Minor Stroke Patients Research Articles

Abstract 3932: High Rate Of Radiographic Stroke Recurrence In Cryptogenic TIA And Minor Stroke Patients: A Prospective Imaging Study

Introduction: Cryptogenic stroke (CS) mechanism in patients with TIA/Minor stroke has a recurrent stroke risk of 1-6% within 3 months. There is some evidence to suggest that an occult embolic phenomenon would be a likely cause of stroke in many patients with CS. It is likely that radiographic event rates are higher than clinical event rates which may potentially be a therapeutic target for proof of concept prevention trials. We sought to determine clinical and radiographic event rates in patients with cryptogenic mechanisms in a TIA/minor stroke population. Methods: Patients with TIA/Minor stroke (NIH Stroke Scale ≤ 3) were prospectively enrolled and imaged within 24 hours of symptom onset as part of two prospective imaging cohorts. [VISION (V) and CATCH (C)]. Patients were included if their baseline modified Rankin scale (mRS) was ≤1. All patients were followed clinically for 3 months to document any clinical recurrence and had a repeat MRI either at day 30 (V) or at day 90 (C). Stroke mechanisms were categorized as per TOAST criteria after parenchymal and vascular imaging and cardiac investigations. Patients were labelled as cryptogenic only after standard etiological workup for ischemic stroke including at least vascular imaging, transthoracic echocardiogram and holter monitoring was completed. Follow up imaging was assessed for any new lesions in comparison to baseline imaging. Results: Among patients enrolled in both prospective studies 380/844(45%) had cryptogenic stroke mechanisms. Of these, 215 patients had follow up imaging. There were 132 (61%) males. Intracranial occlusions was seen in 23/215 (10.6%) with baseline DWI abnormality documented in 66/215 (30.6%). In the VISION dataset, 5/76 (6.6%, 95%CI 2.2-15%) patients had new lesions on follow-up MRI at day 30. In the CATCH dataset 19/131 (14.5%: 9-22%) of patients had new lesions on follow-up MRI at day 90. Baseline DWI abnormalities was a significant predictor of new radiological lesions on follow-up imaging [p=0.003 OR 4.75 95% CI: 1.67-13.2]. Overall clinical recurrence was seen in 10/215 (4.6%: 2.2-8.4%) of patients. Baseline DWI abnormality was not a significant predictor of clinical recurrence (p=0.96). Conclusion: TIA/Minor stroke patients with cryptogenic mechanism show evidence of silent radiological accumulation of disease on follow up imaging at a higher rate than clinical recurrence. Repeat brain imaging at 3 months or potentially later may be a useful surrogate marker for disease activity in treatment trials in this population. There is a need for randomized controlled trials using novel anticoagulants with follow-up imaging as a surrogate marker of disease activity to improve treatment of cryptogenic minor stroke/TIA.

Abstract 3463: Physicians’ Knowledge of Driving Limitation Following Stroke or TIA is Inadequate

Background: An increasing number of TIA and minor stroke patients are assessed and discharged by front-line staff in emergency or acute assessment units. As capacity to drive is affected by a stroke or TIA, we assessed the level of knowledge of driving restrictions after stroke or TIA in frontline doctors. Method: A structured multiple choice questionnaire was used to assess knowledge of driving restrictions after stroke in 195 doctors involved in assessing patients in the Emergency Department or acute assessment units. The questionnaire took between 10-15 minutes to complete and tested knowledge of driving restrictions after minor stroke or TIA for those holding a domestic (Group 1) or a commercial (Group 2) licence. The wording of the questions was similar to that used in statutory medical guidance by the Licensing Authority. Results: The 195 doctors included 8 consultants, 88 senior residents, 22 junior residents and 77 foundation level trainees. Only 43 (23%) doctors had been specifically instructed about driving restrictions in stroke; 89 (45%) had received no formal education on driving restrictions following medical illnesses. The majority (155, 86%) were aware that it was patients’ responsibility to inform the licensing agency of driving restrictions due to medical illnesses. Only 72 (37%) and 84 (43%) doctors correctly identified that TIA patients were not allowed to drive for 1 month if holding a domestic licence and for 1 year if holding a commercial licence respectively. Forty eight (25%) believed that no restrictions applied after a TIA. Driving restrictions for stroke with complete recovery of 1 month for domestic and 1 year for commercial license were correctly answered by 56 (29%) and 117 (71%); only 23 (12%) thought that no restrictions applied. There were no significant variations in knowledge attributable to seniority, formal instruction of driving regulations or working with stroke patients. Conclusions: Doctors have limited knowledge of driving restrictions after TIA or minor stroke, which presents significant public safety and medico-legal risks. Innovative methods are required to improve the acquisition and retention this knowledge in front line doctors.

Abstract 2743: Effectiveness of Early Dual Antiplatelets in Patients with TIA and Minor Stroke: Post-hoc Analysis of CLAIR Study

Background Patients with symptomatic intracranial atherosclerosis are at high risk of early recurrent stroke. Dual antiplatelet therapy appears promising for early secondary prevention of stroke or TIA, yet the ideal patients to benefit from this regime have not been identified. Methods We investigated the efficacy and safety of early dual antiplatelets use in TIA and minor stroke patients (NIHSS 0-3) by performing a post-hoc analysis of CLAIR (Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis) study - a randomized, open-label, blinded-endpoint study in patients who had symptomatic large artery atherosclerosis, in whom micro-embolic signals (MES) were present on transcranial doppler monitoring. MES was used as surrogate marker for recurrent stroke risk. Analysis was by modified intention to treat. Results Sixty-five of 100 patients recruited had TIA or minor stroke (NIHSS 0-3); 30 received dual therapy (aspirin 75-60mg daily and clopidogrel 300mg day 1 then 75mg daily) and 35 received aspirin alone (75-160mg daily) for 7 days. 93% patients had intracranial stenosis. Mean onset-to-randomization was 2.3 days in dual therapy group and 3.2 days in monotherapy group (p=0.03). At day 7, 9 of 29 patients in dual therapy group and 18 of 34 patients in monotherapy group for whom data were available had ≥ 1 MES (relative risk reduction 41.4%, 95% CI 29.8-51.1, p<0.001). The median number of MES on day 7 was 0 in dual therapy group and 1.0 in monotherapy group (p=0.02). Two patients in monotherapy group had recurrent stroke. No patients had intracranial or severe systemic hemorrhage, except two patients in dual therapy group had minor bleeding. Conclusion Early dual therapy with clopidogrel and aspirin reduces MES at day 7 among patients with predominant intracranial atherosclerosis who had minor ischemic stroke or TIA, without causing significant bleeding complications.

Abstract 70: Predicting Recurrent Stroke After TIA And Minor Stroke: Results Of The Prospective CT And MRI In The Triage Of TIA And Minor Cerebrovascular Events To Identify High Risk Patients (CATCH) Study.

Background. TIA and minor stroke have a substantial risk of recurrent stroke, particularly within the first 48 hours. There is therefore a need to identify the highest risk patients urgently to implement early treatments. Imaging using MRI can identify patients at high risk for a recurrent stroke. However MRI is not available emergently in many institutions. If CT/CTA could identify high-risk patients then this would be more widely applicable. Methods. 510 consecutive TIA and minor stroke patients who were assessed by a stroke neurologist and had a CT/CTA completed within 24 hours of onset were prospectively enrolled. 420 had baseline brain MRI completed also. We used multiple imputation based on a previous meta-analysis of predictors of DWI positivity (motor or speech symptoms, atrial fibrillation, symptomatic carotid stenosis >=50% and symptom duration greater than 60 minutes) to impute MRI results for patients without baseline MRI. We assessed the risk of recurrent stroke within 90 days using standard clinical variables and predefined abnormalities on the CT/CTA at risk metric (acute ischemia on CT and/or intracranial or extracranial occlusion or stenosis >=50%) and MRI (DWI positivity). Results. There were 36 recurrent strokes (7.1% 95%CI: 5.0-9.6). Median time to event was 1 day (IQR 7.5). Median time from symptom onset to CTA was 5.5 hours (IQR: 6.4 hours), median time to MRI was 17.5 hours (IQR: 12 hours). In the univariate analysis; symptoms ongoing at first assessment, HR 2.2 (95%CI: 1.02-4.9), CT/CTA at risk metric, HR 4·0 (95%CI: 2·0-8·5) and DWI positivity 3.2 (1.3-7.6) predicted recurrent stroke. In the multivariable analysis only CT/CTA at risk metric (OR 3.6 (1.7-7.5, p=0.001) and DWI positivity (OR 2.3 (0.9-5.8) predicted recurrent stroke. Diagnostic accuracy of CT/CTA in predicting recurrent stroke was: sensitivity 67%, specificity 68%, PPV 14%, NPV 96%. Diagnostic accuracy of MRI: sensitivity 83%, specificity 40%, PPV 10%, NPV 97%. Using ROC analysis CT/CTA and MRI were not significantly different in their accuracy in prediction of recurrent stroke (0.67 versus 0.61, p=0.18). Conclusions. Early assessment of the intracranial and extracranial vasculature using CT/CTA predicts recurrent stroke and clinical outcome in patients with TIA and minor stroke. There is a trade off between sensitivity and specificity when CTA and MRI are compared. In many institutions CTA is more quickly available than MRI and given a median time to event of one day, physicians should access whichever technique is available quicker in their institution to allow implementation of aggressive secondary prevention treatments in appropriate patients.

Abstract 29: Initial NIHSS Predicts Poor Short-term Outcome After Minor Stroke Even at Very Low Scores

Background: Minor ischemic stroke patients often do not receive IV tPA due to mild or rapidly resolving symptoms as it is assumed that they will have excellent outcomes without treatment. Nevertheless, a substantial proportion of these patients have a poor outcome. It is unclear if this is due to factors such as preexisting disability, medical comorbidities, or recurrent stroke, or due to the deficits associated with the minor stroke, We hypothesized that initial stroke severity would predict poor short-term outcome even when the deficits are mild. Methods: We conducted a retrospective cohort study based on chart review of all patients with minor ischemic stroke, as defined by NIHSS≤6 at presentation, who were admitted to our hospital over a 30-month time period. Poor short-term outcome was defined by in-hospital death or discharge to any destination other than home. Results: Data were complete for 461 of 471 patients with minor stroke. A substantial proportion, 38% (95%CI 34-43%), had a poor short-term outcome, including 31% discharged to rehabilitation, 5% discharged to a nursing facility, and 2% dead or discharged to hospice. Impaired ambulation prior to admission was associated with a poor outcome (OR 3.4; 95%CI 1.1-10, p<0.03), but only present in 3% of patients. In multivariable analysis, poor outcome was strongly associated with initial NIHSS ( figure ; OR 1.5; 95%CI 1.3-1.7, p<0.001) and age (OR 1.04; 95%CI 1.03-1.06, p<0.001). Similarly, NIHSS predicted poor outcome when analysis was limited to initial NIHSS≤3 (OR 1.8; 95%CI 1.3-2.4, p<0.001). Of the 112 patients presenting within 4.5 hours of time last seen well, 15% received IV tPA and 45% were excluded solely due to mild or rapidly improving symptoms. NIHSS was lower in those patients excluded than in those who received tPA (median 2 vs. 5, p<0.001). After adjustment for age, NIHSS, and prior ambulatory status, there was no significant difference in poor outcome, which occurred in 42% of patients treated with tPA and 24% of those excluded due to mild or rapidly improving symptoms (OR 1.9 for poor outcome after tPA; 95%CI 0.4-9.5, p=0.43). Conclusions: More than one-third of patients with minor stroke had a poor short-term outcome, including nearly one-fourth of those who were excluded from IV tPA due to mild or rapidly improving symptoms. NIHSS was predictive of poor outcome at very low scores, consistent with the hypothesis that the deficits due to the initial stroke were responsible for poor outcome. However, the impact of tPA treatment in this population is uncertain.

SPREAD-STACI Study: A Protocol for a Randomized Multicenter Clinical Trial Comparing Urgent with Delayed Endarterectomy in Symptomatic Carotid Artery Stenosis

In patients with >50% carotid artery stenosis (as measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) suffering a transient ischemic attack or a minor ipsilateral stroke, carotid endarterectomy exerts maximum benefits, when performed within the first 15 days from the initial ischemic symptom. It is also known that the probability of a major stroke spikes within the first few days after a transient ischemic attack/minor stroke and then flattens out in the following days and weeks. It could be hypothesized that urgent carotid endarterectomy has greater benefit than delayed procedure. Demonstrate that urgent carotid endarterectomy is more effective than delayed interventions. Centers employing neurolgist/stroke physicians and vascular surgeons will enroll TIA or minor stroke patients with >50 % carotid artery stenosis (Nascet criteria), randomized in two groups: urgent carotid endarterectomy (within 48 hours) and delayed carotid endarterectomy ( operated between 48 hours and 15 days after onset of symptoms) Risk factors will be evaluated at enrollment. TIA will be classified by ABCD2 scoring system,and minor stroke by National Institutes of Health Stroke Scale (NIHSS) scores. The study will last 90 days per patient,starting from their initial symptom,and the follow-up will be performed by an indipendent neurologist. A total of 456 patients (228 / group) is needed to observe an absolute difference of 10% between groups. Primary end-point is reduction in all types of stroke, AMI or death in urgent endarterectomy groupo compared to delayed ones. Secondary end-points are: Reduction of ipsilateral ischemic stroke in group 1 with respect to Group 2 Identification of predictive risk factors and Confirmation of no different rate for hemorragic/ischemiccomplications between groups.

Transient Cognitive Impairment in TIA and Minor Stroke

Acute cognitive impairment and delirium occur after major stroke and are associated with poor cognitive outcome. We conducted a population-based study to determine whether transient cognitive impairment (TCI) is seen acutely after cerebral transient ischemic attack (TIA) or minor stroke, and whether it predicts long-term cognitive decline. Mini-mental-state examination was performed in consecutive testable patients with TIA or minor stroke (National Institutes of Health Stroke Scale ≤3) seen acutely (1-7 days) in the Oxford Vascular Study (2002-2005) versus after 7 days, and in referrals seen acutely who had a subsequent noncerebrovascular diagnosis. We defined TCI as a baseline Mini-mental-state examination score ≥2 points below the 1-month follow-up score, and identified cognitive impairment (Montreal Cognitive Assessment [MoCA] <26/30) and severe dementia at 1-, 2-, and 5-year follow-up. In 280 TIA and minor stroke patients (mean age/SD 73.5/11.8 years), TCI was more frequent in those seen at 1 to 7 days (80/206; 38.9%) versus later (14/74; 19%; P=0.002) or in noncerebrovascular patients (10/47; 21%; P=0.004). TCI was associated with acute confusion (OR, 5.5; 95% CI, 2.5-11.7; P<0.0001), acute infarct on computed tomography (OR, 2.0; 1.2-3.5; P=0.01), and with residual focal deficits (OR,1.94; 1.13-3.34; P=0.01). However, it was still seen acutely in those whose focal deficits had resolved by time of assessment (41/120; 34%). Although patients with TCI had similar Mini-mental-state examination score by 1 month compared with those without TCI, their 5-year risks of cognitive impairment (OR, 4.3; 1.2-15.7; P=0.03) and severe dementia (OR, 4.9; 1.0-25.8; P=0.05) were increased. TCI is a manifestation of TIA and minor stroke, and may persist beyond resolution of focal symptoms. Our findings have implications for definitions in TIA and minor stroke and suggest that cognitive fragility may be revealed by minor cerebrovascular events.

Outcome of Acute Ischemic Stroke in Very Elderly Patients: Is Intravenous Thrombolysis Beneficial?

Background/Aims: Intravenous tissue plasminogen activator (tPA) treatment is recommended in acute stroke within 3 h of onset; however, the benefit of its use in the elderly remains uncertain. We assessed the safety and efficacy of tPA treatment in elderly patients. Methods: We recruited 97 elderly Chinese patients aged ≧80 years with cerebral ischemia presenting within 3 h of onset. Favorable outcomes were defined as discharge to home and modified Rankin Scale (mRS) ≤2 at discharge. Results: For moderate to severe patients (NIHSS ≧6), the baseline characteristics between the tPA (n = 30) and non-tPA (n = 41) group were not different. The proportion of patients discharged home was 56.7 and 61%, respectively (p = 0.72). For patients with baseline mRS ≤2, the frequency of discharged mRS ≤2 was not different (27.3% of the tPA group and 26.9% of the non-tPA group; p = 1.00). Symptomatic intracranial hemorrhage was 6.7 and 2.4%, respectively (p = 0.31). For minor stroke patients (NIHSS ≤5), tPA was not considered and the outcome of those discharged home and mRS ≤2 was 73 and 88%, respectively. Conclusion: Elderly patients can be treated safely with intravenous tPA, whereas our data did not support routine thrombolysis. Further randomized trials in the elderly are encouraged.

Internal Border Zone Lesions as a Predictor of Early Neurological Deterioration in Minor Stroke Patients with Severe Arterial Steno-Occlusion

Early neurological deterioration (END) of acute ischemic stroke may be important because it can predict clinical outcomes. We described several cases with similar clinical findings but different outcomes and analyzed the characteristics of their imaging studies. We retrospectively analyzed minor stroke patients with severe arterial stenosis within 6 hours of stroke onset. We defined END as 4 or more deterioration of the National Institutes of Health Stroke Scale score. Diffusion-weighted imaging (DWI) lesions were classified as lesions of the pial artery (PI), perforating artery (PAI) and border-zone (BZ). We consecutively analyzed a total of 12 subjects in this study. The patterns of initial DWI lesions were internal BZ (50%), PI (50%), PAI (25%), and cortical BZ (16.7%). Among them, the number of subjects with END was 5, and the frequency of internal BZ on initial DWI was significantly higher in patients with END than in those without. In conclusion, the results of this study suggest that when internal BZ infarcts are detected in patients with acute minor strokes accompanied by severe arterial stenosis, close observation and careful management should be performed because END can be induced at an early stage.

Magnetic Resonance Imaging-Guided Thrombolysis in Minor Stroke

We thought your readers would like to know that mild or improving stroke symptoms remain a common cause for exclusion from intravenous tissue plasminogen activator (tPA) treatment. Still, up to 30% of these patients are at risk of death and dependence (1, 2). Clinical criteria are poorly predictive of proximal intracranial occlusion, and may thus underestimate the risk of subsequent neurological deterioration (3). Acute stroke magnetic resonance imaging (MRI) was shown to increase the safety of intravenous thrombolysis (4). We assessed the safety of MRI-guided thrombolysis in patients with minor deficits. Consecutive patients with baseline National Institutes of Health Stroke Scale (NIHSS) r4 and pretreatment MRI, including diffusion and perfusion sequences, were identified from a prospective database that included all patients treated with intravenous tPA between January 2008 and April 2010 (n5302). Twenty-eight patients had a baseline NIHSSr4; among these, three patients were managed with CT. Twentyfive patients were eventually included with a median NIHSS score of 4 (range, 0–4). Persistent occlusion and/or hypoperfusion were confirmed in all patients. All patients had limited diffusion lesions (median volume and range: 0 8, 0– 16 0 ml). Five patients had no visible lesion on diffusion MRI, while a perfusion defect and/or arterial occlusion were confirmed. All patients with perfusion MRI (n5 21) showed significant hypoperfusion volumes (median volume and range: 88 2, 0 9–206 2 ml) with a diffusion–perfusion mismatch. No symptomatic intracranial haemorrhage was observed. All patients were independent at three-months (modified Rankin scale: 0–2) (Fig. 1). These results are in line with a recent series of minor stroke patients (5) and confirm the safety of MRI-based thrombolysis in patients with minor stroke. A proximal occlusion was found in 68% of our patients, emphasising the necessity of a complete neurovascular assessment. The effectiveness of MRI-guided thrombolysis in minor stroke patients needs to be confirmed in randomised trials.

Transient Ischemic Attack and Stroke Can Be Differentiated by Analyzing the Diffusion Tensor Imaging

ObjectiveWe wanted to differentiate between transient ischemic attack (TIA) and minor stroke using fractional anisotropy and three-dimensional (3D) fiber tractography.Materials and MethodsThe clinical data, conventional magnetic resonance imaging (MRI), diffusion weighted imaging (DWI) and diffusion tensor imaging (DTI) were obtained for 45 TIA patients and 33 minor stroke patients. The fractional anisotrophy ratio (rFA) between the lesion and the mirrored corresponding contralateral normal tissue was calculated and analyzed. The spatial relationship between the lesion and the corticospinal tract (CST) was analyzed and the lesion sizes in the minor stroke patients and TIA patients were compared.ResultsTwenty-two of the 45 TIA patients (49%) revealed focal abnormalities following DWI. The rFA was significantly lower (p < 0.05) in the stroke patients (0.71 ± 0.29) compared to that of the TIA patients (1.05 ± 0.37). The CST was involved in almost all stroke lesions, but it was not involved in 68% of the TIA lesions. The TIA patients had significantly lower CST injury scores (3.25 ± 1.75) than did the stroke patients (8.80 ± 2.39) (p = 0.004).ConclusionOur data indicate that TIA and minor stroke can be identified by analyzing the rFA and the degree of CST involvement, and this may also allow more accurate prediction of a patient's long-term recovery or disability.

Potential Role of Group Clinics to Boost Outcomes Among Elderly Spanish-Only Speaking Stroke Patients

Ethnic minorities are generally at higher risk for experiencing a stroke and dying from a stroke than non-Hispanic Whites, but are less likely to have optimal stroke risk factor control. Part of this ethnic disparity in stroke outcomes can be attributed to sociocultural factors. As such, there is a need to use culturally sensitive qualitative analysis to explore various strategies for enhancing vascular risk reduction in minority stroke patients encountered in under-resourced health systems. One potential strategy could be the use of nurse-led group clinics. Group clinics might be a relatively straightforward way of supplementing physician-centered efforts to improve outcomes in under-resourced settings by improving efficiency and encouraging patient self-management. However, research is limited on the implementation of group clinics among low-income, ethnic minority populations. This study aimed to obtain information about the feasibility of successfully implementing group clinics to boost treatment adherence among elderly Spanish-speaking only stroke patients within an under-resourced urban health system. A total of 13 Spanish-only speaking participants aged >or=60 years discharged from a local government hospital in Los Angeles within 18 months of an index ischemic stroke, and 6 caregivers, engaged in focus groups and interviews. Structured interviews were conducted with 11 care providers and 9 administrators at the hospital. Framework analysis examined the data and elicited themes necessary for successful execution of nurse-led group clinics for promoting vascular risk reduction treatment adherence among Elderly Spanish-only speaking stroke patients encountered within an urban health care system.

Computed Tomography and Computed Tomography Angiography Findings Predict Functional Impairment in Patients with Minor Stroke and Transient Ischaemic Attack

Abnormalities on acute magnetic resonance imaging predict outcome in minor stroke and transient ischaemic attack patients. We hypothesised that noncontrast computed tomography and computed tomography angiography findings in minor stroke and transient ischaemic attack patients would also predict functional outcome. We analysed consecutive patients with a transient ischaemic attack or a minor stroke with an National Institute of Health Stroke Scale <or=3 who were assessed with a noncontrast computed tomography and CT angiography of the circle of Willis and neck within 24 h of symptom onset. We assessed the association between clinical or imaging features and functional impairment on the modified Rankin Scale (mRS >or=2 ) at 90 days. Among 457 patients, the median baseline National Institute of Health Stroke Scale score was 1. Median time from symptom onset to noncontrast computed tomography was 278 min (interquartile range 151-505) and median delay from noncontrast computed tomography to CT angiography was 3 min (interquartile range 0-13). At 90 days, 57 patients (12.5%) had a mRS >or=2. Clinical factors that were associated with functional impairment were age >or=60 years (RR 2.05 CI(95) 1.16-3.64) and baseline National Institute of Health Stroke Scale score >0 (RR 3.23 1.72-6.06). All the assessed computed tomography parameters (acute stroke on noncontrast computed tomography and intracranial or extracranial stenosis or occlusion) were individually predictive of functional impairment. A composite computed tomography imaging 'at risk' metric, defined by acute stroke on noncontrast computed tomography, Circle of Willis intracranial vessel occlusion or >or=50% stenosis, extracranial occlusion or >or=50% stenosis, was associated with poorer outcome (RR 2.92 CI(95) 1.81-4.71). The presence of an acute stroke on noncontrast computed tomography or an intracranial or extracranial occlusion or stenosis was associated with an increased risk of functional impairment. Multi-modal computed tomography could be used to identify high-risk transient ischaemic attack or minor stroke patients.

Prognostic indicators for mortality in transient ischemic attack and minor stroke.

In a prospective study, 129 consecutive patients with transient ischemic attacks (TIAs) and 80 consecutive patients with minor ischemic stroke, involving the carotid artery territory in both cases, were followed-up for six years from their inclusion during the period from January 1984 to October 1985. All patients were 40-80 years old at inclusion, the median age being 74 years in the TIA group and 76 years in the minor stroke group. Overall mortality in the TIA group was significantly higher than in the minor stroke group, [44%, (57/129) vs 20% (16/80), p < 0.0006 after correction for age], and that in the general population of Malmö. Pre-existing vascular disease was slightly more prevalent in the TIA than in the minor stroke group [27% (35/129 vs 21% (17/80), NS]. Of the 19 patients with intermittent claudication, who all died [12 (63%) of them due to myocardial infarction (MI)], 18 belonged to the TIA group and only one to the minor stroke group. The respective frequencies of the putative risk factors in the TIA and minor stroke groups were 28% (36/129) vs 9% (7/80) for hypertension (p = 0.016), 9% (12/129) vs 6% (5/80) for diabetes mellitus (NS), and 8% (10/129) vs 9% (7/80) for cardiac arrhythmia (NS). Mortality due to MI was higher in the TIA than in the minor stroke group[24% (31/129) vs 6% (5/80), p = 0.001]. Of the minor stroke patients, none without vascular disease died of MI.(ABSTRACT TRUNCATED AT 250 WORDS)

ESPRIT: is aspirin plus dipyridamole superior to aspirin alone in TIA or minor stroke patients?

Transient ischemic attack (TIA) or a (minor) ischemic stroke increases the risk of a recurrent stroke or death. Antiplatelet therapy with aspirin or clopidogrel is, in the absence of a potential cardiac embolic source, common practice to lower this risk. Until recently, adjuvant dipyridamole or low intensity oral anticoagulation were not generally prescribed in secondary prevention. In this article, we will summarize and discuss the published results of the European/Australasian Stroke Prevention in Reversible Ischemia Trial (ESPRIT). In this trial, treatments with anticoagulants, aspirin alone and the combination of aspirin plus dipyridamole were compared, in a multicenter, three-armed, randomized, open-label study in patients with TIA or minor stroke.

Transient Ischaemic Attack is an Emergency: Think about Best Current Stroke Prevention Options

A medical emergency is a condition that requires immediate action to prevent severe disability or death. Despite the apparent well-being of the patient after the ictus, transient ischaemic attack (TIA) is an emergency. Transient ischemic attack has long been known as a precursortomajorischaemicstroke.Inarecentmeta-analysis,the risk of stroke after TIA was estimated to be 31%, 64% and 87% at 2 days, 1 month and 3 months, respectively. In the same review, using only data from studies using active outcome ascertainment, the risk was estimated at 99%, 134% and 173% for the same time points (1). Half of the 90-day stroke risk occurs in the first 2 days after TIA, and 76% of strokes required hospitalization (2). The FASTER trial provided the first prospective evaluation of early risk of stroke after TIA in a randomized trial, enrolling patients within 24 h of symptom onset. In this selected population of minor stroke or TIA patients with weakness or speech disturbance for more than five minutes as part of their clinical event, the 90-day risk of stroke was 89% across treatment groups and the median time to the event was only 1 day (3). Thus, TIA portends a serious risk of early major stroke and the time window for intervention is short. Immediately after the resolution of neurological deficits, a patient has the whole high risk period before him. For patients with rapidly improving or fully resolved deficits, several reports indicate a high risk of deterioration and permanent deficits, especially for patients with a marked initial improvementon theNationalInstitute ofHealthStrokeScale(NIHSS) (4). Indeed, as a general rule, the risk of stroke and new neurologicaldeficitsishigherinpatientswithTIAthanamong patients with completed stroke, indicating an unstable ongoing process. In parallel, the long-term prognosis after TIA is grave. The combined risk of stroke, MI or death in the first year after TIA has been estimated at 22%, with the composite outcome primarily driven by the high stroke rate (5). A meta-analysis estimated a similar 22% annual rate of MI and a 21% annual rate of non-stroke vascular death after TIA (6). The concept of TIA has evolved, and a new definition has been proposed (7). The current WHO definition states that TIA is a sudden episode of neurological dysfunction, of vascularorigin,lastingo24h.Itissuggestedthatthediagnosis

Driving after a transient ischaemic attack or minor stroke

The frequency of adherence to the UK Driver and Vehicle Licensing Authority (DVLA) guidelines for patients referred to a neurovascular clinic is not known. Of 166 consecutive patients, 95 (57.2%)...

Factors Associated With a High Risk of Recurrence in Patients With Transient Ischemic Attack or Minor Stroke

The aim of our study was to identify factors associated with stroke recurrence after an initial minor stroke or transient ischemic attack (TIA) in a prospective hospital-series. Included in the series were 689 patients with NIHSS lower than 4 at hospital admission. The end point was a new neurological event (worsening >/=4 points in the initial NIHSS was considered as recurrence) at 90 days (and additionally at 7 days). Factors based on two previous reported scores (ABCD and SPI-II) were analyzed in relation with stroke recurrence: age, duration of symptoms >1 hour, weakness, speech impairment, initial hypertension, hypertension, diabetes, coronary disease, minor stroke versus TIA, prior stroke, and heart failure. We also analyzed: gender, hyperlipidemia, severe alcohol intake (>60gr/d), current smoking habits, peripheral arterial disease, atrial fibrillation, acute lesion in initial head computed tomography, severe symptomatic extra or intracranial arterial disease (SSAD; arterial stenosis >/=70%), previous TIA, and vertebrobasilar event. Patients were also analyzed separately according to diagnosis of TIA or minor stroke. 90-day recurrence occurred in 111 patients (16.1%), whereas 62 patients had 7-day recurrence (9%). The independent variables associated with 90-day recurrence were: SSAD (OR=4.97), weakness (OR=3.25), speech impairment (OR=1.96), severe alcohol intake (OR=4.18), heart failure (OR=2.41), previous TIA (OR=4.62), and vertebrobasilar events (OR=2.87). SSAD was independently associated with 7-day recurrence (OR=7.73) and also for TIA (OR=3.45) and minor stroke (OR=5.15) patients. An arterial study to discard SSAD would be necessary, in combination with clinical factors, to improve the identification of patients with a higher risk of 90-day recurrence after an initial minor stroke or TIA.

A Lancet Issue Devoted to Stroke

Marc Fisher MD Kennedy Lees MD Section Editors: The dominant theme of the January 27, 2007 issue of Lancet is stroke. In a new editorial policy the Lancet decided to publish themed issues of particular interest to both general clinicians and specialist researchers. Stroke is undoubtedly a disease that requires special attention: approximately 1% of the 6.5 billion people living on our planet—twice the population of Canada or 8 times the population of Switzerland—will die each year of stroke. Many of these strokes are either preventable or could be delayed to a more advanced age. Considering such figures, the Lancet editors have to be congratulated for their decision, which is an important step in the struggle to reduce the burden of stroke in our societies. They have carefully selected original articles, seminars, and reviews on stroke. In the following we will comment on the 4 original articles. ### Wahlgren N, Ahmed N, Davalos A, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L, Toni D, Vanhooren G, for the SITS-MOST investigators. Thrombolysis with alteplase for acute ischemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369:275–282. The European Agency for the Evaluation of Medicinal Products (EMEA) mandated a postlicensing observational registry of thrombolysis use in Europe as a condition of licensing. The web-based SITS-MOST registry was launched in response to this need and collected more than 6000 patients from nearly 300 European centers. #### Methods Any European center was eligible as long as they agreed to enter all consecutive patients and agreed to site monitoring and aggregrate data reporting. Both experienced and inexperienced thrombolysis sites were eligible. The primary outcomes were safety outcomes: symptomatic ICH and death at 3 months from treatment. #### Results Patients enrolled in the registry were typically similar to those enrolled in prior trials and stroke thrombolysis registries. The mortality rate was 11.3% and symptomatic ICH rate 7.3%. Excellent functional outcome was achieved in 39% of patients. #### Interpretation This experience represents the largest stroke thrombolysis registry globally. It documents the safety and effectiveness of alteplase for stroke in routine clinical …

Determining future stroke risk using MRI

While the relative utility of MRI vs CT in the hyperacute management of acute brain ischemia remains controversial, there is little doubt that MRI remains the most useful imaging modality for the diagnostic evaluation of these patients. Aside from its superior sensitivity, higher resolution, and broad availability, MRI also detects abnormalities in many patients with transient ischemic neurologic symptoms.1,2 Up to 50% of patients with TIA have diffusion-weighted imaging (DWI)–identified lesions on MRI if imaged within a few days of symptoms. Clinical features such as focal weakness and aphasia are associated with a higher probability of DWI positivity.3 MR angiography can also simultaneously detect abnormalities of the large extra- and intracranial arteries, an important cause of stroke. A major clinical issue is identifying who is at high risk for early recurrent symptoms. Few data on high-risk neuroimaging characteristics are available. MRI and in particular DWI may be especially useful in this regard. Recent studies have reported specific MRI findings associated with an increased risk of early recurrence in these patients.1,4,5 In one study, minor stroke and TIA patients with a lesion on DWI and a …