Presence Of Transient Ischemic Attack Research Articles

Pathological tortuosity of the internal carotid arteries in childhood

Objective — to identify the incidence of PT ICA in pediatric patients and assess their clinical significance depending on the clinical and anatomical forms. Methods and subjects. On the basis of the Department of Vascular Surgery of the Department of Emergency and Restorative Vascular Surgery of the Institute of Emergency and Restorative Surgery named after V. K. Husaka of the National Academy of Sciences of Ukraine, together with the Donetsk regional children’s psychoneurological dispensary, we conducted a screening study of brachiocephalic arteries in 420 children in the period from 2005 to 2007. The age of the patients is from 2 to 16 years, the average age is (9 ± 4) years. The control group consisted of 100 people without complaints, neurological deficits, and psycho‑emotional retardation. A comprehensive examination included an examination by a pediatrician, a pediatric neurologist, a cardiologist, a vascular surgeon, a psychoneurologist, a duplex scan of the brachiocephalic vessels, a study of cardiac hemodynamics (electrocardiography, echocardiography), and magnetic resonance imaging of the brain as indicated. The criteria for the hemodynamic significance of LV were considered to be: the presence of a septal inflection of the ICA, an angle < 60°, microaneurysms, loop formation, blood flow acceleration in the zone of LV > 140 cm/s, the value of the resistivity index in the presence of a microaneurysm < 0.5, in the absence of a microaneurysm > 0.7. The type of PZ ICA was determined according to the classification of J. Weibel and W. Fields (1965) with additions by J. Vollmar (1976). Results. Hemodynamically significant ISA was detected in 108 (25.7 %) children of the main group (in 32 (30 %) boys and 76 (70 %) girls), the presence of transient ischemic attacks was in 8 (7.4 %), ischemic stroke was in 5 (4.6 %) school‑age patients due to disease progression. The most clinically unfavorable clinico‑anatomical forms are S‑like PZ ICA (42 (39 %)) and loop formation (11 (10 %)). The most frequent neurological disorders in preschool children caused by the pathological tortuosity of the internal carotid arteries are delayed language development (29 (27 %), impaired adaptation in a team, delayed self‑care skills (delayed in neuropsychological development) (33 (31 %)), impaired emotional sphere and behavior (irritability, mild excitability) (84 (78 %)), sleep disturbances (16 (15 %)). The most serious neurological disorders in children with pathological tortuosity of the internal carotid arteries occur during the school period, which is the result of the progression of early cerebrovascular insufficiency. At this age, the following manifestations of early cerebrovascular insufficiency are typical: headache (100 (93 %)), decreased vision (35 (32 %)), decreased performance at school (88 (82 %)), irritability, anxiety, reduced work capacity, attention disorders (96 (89 %)), cerebral circulation disorders (5 (4.6 %)).Predominant neurological disorders in preschool‑aged children with PT ICA: delayed language development (29 (27 %)), delayed self‑care skills (delayed neuropsychological development) — 33 (31 %); disorders of the emotional sphere and behavior — 84 (78 %), sleep disorders (16; 15 %). Conclusions. Timely detection and early diagnosis of ICA in children by a screening examination prevent the progression of cerebrovascular insufficiency.

Timing of Carotid Intervention in Symptomatic Cerebrovascular Disease: Outcomes of a Single-Institution Experience

The optimal timing for carotid endarterectomy in patients with symptomatic cerebrovascular disease has remained unclear. We compared the clinical outcomes of carotid endarterectomy performed before and 2 weeks after symptom onset. A retrospective analysis was performed of patients who had presented to our institution with symptomatic cerebrovascular disease, defined by the presence of transient ischemic attack (TIA) or cardiovascular accident (CVA) symptoms, from January 2012 to February 2020. The data collected included demographics, National Institutes of Health stroke scale (NIHSS) and modified Rankin scale (mRS) scores, and postoperative complications, including recurrent TIA or CVA, myocardial infarction, and death during admission and at discharge. The patients were followed up for 1 year. The primary end points included NIHSS scores, mRS scores, and changes in the scores from baseline to 30 days, with the secondary end points extending to 90 days and 1 year. A total of 169 patients were included, of whom, 58.6% had undergone carotid endarterectomy within 2 weeks of symptom onset. The baseline demographic and clinical characteristics were similar between groups. No differences in the primary or secondary end points were demonstrated at any interval (P = 1.0, P = .77, and P = .4 for the 30-day NIHSS score, mRS score, and 30-day change in the mRS score, respectively; and P = .9, P = .22, and P = .07 for the 90-day NIHSS score, mRS score, and 1-year mRS score, respectively). We found a difference in postoperative complications, including recurrent TIA/CVA, myocardial infarction, and death. A subgroup analysis of interventional neurology involvement was performed; they had evaluated 44.4% of the patients. No further intervention was required for 42.7%, diagnostic cerebral arteriography was performed in 36.0%, and an additional intervention was required for 21.3%. Interventional neurology involvement demonstrated no differences in the primary or secondary end points. Carotid endarterectomy was safe if performed within 2 weeks of symptom onset with equivalent outcomes compared with delayed surgery. Involvement of interventional neurology did not affect the neurologic outcomes for early vs late operative timing.

Blood-Brain Barrier Leakage May Yield Clues to Presence of Transient Ischemic Attacks

Blood-Brain Barrier Leakage May Yield Clues to Presence of Transient Ischemic Attacks

Clinical neurological characteristics of ischemic stroke subtypes in acute phase

Objectives. The aim of the present study was to clarify clinical neurological characteristics and different ischemic stroke subtypes unfavorable course predictors in acute phase. Material and Methods. 482 patients with different ischemic stroke subtypes were observed. Among them there were 125 (25.9 %) with cardioembolic infarct (CEI), 119 (24.7 %) with large artery atherosclerosis (LAAS) infarct, 122 (25.3 %) with lacunar stroke (LAC), 116 (24.1 %) with stroke of undetermined etiology (UDE). The comparative analysis of clinical picture was performed. The predictors of unfavorable course of acute phase were established. Results. We have found out that severe neurological deficit, high mortality and the worst functional outcome during the first 14 days were observed in patients with CEI and LAAS. The highest frequency of early neurological deterioration (END) was detected at LAC (in 22.7 % of patients). There was a relationship between END and presence of transient ischemic attack (TIA) in past medical history, the level of systolic blood pressure (SBP) at the beginning of the disease and the degree of carotid arteries stenosis on the side of lesion. The patients with LAC had mild neurological deficit and better prognosis compared with other ischemic stroke subtypes. Among the clinical factors that have impact on the CEI, LAAS and UDE acute phase course were: the size of lesion, the level of consciousness on the 1st day, the baseline SBP, patient’s age. At LAAS, the presence of transient ischemic attack (TIA) in past medical history and low SBP in the onset of the disease (less than140 mm Hg) has an additional prognostic value for an unfavorable functional outcome. The severity of LAC in acute period depended on its localization and size. Localization of LAC in the internal capsule, thalamus and pons were characterized by the highest severity. Conclusions. Clinical neurological features of ischemic stroke depend on its subtype and have some prognostic value for the course of different ischemic stroke subtypes in acute phase.

Clinical Features, Surgical Treatment and Long-Term Outcome in Adult Patients with Moyamoya Disease in China

Background: Moyamoya disease (MMD) develops mostly in Asian countries including Japan, Korea, mainland China and Taiwan. However, there are few detailed demographic and clinical data about Chinese patients with MMD. Currently, the most effective treatment in adult patients with MMD is unknown. There have only been a few small case series reporting on encephaloduroarteriosynangiosis (EDAS) in an adult population. Here we describe the clinical features, surgical treatment and long-term outcome of adults with MMD treated at a single institution in China. Methods: Our cohort included 470 adult patients with MMD. The demographic and clinical characteristics were obtained by retrospective chart review and long-term outcome was evaluated using the stroke status. The modified Rankin Scale (mRS) was used to determine the neurological functional outcome. Univariate and multivariate logistic regression analyses were performed to determine risk factors for postoperative morbidity and functional outcome. The risk of subsequent stroke was determined using the Kaplan-Meier method and Cox regression was used to determine risk factors for postoperative or subsequent strokes. Results: The median age for the onset of symptoms was 36.8 (range, 18–59) years. The ratio of female to male patients was 1:1 (231/239). Familial occurrence of MMD was 2.3%. The most common initial symptom was a cerebral ischemic event. The incidence of postoperative ischemic events or hemorrhage was 5.9% (9.8% of patients). Older age at symptom onset, posterior cerebral artery (PCA) involvement and the presence of transient ischemic attack (TIA) were identified as predictors of adverse postoperative events. The Kaplan-Meier estimate stroke risk was 10.1% in the first 2 years, and the 5-year Kaplan-Meier risk of stroke was 13% after surgery for all patients treated with surgical revascularization. Older age at symptom onset, PCA involvement and the presence of TIA were identified as predictors of postoperative or subsequent strokes. Overall, 73.2% of patients had an independent life with no significant disability, with the strongest predictor being the preoperative mRS score. Conclusion: Clinical characteristics of adult MMD in China are different from those in other Asian countries. EDAS in adult patients with MMD carries a low risk, is effective at preventing future ischemic events and improves quality of life.

Effect of Cardiovascular and Metabolic Disease on Cognitive Test Performance and Cognitive Change in Older Adults

To examine the effect of cardiovascular and metabolic diseases on initial cognitive test performance and rate of change in three cognitive measures. Prospective cohort study. General practices in six towns throughout Germany. Three thousand three hundred twenty-seven participants aged 75 and older (average 79.7 ± 3.6). Data were collected during home visits every 18 months and included sociodemographic variables, depression, disease status, drug intake, and cognition. Although the presence of transient ischemic attack (TIA) or stroke and diabetes mellitus was related to poor initial cognitive test performance, the presence of those and other far-reaching chronic diseases or a higher disease burden were not related to the rate of change in cognition over time. Diabetes mellitus, stroke and TIA affect cognitive test performance beyond well-known sociodemographic variables and depressive symptoms, although none of these diseases contributed to cognitive decline over time. In practical terms, prevention and diagnosis of cardiovascular and metabolic diseases may be essential to cognitively healthy aging.

Can We Predict Early Recurrence in Acute Stroke?

Background: The prevention of early recurrent stroke, which worsens outcomes after a cerebral infarction, is a major objective for acute stroke therapy. The ability to predict which patients are at risk for early recurrence would be useful for both the management and design of clinical trials. Methods: Using the prospective database with the 1,266 stroke patients admitted in the TOAST study, we analyzed all the patients who had suffered either a transient ischemic attack (TIA) or a recurrent stroke within 3 months after stroke, and their possible association with 20 selected clinical variables. Both univariate and stepwise regression analyses were performed. Results: Sixty-two patients (4.9%) had a second stroke, and 47 patients (3.7%) had at least one TIA. No particular high-risk period was observed. Early recurrent stroke was associated with the large artery atherosclerosis subtype. A prior history of TIA increased the odds for recurrent stroke (OR = 2.52; 1.16–5.46) or poststroke TIA (OR = 3.46; 1.59–7.48). In addition, patients who had a TIA after the stroke had a 17% chance of having an early recurrent stroke, as compared with 4.4% among those that did not (p = 0.001). Conclusion: Our present ability to identify patients at risk for early recurrence based on baseline clinical features remains limited. While the presence of TIA before or after the stroke denotes a subgroup of acute stroke patients at higher risk for early recurrence in the first 3 months, no other factors reliably identify high-risk patients.

Cerebrovascular CO2 reactivity after carotid artery occlusion.

Cerebral blood flow (CBF) was measured in 39 men at normocapnia and after 5% CO2 inhalation using the xenon-133 technique. Twenty-three patients had unilateral carotid artery occlusion with no angiographic evidence of contralateral carotid artery stenosis or ophthalmic collateral flow. Eleven of these patients had undergone extracranial-intracranial (EC-IC) bypass surgery. Sixteen age-matched normal men underwent CBF measurements at normocapnia and hypercapnia to provide control data. Mean hemispheric CBF was not different between hemispheres ipsilateral and contralateral to the carotid artery occlusion either in the patients who had undergone bypass surgery or in those with carotid artery occlusion alone. Considering all patients with carotid artery occlusion, mean CO2 reactivity was decreased in the hemisphere ipsilateral to the occlusion as compared to the contralateral hemisphere in both groups. Based on data from normal individuals, a hemispheric difference in CO2 reactivity of more than 0.94%/mm Hg PaCO2 or a global CO2 reactivity of less than 0.66%/mm Hg PaCO2 was considered abnormal for an individual patient. Six of 23 patients with carotid artery occlusion (three with an EC-IC bypass) had global or hemispheric abnormalities in CO2 reactivity. Patients with impaired CO2 reactivity were not distinguishable from other patients by neurological examination, presence of transient ischemic attacks, or evidence of infarction on computerized tomography scanning. This test was safe and simple to perform and may be a useful means of detecting impaired cerebrovascular collateral reserve capacity. If impaired CO2 reactivity after carotid artery occlusion proves to be associated with a high risk of subsequent stroke, the test would provide a physiological basis for selecting a subgroup of patients who could be helped by cerebral revascularization.