptomatic ischemic events after LAAC with an epicardial suture ligation system; further study is needed to assess its relative safety compared to alternate LAAC devices in patients intolerant to oral anticoagulation.

Anatomic variables contributing to a higher periprocedural incidence of stroke and TIA in carotid artery stenting

This study was conducted to identify patient-related variables that are associated with a higher rate of neurological adverse events during carotid artery stenting (CAS). CAS is considered as an alternative treatment for patients with carotid artery stenosis. Despite technical advancements and increase of operator experience, periprocedural neurologic complications cannot completely be prevented. Case selection based on anatomical criteria and other patient characteristics could improve the outcome after CAS. Between 2006 and 2009, 833 CAS procedures were performed in 751 consecutive patients under cerebral protection. The influence of patient characteristics, procedural details, and the anatomy of the supraaortic vessels on the incidence of major in-hospital adverse events was assessed. Successful CAS was performed in 99.2% of the procedures. The in-hospital death and stroke rate was 2.0% (1 major stroke, 10 minor strokes, and 7 deaths). Octogenarians had a fourfold higher death and stroke rate than patients younger than 80 years old. There was an increased risk of stroke and death in patients with critical aortic stenosis. Presence of a bovine arch, tortous common carotid artery (CCA) and angulated distal internal carotid artery were associated with a higher risk of stroke and transient ischemic attack. A recently developed scoring system for anatomic suitability correlates well with the periprocedural neurological outcome in this case series. Anatomical conditions and octogenarian age were associated with an increased rate of neurologic adverse events during CAS. Our findings support a newly proposed scoring system for anatomic suitability to identify patients at high risk for CAS.

P-022 Association of smoking with increased risk of stroke or transient ischemic attack in the treated vessel territory following angioplasty and stenting for intracranial atherosclerotic disease

PurposeIntracranial atherosclerotic disease (ICAD) is one of the leading causes of ischemic stroke worldwide. Percutaneous transluminal angioplasty (PTA) and stenting has emerged as a treatment for ICAD since there is...

COMPARISON OF LONG TERM STROKE OR TIA RISK BETWEEN PATIENTS WITH ATRIAL FIBRILLATION WHO UNDERGO RADIOFREQUENCY CATHETER ABLATION VS. MATCHED PATIENTS WHO HAVE NOT HAD AN ABLATION PROCEDURE

Background: Evidence informing the role of radiofrequency catheter ablation (RFCA) in the care of patients with AF is growing rapidly, but little is known about long-term outcomes, particularly in regards to the incidence of stroke or TIA. The objective of this study was to compare long term safety for a propensity matched sample of ablation and non-ablation patients with AF. Methods: We performed a retrospective cohort analysis of the incidence of stroke/TIA in AF patients who underwent RFCA compared to those that were treated with at least two different rhythm-control medications but no ablation. We used a coding algorithm to identify 3,194 RFCA patients and 6,028 non-ablation patients from the Thomson Reuters MarketScan® Research Database. This database contains individual-level claims information from employers, health plans, hospitals, Medicare, and Medicaid. The analytic start date for the RFCA patients was the date of their first ablation and for non RFCA patients it was the date of their second rhythm control medication fill. From this sample, 801 pairs were propensity matched based on 15 characteristics, which included patient demographics, comorbid conditions, medication usage and prior stroke/TIA. The primary outcome measure was a record of stroke or TIA at any time up to 3 years. Results: Kaplan Meier analysis in the propensity matched pairs demonstrated a significant reduction in stroke/TIA rates for RFCA patients compared to non-ablation patients during the follow-up period. Preliminary findings include a multivariable Cox proportional hazards model, which adjusted for covariates still statistically different after matching (time in the database, baseline diabetes mellitus, rate medication pre time zero), showing a reduction in stroke/TIA rates with RFCA hazard ratio of 0.664 [p=0.04, 95% CI ( .45,.98)]. A second multivariable Cox proportional hazards model, which included an additional adjustment of prior stroke/TIA, revealed consistent findings; hazard ratio .695 [p=.07, 95% CI (.47,1.00)]. Conclusion: In this analysis, 801 propensity-matched pairs demonstrated a significant reduction in the risk of stroke/TIA in AF patients treated with RFCA.

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Eversion Carotid Endarterectomy Versus Best Medical Treatment in Symptomatic Patients with Near Total Internal Carotid Occlusion: A Prospective Nonrandomized Trial

We sought to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total internal carotid artery (ICA) occlusion. From January 2003 to December 2006, a total of 309 recently (within 12 months) symptomatic patients with near total ICA occlusion who were eligible for surgery were identified in our institution. Patients were nonrandomly divided into group A (259 patients), who underwent ECEA surgery, and group B (50 patients), who refused surgery. Patients in group B received the best medical treatment based on the opinion of the attending vascular surgeon and/or angiologist. Patients were followed for ipsilateral stroke, transient ischemic accident, and neurologic mortality for 12 months. There were no intraoperative and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients. There were no differences between the groups with respect to medications on discharge. Cumulative 12 month incidence of TIA, ipsilateral stroke and neurologic mortality was lower in patients who underwent ECEA than in patients on medical therapy (13 [5%] versus 12 [24%], p < 0.001; 4 [1.5%] versus 7 [14%], p < 0.001; and 4 [1.5%] versus 4 [8%], p = 0.034, respectively). Restenosis of the operated ICA was noted in 7 (3%) patients, and progression of near to total occlusion was seen in 15 (37%) patients in group B. Our data indicate that recently (within 12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

Nationwide incidence of first stroke and TIA in the Netherlands

Information on incidence of stroke is important for developing and maintaining public health strategies in primary and secondary prevention. Nationwide data on the incidence of stroke are scarce and absent for the Netherlands. New cases of first stroke and stroke subtypes in the Dutch population in 2000 were identified through linkage of national registers and included hospitalized patients for first stroke and out-of-hospital deaths from first stroke. The number of non-fatal, non-hospitalized stroke patients was estimated based on data from the Rotterdam study, a population based cohort. We identified 26,556 patients with a first stroke (20,798 hospitalized patients, 5758 out-of-hospital deaths). The number of non-fatal, non-hospitalized first stroke patients was estimated to be 12,255. Extrapolation of the data to the total Dutch population led to an overall estimate of approximately 41,000 patients with a first stroke. Stroke incidence increased with age and was higher in men than in women, except in the lowest (< 45 years) and highest age group (> 85 years). The present study provides for the first time incidence estimates of first stroke (hospitalized patients, out-of hospital deaths and non-fatal, non-hospitalized patients) based upon virtually the entire Dutch population.

Major Ongoing Stroke Trials

Major Ongoing Stroke Trials

Major Ongoing Stroke Trials

Major Ongoing Stroke Trials

The high risk of stroke immediately after transient ischemic attack: a population-based study.

The risk of stroke is elevated in the first 48 hours after TIA. Previous prognostic models suggest that diabetes mellitus, age, and clinical symptomatology predict stroke. The authors evaluated the magnitude of risk of stroke and predictors of stroke after TIA in an entire population over time. Administrative data from four different databases were used to define TIA and stroke for the entire province of Alberta for the fiscal year (April 1999-March 2000). The age-adjusted incidence of TIA was estimated using direct standardization to the 1996 Canadian population. The risk of stroke after a diagnosis of TIA in an Alberta emergency room was defined using a Kaplan-Meier survival function. Cox proportional hazards modeling was used to develop adjusted risk estimates. Risk assessment began 24 hours after presentation and therefore the risk of stroke in the first few hours after TIA is not captured by our approach. TIA was reported among 2,285 patients for an emergency room diagnosed, age-adjusted incidence of 68.2 per 100,000 population (95% CI 65.3 to 70.9). The risk of stroke after TIA was 9.5% (95% CI 8.3 to 10.7) at 90 days and 14.5% (95% CI 12.8 to 16.2) at 1 year. The risk of combined stroke, myocardial infarction, or death was 21.8% (95% CI 20.0 to 23.6) at 1 year. Hypertension, diabetes mellitus, and older age predicted stroke at 1 year but not earlier. Although stroke is common after TIA, the early risk is not predicted by clinical and demographic factors. Validated models to identify which patients require urgent intervention are needed.

TIA incidence and prevalence: the Stroke Belt perspective.

A 12-state area in the southeastern United States (figure) has been dubbed the “stroke belt” because there is excess stroke mortality in this region for both black and white Americans.1 There is heterogeneity of stroke mortality in this geographic area, with the highest rates being reported in a 153-county area of the coastal plain states of Georgia and the Carolinas. The precise reason for this excess has been a topic of debate and controversy.2 More recently, it has been observed that the stroke belt may be breaking up as excess rates of stroke mortality spread into the lower Mississippi Valley3 and possibly into the northwestern United States.4 This section of the supplement reviews the prevalence of TIA based on reports from the Atherosclerosis Risk in Communities (ARIC) Study5 and a study conducted in Evans County, Georgia.6 Figure. The “Stroke Belt” in the southeastern United States is composed of 11 states, part of another (southern Indiana*), and the District of Columbia. (Map/inset design and concept contributed by Michael McClain, Art Director, and Fred Balzac, Editor, of Chase Medical Communications, Wilton, CT, USA, based in part on a map provided by the National Stroke Association.) The ARIC Study is a prospective study of independent-living adults 45 to 64 years of age in Forsyth, North Carolina, Jackson, Mississippi, suburban …

Do antiphospholipid antibodies increase the long-term risk of thrombotic complications in young patients with a recent TIA or ischemic stroke?

The purpose of our study was to determine the relative risk of thrombotic events in young patients with a recent TIA or ischemic stroke and positive antiphospholipid antibodies (aPL). We included 128 consecutive patients aged 18-45 years with a recent TIA or ischemic stroke. All patients underwent computed tomography scanning and were screened for cardiovascular risk factors, cardiac disorders and large vessel disease. Lupus anticoagulant (LA) was screened for by an APTT-based assay and a diluted PT-assay. Anticardiolipin antibodies (aCL) were tested by enzyme-linked immunosorbent assay, using cardiolipin and anti-human IgG and IgM. Thrombotic events could be TIA, stroke, myocardial infarction, deep venous thrombosis or pulmonary embolism. Product limit estimates of the time free of TIA or stroke and of the time free of any thrombotic event were made. The relative risk was estimated by means of a Cox proportional hazards regression model. Of the 128 patients, 22 (17.2%) had aPL. The mean follow-up was 3 years and 3 months (range 41 days to 6 yrs). The incidence of any thrombotic event per 100 patient years of follow-up was 9.0, and the incidence of recurrent stroke or TIA was 7.9. The relative risk of any thrombotic event in patients with aPL was 0.9 (95% CI: 0.3-2.4) and for recurrent ischemic stroke or TIA 0.7 (95% CI: 0.3-2.2). In young patients with a recent TIA or ischemic stroke, aPL do not seem to be a strong risk factor for recurrent stroke or TIA, nor for other thrombotic complications.

Abstracts of Literature

Abstracts of Literature

Incidence of Transient Ischemic Attacks in Dijon, France

The aim of this study was to determine the incidence of first-ever TIA and the distribution of risk factors in those patients with TIA in Dijon. We performed a prospective population-based study in Dijon City with 135,000 inhabitants, from 1990 to 1994, using several case-collection sources. Over a 5-year period, we recorded 258 cases of first-ever TIA, giving a crude annual incidence rate of 38.68/100,000 for men and 32.70/100,000 for women. The mean age of first-ever TIA was higher in women (71.75 years) than in men (70.35 years). A CT scan was performed in 97% of the cases and silent lacunes were discovered in 17% of cases. In our 5-year study in Dijon of first-ever TIA, we found incidence rates similar to those of previous population-based studies. Our results also support the hypothesis that risk factors for TIA are similar to those for stroke.

Long-term follow-up study after extracranial-intracranial bypass surgery for anterior circulation ischemia in childhood moyamoya disease.

Between May, 1974, and March, 1991, 104 patients with moyamoya disease, all under 16 years old at the time of first surgery, underwent superficial temporal-to-middle cerebral artery anastomosis and/or encephalomyosynangiosis. The mean follow-up period was 9.6 years (range 4.8 to 16.0 years). Hemiplegia was the most frequent symptom before the first operation. Transient ischemic attacks (TIA's) were noted in 57 patients and minor stroke with hemiplegia in 44. The most frequent type of cortical dysfunction was aphasia (21 cases). Postoperatively, the incidence of TIA's and/or completed stroke with motor weakness of the extremities was markedly decreased, but visual disturbance progressed and major or minor stroke with visual disturbance was found in two cases. In patients under the age of 3 years, a major stroke prior to surgery resulted in a poor outcome in 36% of cases. Preoperative major stroke in patients between the ages of 3 and 7 years was less frequent, and poor outcomes were seen in 17% of this group. There were no major preoperative strokes in patients with surgery after the age of 7 years, and no poor outcomes were recorded in this group. A major preoperative stroke prior to surgery had adverse impact on the ultimate patient intelligence quotient (IQ) following surgery. All patients operated on after the age of 7 years had a normal or borderline IQ at follow-up examination.