Recurrent Transient Ischemic Attacks Research Articles

Risk of Recurrent Neurologic Stroke or Transient Ischemic Attack in Patients with Cryptogenic Stroke and Intrapulmonary Shunt.

Cardio-embolic phenomenon is believed to underlie a significant proportion of cryptogenic strokes. We recently showed that intrapulmonary shunt (IPS) was associated with cryptogenic stroke and transient ischemic attack (TIA). We hypothesized that patients with prior cryptogenic stroke or TIA that had an IPS were at a higher risk for recurrent ischemic events. The population included subjects with cryptogenic cerebrovascular accident (CVA) or TIA. Inclusion criteria were age ≥18 years, sinus rhythm, and clinically indicated transesophageal echocardiography (TEE). Exclusion criteria were hemorrhagic CVA, septal defect, and patent foramen. Patients were followed from index TEE. Of 71 patients, 8 were lost to follow-up. A total of 23 patients had and 40 were without IPS. Average follow-up duration was 38.3 ± 19.2 months. Groups were similar at baseline. There was no significant difference in the recurrence of ischemic CVA or TIA in the IPS versus non-IPS groups (0% vs. 7.5%; P = NS). There was no difference between the incidence of hemorrhagic CVA in the IPS and non-IPS groups (4.3% vs. 5.0%; P = NS). The proportion of patients on warfarin in the IPS group was significantly higher compared to the non-IPS group (17.4% vs. 0%; P < 0.05). Patients with IPS and cryptogenic stroke or TIA did not have a higher recurrence of ischemic cerebral events. Warfarin was significantly higher at follow-up in the IPS compared to the non-IPS group, which may explain these findings. A study randomizing patients with IPS and cryptogenic stroke or TIA to warfarin or no warfarin would be of great interest.

Patent foramen ovale closure following cryptogenic stroke or transient ischaemic attack: Long-term follow-up of 301 cases.

Patent foramen ovale has been identified as a conduit for paradoxical embolism resulting in cryptogenic stroke or transient ischemic attack (TIA). We aimed to establish rates of death, recurrent stroke or TIA among patients undergoing PFO closure for stroke or TIA at our unit. A retrospective analysis of all PFO closure patients was performed between May 2004 and January 2013. Follow up was performed by mortality tracing using the Medical Research Information Service of the Office of National Statistics. With regard to stroke or TIA recurrence, written consent forms and questionnaires were mailed with follow up telephone calls. Medical notes and imaging records were consulted where adverse events were noted. 301 patients aged 48.6 ± 11.0 years, 54.4% male, with ≥1 thromboembolic neurovascular event had percutaneous PFO closure with one of eight devices, with successful implantation in 99% of cases. Follow-up duration was 40.2 ± 26.2 months (range 1.3-105.3); complete in 301 patients for mortality (100%) and 283 patients (94.0%) for neurovascular events. Two patients died during follow-up (respiratory failure n = 1; road traffic accident n = 1). Recurrent stroke (MRI or CT confirmed) was observed in five patients (0.5%; 0.55 per 100 person-years) and TIA in 9 (1.1%; 0.98 per 100 person-years). Atrial fibrillation requiring treatment was documented in 14 patients (1.7%). Percutaneous PFO closure in patients with cryptogenic stroke or TIA is a safe treatment with a low incidence of procedural complications and recurrent neurovascular events. Registry data like these may help to demonstrate the utility of PFO closure in stroke.

Encephaloduroarteriosynangiosis for adult intracranial arterial steno-occlusive disease: long-term single-center experience with 107 operations.

Encephaloduroarteriosynangiosis (EDAS) is a form of revascularization that has shown promising early results in the treatment of adult patients with moyamoya disease (MMD) and more recently in patients with intracranial atherosclerotic steno-occlusive disease (ICASD). Herein the authors present the long-term results of a single-center experience with EDAS for adult MMD and ICASD. Patients with ischemic symptoms despite intensive medical therapy were considered for EDAS. All patients undergoing EDAS were included. Clinical data, including recurrence of transient ischemic attack (TIA) and/or stroke, functional status, and death, were collected from a retrospective data set and a prospective cohort. Perren revascularization and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral grades were recorded from angiograms. A total of 107 EDAS procedures were performed in 82 adults (36 with ICASD and 46 with MMD). During a median follow-up of 22 months, 2 (2.4%) patients had strokes; both patients were in the ICASD group. TIA-free survival and stroke-free survival analyses were performed using the product limit estimator (Kaplan-Meier) method. The probability of stroke-free survival at 2 years in the ICASD group was 94.3% (95% CI 80%-98.6%). No patient in the MMD group suffered a stroke. The probability of TIA-free survival at 2 years was 89.4% (95% CI 74.7%-96%) in ICASD and 99.7% (95% CI 87.5%-99.9%) in MMD. There were no hemorrhages or stroke-related deaths. Angiograms in 85.7% of ICASD and 92% of MMD patients demonstrated Perren Grade 3 and improvement in ASITN/SIR grade in all cases. EDAS is well tolerated in adults with MMD and ICASD and improves collateral circulation to territories at risk. The rates of stroke after EDAS are lower than those reported with other treatments, including intensive medical therapy in patients with ICASD.

Atypical presentations of thrombotic thrombocytopenic purpura in middle-aged women with recurrent cerebral macrovascular thrombosis: a case report

Dear Editor, In the current clinical practice, minimal criteria to define thrombotic thrombocytopenic purpura (TTP) are the presence of signs of microangiopathic haemolytic anaemia and low platelet (PLT) count [1]. TTP relapses (20–50 % of cases) are defined as the recurrence of acute TTP symptoms 30 days after the first episode, while exacerbations occur within 30 days [2]. We here report on an atypical case of acquired TTP where minimal criteria were met only after many recurrent macrovascular ischemic events. A 42-year old Caucasian woman with a history of coronary and cerebral ischemic events was admitted on June 2013, following a recurrent transient ischemic attack (TIA). She had severe anaemia and thrombocytopenia with laboratory signs of intravascular haemolysis and mild renal impairment. In her past medical history, recurrent ischemic events occurred from 2008 to 2012, without known risk factors and regardless of treatment. The patient was treated with acetyl salicylic acid (100 mg daily) after the first ischemic event (stroke, in 2008) plus anticoagulation with warfarin after the third stroke (in 2010), with a good compliance . Screening for autoimmune disease, Factor V Leiden and Factor II (G20210A) gene mutations and circulating anticoagulants were normal. Blood cell count and peripheral blood smear did not show any significant abnormalities in the past, without evidence of schistocytes; a slight decrease in PLT count (92×109/L) was observed only once (in 2012), at that time, ADAMTS13 activity (ADAMTS-13: AC) was 65 %. At the current admission, ADAMTS-13: AC was 6 %, inhibitors were at high titer (2 Bethesda Units, BU). A genetic test for Upshaw-Schulman syndrome was normal. Therapeutic plasma exchange (TPE) and prednisone (1 mg/kg body weight) treatment was started and maintained until clinical and haematological remission [3]. TPE (Gambro®, Italy) was performed daily for 3 weeks with an increase of ADAMTS13: AC to 50 %. TTP exacerbated after 10 days, it was well controlled with weekly rituximab (375 mg/m body surface), for 4 weeks. A relapse occurred after 37 days with the patient presenting seizures: ADAMTS-13: AC, which was 54 % after the last treatment, had decreased to 6 %. A second course of weekly rituximab, followed by maintenance with azathioprine (50 mg twice daily for 10 days, then 50 mg, daily) was followed by clinical and haematological remission. Rituximab was re-administered for its previous rapid efficacy and to prevent further complications [4]. The patient is alive and free from recurrences for 18 months; azathioprine maintenance is still on course. ADAMTS13: AC is monitored every 4 months, and it ranges from 45 to 51 %; inhibitors are no longer detectable. * Alessandro Lucchesi alessandro.lucchesi@irst.emr.it

Recurrent stroke in patients with patent foramen ovale: An observational prospective study of percutaneous closure of PFO versus non-closure

AimsObservational studies favor percutaneous closure of patent foramen ovale (PFO) over medical therapy to reduce the risk of recurrent stroke, whereas randomized clinical trials have not shown significant differences. This study aims to compare long-term outcomes of PFO closure versus non-closure. Methods and resultsPatients with PFO and stroke considered for PFO closure were invited to a long-term clinical follow-up. Of the 314 patients, 151 (48%) were accepted for closure and 163 (52%) were not accepted (mean age 50 vs. 58years). The cumulative incidence of all-cause mortality, stroke or transient ischemic attacks (TIAs) for closure vs. non-closure under a mean follow-up time of five years was 10.6% (16 events) vs. 12.9% (21 events), p=0.53. Six patients, 3.7% vs. 3.6%, died in each group, but no deaths were associated with PFO closure, recurrent stroke or TIA. The incidence of recurrent stroke or TIA for closure vs. non-closure was 6.6% (10 events) vs. 9.2% (15 events), p=0.63. The respective event rates for stroke were 3.9% (6 events) vs. 5.5% (9 events), p=0.50 and for TIA, 2.6% (4 events) vs. 3.7% (6 events), p=0.59. ConclusionPFO closure was associated with a low risk of recurrent events; however, compared to the non-closure group, no significant differences could be demonstrated. Careful patient selection can avoid under- as well as over-treatment of PFO patients.

PP03.16 – 2713: Metabolic disorder disguises in pediatric neurology practice

Objective To present the case of a male pediatric patient aged 2 years, who was admitted to our Department for brief paroxysmal episodes consisting in left hemiplegia, with sudden onset and ending. To study the paraclinical aspects and evolution of a condition with metabolic substrate and atypical clinical manifestations. Methods The child has been evaluated clinically and para-clinically during periodical admissions within one year, since the onset of the symptoms. We performed a full blood count, thrombophilia workup and testing for metabolic disorders. Repeated wake and sleep electroencephalographic recordings, a cerebral MRI and a cardiologic evaluation were also performed. The evolution under treatment with topiramate and later on, with levetiracetam, was noted. Results The neurologic examination of the patient was normal, except for a relative delay in the acquisition of expresssive language. The thrombophilia workup revealed a homozigous A1298C mutation in the MTHFR gene. Intermittent orotic aciduria was found. The seric homocysteine, folate, vitamin B12 were normal. The cardiologic evaluation was normal. All of the electroencephalograms performed over time were normal. The cerebral MRI was normal. The paroxysmal episodes remitted under treatment with topiramate, which the patient took for 7 months. The treatment was switched to levetiracetam, taking into consideration the parents' concern for the child's cognitive development. Under this treatment, the patient was also free of paroxysmal episodes. Conclusion The case illustrates a possible interconnected mechanism of production of the paroxysmal episodes described above. Initially, their clinical aspect pointed us towards three possible diagnoses: epileptic seizures, recurrent transient ischemic attacks (TIA) and hemiplegic migraine. The paraclinical tests favored the TIA hypothesis, with a combined, metabolic and hypercoagulability, substrate. Although no pathological electroencephalographic patterns were found, the epileptic hypothesis remains supported by the positive evolution under antiepileptic treatment, not only topiramate which could also be linked to migraine, but also levetiracetam.

Prevalence of Positive Diffusion-Weighted Imaging Findings and Ischemic Stroke Recurrence in Transient Ischemic Attack

The relationship between transient ischemic attack (TIA) clinical etiology, positive diffusion-weighted imaging (DWI) findings, and stroke recurrence is controversial. This study aimed to clarify the prevalence of positive DWI findings and TIA recurrence in relation to TIA patient characteristics. The subjects were patients admitted to our stroke unit within 7 days after symptom onset between January 2006 and July 2013. We examined DWI findings and TIA recurrence according to etiologic subtypes. We enrolled 139 patients with lacunar TIA (n = 17), atherothrombotic TIA (n = 35), cardioembolic TIA (n = 25), TIA due to other causes (n = 32), or TIA with undetermined etiology (n = 30). The prevalence of positive DWI findings was highest among the cardioembolic TIA patients (56.0%). No association was found between the prevalence of positive DWI findings and symptom duration, motor presence, or ABCD(2) score. Plasma d-dimer level was significantly higher in the DWI-positive group than that in the DWI-negative group (P = .01). The prevalence of TIA recurrence was highest (5 of 35, 14.3%) among the atherothrombotic TIA patients, regardless of positive DWI findings. None of the patients treated with the anticoagulant and antiplatelet combination therapy experienced a recurrence. In contrast, almost all patients with cardioembolic TIA received anticoagulant treatment and none experienced recurrence. The prevalence of positive DWI findings was high among the cardiogenic TIA patients. TIA recurrence was often observed among the atherothrombotic TIA patients treated with antiplatelets. Management of patients with atherothrombotic TIA requires further aggressive antithrombotic strategy.

Prediction factors of recurrent ischemic events in one year after minor stroke.

BackgroundThe risk of a subsequent stroke following a minor stroke is high. However, there are no effective rating scales to predict recurrent stroke following a minor one. Therefore, we assessed the risk factors associated with recurrent ischemic stroke or transient ischemic attack (TIA) within one year of minor stroke onset in order to identify possible risk factors.MethodsEight hundred and sixty-three non-cardioembolic ischemic stroke patients in the Chinese IntraCranial AtheroSclerosis Study that presented with minor stroke, defined as an admission National Institutes of Health stroke scale (NIHSS) score of ≤3, were consecutively enrolled in our study. Clinical information and imaging features upon admission, and any recurrent ischemic stroke or TIA within one year was recorded. Cox regression was used to identify risk factors associated with recurrent ischemic stroke or TIA within the year following stroke onset.ResultsA total of 50 patients (6.1%) experienced recurrent ischemic stroke or TIA within one year of minor stroke onset. Multivariate Cox regression model identified lower admission NIHSS score (HR, 1.75; 95% CI, 1.32 to 2.33; P<0.0001), history of coronary heart disease (HR, 2.62; 95% CI, 1.17 to 5.86; P = 0.02), severe stenosis or occlusion of large cerebral artery (HR, 4.68; 95% CI, 1.87 to 11.7; P = 0.001), and multiple acute cerebral infarcts (HR, 2.61; 95% CI, 1.01 to 6.80; P = 0.05) as independent risk factors for recurrent ischemic stroke or TIA within one year.ConclusionsSome minor stroke patients are at higher risk for recurrent ischemic stroke or TIA. Urgent and intensified therapy may be reasonable in these patients.

In-hospital stroke recurrence and stroke after transient ischemic attack: frequency and risk factors.

We aimed to assess the risk of recurrent ischemic events during hospitalization for stroke or transient ischemic attack (TIA) with optimal current management and to identify associated risk factors. We performed a retrospective analysis of all patients treated for acute ischemic stroke or TIA in 3 stroke units between 2010 and 2013. Recurrent stroke was defined as new persisting (≥24 hours) neurological deficit occurring >24 hours after the index event and not attributable to other causes of neurological deterioration. Cox proportional hazard regression identified risk factors associated with recurrent stroke. The study included 5106 patients. During a median length of stay of 5 days (interquartile range, 4-8), stroke recurrence (or stroke after TIA) occurred in 40 patients (0.8%) and was independently associated with history of TIA, symptomatic carotid stenosis (≥70%), or other determined etiology. Patients with recurrent stroke and other determined etiology had cervical arterial dissection (n=2), primary angiitis of the central nervous system (n=1), giant cell arteritis (n=1), and lung cancer with nonbacterial thrombotic endocarditis (n=1). In patients with initial TIA or minor stroke (National Institutes of Health Stroke Scale ≤5) recurrence was associated additionally with pneumonia after the inciting ischemic event but before stroke recurrence. Patients with initial stroke and aphasia had a lower stroke recurrence rate and there were no recurrences in patients with lacunar stroke. Recurrence was associated with significantly higher in-hospital mortality (17.5% versus 3.1%; P<0.001). In-hospital stroke recurrence was low with optimal current management. Patients with a history of TIA, severe symptomatic carotid stenosis, or uncommon causes of stroke were at higher risk. Pneumonia was associated with a higher risk of stroke recurrence in patients with initial TIA or minor stroke but not in the overall population studied. Aphasia may bias the detection rate by concealing new neurological symptoms.

Percutaneous patent foramen ovale closure: The Paradoxical Cerebral Embolism Prevention Registry

IntroductionThe natural history and therapeutic interventions for secondary prevention after a cerebrovascular event in patients with patent foramen ovale (PFO) are not yet established. This study aims to assess the safety and efficacy of percutaneous PFO closure in a population of patients with ischemic cerebrovascular disease of unknown etiology. MethodsThis prospective observational study included patients with a history of cryptogenic transient ischemic attack (TIA) or stroke who underwent percutaneous PFO closure. The effectiveness of the device for the secondary prevention of TIA or stroke was assessed by comparing observed events in the sample with expected events for this clinical setting. ResultsThe sample included 193 cases of percutaneous PFO closure (age 46.4±13.1 years, 62.2% female) with a mean follow-up of 4.3±2.2 years, corresponding to a total exposure to ischemic events of 542 patient-years. The high-risk characteristics of the PFO were assessed prior to device implantation. There were seven primary endpoint events during follow-up (1.3 per 100 patient-years), corresponding to a relative risk reduction of 68.2% in recurrent TIA or stroke compared to medical therapy alone. The procedure was associated with a low rate of device- or intervention-related complications (1.5%). ConclusionsIn this long-term registry, percutaneous PFO closure was shown to be a safe and effective therapy for the secondary prevention of cryptogenic stroke or TIA.

Encerramento percutâneo de foramen ovale patente – registo da prevenção da embolia cerebral paradoxal

IntroductionThe natural history and therapeutic interventions for secondary prevention after a cerebrovascular event in patients with patent foramen ovale (PFO) are not yet established. This study aims to assess the safety and efficacy of percutaneous PFO closure in a population of patients with ischemic cerebrovascular disease of unknown etiology. MethodsThis prospective observational study included patients with a history of cryptogenic transient ischemic attack (TIA) or stroke who underwent percutaneous PFO closure. The effectiveness of the device for the secondary prevention of TIA or stroke was assessed by comparing observed events in the sample with expected events for this clinical setting. ResultsThe sample included 193 cases of percutaneous PFO closure (age 46.4±13.1 years, 62.2% female) with a mean follow‐up of 4.3±2.2 years, corresponding to a total exposure to ischemic events of 542 patient‐years. The high‐risk characteristics of the PFO were assessed prior to device implantation. There were seven primary endpoint events during follow‐up (1.3 per 100 patient‐years), corresponding to a relative risk reduction of 68.2% in recurrent TIA or stroke compared to medical therapy alone. The procedure was associated with a low rate of device‐ or intervention‐related complications (1.5%). ConclusionsIn this long‐term registry, percutaneous PFO closure was shown to be a safe and effective therapy for the secondary prevention of cryptogenic stroke or TIA.

The Importance of Encephalo-Myo-Synangiosis in Surgical Revascularization Strategies for Moyamoya Disease in Children and Adults

The optimal surgical procedure (direct, indirect, or combined anastomosis) for management of moyamoya disease is still debated. We evaluated the outcome of our broad area revascularization protocol, the Tokyo Daigaku (The University of Tokyo) (TODAI) protocol, analyzing the relative importance of direct, indirect, and combination revascularization strategies to identify the optimal surgical protocol. The TODAI protocol was used to treat 65 patients with moyamoya disease (91 hemispheres, including 48 in 29 childhood cases collected during 1996-2012). The TODAI protocol combined direct superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis with indirect revascularization using encephalo-myo-synangiosis (EMS) forpatients ≥10 years old or indirect revascularization using encephalo-duro-arterio-synangiosis (EDAS) with EMS for patients ≤9 years old. Clinical outcome was evaluated retrospectively. Digital subtraction angiography was performed for postoperative evaluation of revascularization in 47 patients (62 hemispheres; 27 adults and 35 children). Based on the relative contribution of additional flow from each revascularization path, 4 revascularization patterns were established. The mean follow-up period was 90 months in children and 72 months in adults. Perioperative complications were seen in 4 of 48 operations in children and 1 of 43 operations in adults. Except for 1 child with recurrent transient ischemic attacks and 1 adult with intracerebral hemorrhage, the patients showed excellent clinical outcomes. Postoperative digital subtraction angiography evaluation showed that in STA-MCA anastomosis+ EMS cases (34 hemispheres; 25 adults and 9 children), STA-MCA anastomosis provided greater revascularization than EMS (STA-MCA anastomosis > EMS) in 7 hemispheres, the opposite was true (STA-MCA anastomosis < EMS) in 14 hemispheres, an equivalent contribution to revascularization (STA-MCA anastomosis ≈ EMS) was present in 12 hemispheres, and no functioning anastomosis was present in 1 hemisphere. In cases of EDAS+ EMS (28 hemispheres; 2 adults and 26 children), all hemispheres showed revascularization: EDAS was dominant to EMS (EDAS > EMS) in 1 hemisphere, the opposite (EMS > EDAS) was true in 14 hemispheres, and EDAS was equivalent to EMS (EDAS ≈ EMS) in 13 hemispheres. EMS plus direct or indirect anastomosis is an effective surgical procedure in adults and children. The TODAI protocol provided efficient revascularization and yielded excellent results in preventing strokes in patients with moyamoya disease with very few complications. EMS had a main role in revascularization in each of the combined techniques.

Abstract W P117: Risk of Carotid Revascularization During the Acute Period According to Neurological Instability

Background: Neurological instability may increase operative risks and decrease the benefit of early carotid revascularization in patients with carotid stenosis. This study aims to define the risks after carotid revascularization performed during the acute period stratified for the presenting neurological event. Methods: Consecutive patients undergoing carotid revascularization in 2009-2014 during the acute period (within 15 days from the last neurological event) were reviewed. Thirty-day and 4-year stroke/death rates were analyzed in patients presenting with Transient Ischemic attack (TIA), recurrent TIA (more than one in the last 2 weeks before treatment) and stable stroke. Results: There were 227 patients (71% males; mean age 73.6y): 104 (45.8%) were treated after stable stroke. In 46 (20.3%) recurrent TIA were recorded before treatment. According to timing, 123 interventions were performed within the first 7 days and 36 within the first 48hours from index symptom. At 30-day there were 2 deaths, 1 fatal cerebral hemorrhage and 4 recurrent ischemic strokes. 30-day stroke/death rate was 1.6% in patients with TIA, 4.9% in patients with stroke, 4.5% in those with recurrent TIA. Multivariable analysis (backward stepwise) for 30-day stroke/death risk identified recurrent TIA presentation as the strongest independent predictor (Odds ratio,OR, 16.8; 95% Confidence Interval, CI, 1.47-191.7; P=.023), while stroke presentation was retained as a borderline statistical predictor (OR 14.8; 95%CI 0.96-228.6; P= 0.05). At 4-year, survival (86% vs. 94.9% P=.034) and freedom from stroke recurrence (90.4% vs. 97%; P=.055) rates were lower for patients with stroke presentation compared to other patients. Patients with recurrent TIA a showed comparable 4-year outcomes than other TIA patients (survival 94% vs 95% P=. 93; Stroke freedom rates 97% vs 97%; P=.86) Conclusions: For symptomatic patients undergoing carotid intervention during the acute period, presentation with recurrent TIA may expose to increased periprocedural 30-day stroke/death risk. Nevertheless, stroke remains a major marker of poorer late outcomes while recurrent TIA does not impact long-term survival and stroke recurrence.

Abstract NS24: Algorithm Development to Improve Transient Ischemic Attack Outcomes

Background and Purpose: Management of care for the patient experiencing a transient ischemic attack (TIA) is inconsistent and compromises patient outcomes. This is due to the absence of a clearly defined protocol for TIA aimed at expediting care to reduce delays in diagnosis and treatment. The purpose of this study was to establish an evidence-based method for early identification, assessment, and consistent treatment of TIA. Methods: A TIA algorithm was designed and implemented based on translation of current evidence. Effectiveness of the algorithm was determined by comparing two separate groups using secondary data analysis of patients presenting to emergency department triage diagnosed with TIA six months prior to implementation of the algorithm (n= 80) and six months following implementation (n= 67). Patients in the implementation group received the evaluation and treatment outlined in the algorithm as the new standard of care. Primary outcomes were analyzed using a Chi-Square test of independence to evaluate recurrent ischemic events post-index TIA and independent samples t -tests for measuring length of stay (LOS) and total direct costs of care. Results: Significant reductions in overall direct costs of care [ t (121) = 7.23, p = .001, d = 1.20] and LOS [ t (142) = 2.40, p = .018, d = 0.40] associated with consistency in diagnostic testing and patient disposition were found. Recurrent TIA [ X 2 (1, N = 147) = 1.52, p= .22, r 2 = 0.01] and stroke [ X 2 (1, N = 147) = 2.83, p= .093, r 2 = 0.02] events post-index TIA were noted within the implementation group. Although not significant in this sample size, the clinical importance of findings demonstrated a 7.2% difference in overall stroke events with no recurrence of TIA as evaluated at 2, 30, 60, and 90-day time intervals. Conclusions: Findings from this study demonstrated that the use of a TIA algorithm was successful in guiding the interdisciplinary team to impact outcomes for the patient at risk for stroke. Recommendations for further testing of the algorithm in a multi-site cohort study would allow for a larger sample to evaluate this disease specific care model.

Abstract W P50: FLAIR Vessel Hyperintensity In TIA and Minor Stroke Predicts Early Recurrent Stroke

Objectives: FLAIR vessel hyperintensity (FVH) is frequently seen in patients with major acute ischemic stroke, but its significance in patients with transient ischemic attack (TIA) and minor stroke is not known. We sought to establish the prevalence of FVH in TIA and minor stroke and assess whether FVH predicts recurrent TIA or ischemic stroke. Methods: Consecutive patients from a prospective registry with high-risk TIA or minor stroke between 8/2012-7/2013 were analyzed based on these inclusion criteria: symptoms of unilateral weakness and/or speech deficit, NIHSS score ≤5, and completion of MRI within 48 hours of symptom onset. We excluded patients with isolated brainstem or cerebellar syndromes. MRI scans were reviewed by a single rater who was blinded to clinical data and used examples from published literature to score the presence of FVH and classify its location as proximal MCA, distal MCA, or PCA. After FVH rating, DWI and head and neck MRA were rated for presence of restricted diffusion and stenosis or occlusion. We employed univariable and multivariable statistics to identify independent predictors of FVH, and to examine the association between FVH and stroke recurrence. Results: Among 136 patients (mean age 69.5 ± 13.5 years; 43.4% female; 69.1% white; median NIHSS 1), 29 (21.3%) had FVH. The most common location was MCA (distal only 23; proximal only 1; distal/proximal: 3) with only 2 in the PCA. In multivariable analysis, the following variables were strongly associated with FVH: ipsilateral intracranial occlusion/stenosis (OR 13.7, 95% CI 4.8-39.2, p&lt;0.001) and cardioembolic TOAST subtype (OR 7.4, CI 2.3-23.4, p=0.001). Neither DWI lesion nor ABCD2 score was associated with FVH. Patients with FVH were more likely to experience recurrent stroke or TIA within 90 days (17.2% vs. 1.9%; p=0.005). Conclusions: FVH is common in high-risk TIA and minor stroke patients, is associated with ipsilateral intracranial stenosis or occlusion, and strongly predicts recurrent TIA or stroke within 90 days. Since FVH did not correlate with DWI or ABCD2 scores, it should be considered in larger studies of clinical-imaging prediction tools of stroke risk after TIA and minor stroke.

Abstract T P102: Recurrent Stroke Risk in Patients With ICAD Treated With Aggressive Medical Management: A Comparison With The Sammpris Trial

Background: Since the SAMMPRIS trial, aggressive medical management (AMM) with the use of dual antiplatelets (aspirin, clopidogrel) and high dose statin therapy has been standard of care for patients with symptomatic intracranial atherosclerotic disease (ICAD). However, there is limited data on the “real-world” application of this regimen. We hypothesized that 30-day recurrent stroke risk among patients treated with AMM would be similar to that in SAMMPRIS medically-treated patients. Methods: Using the prospective Northwestern University Brain Attack Registry, we identified all patients admitted between 8/1/12 and 1/31/14 with 1) confirmed ischemic stroke or transient ischemic attack (TIA); 2) independently adjudicated symptomatic ICAD; and 3) discharged on AMM. At 30 days (28-35 day window) post-stroke, patients or proxies were contacted by telephone to review events and outcomes. We also utilized an electronic surveillance system of hospital records at any of 3 health system hospitals with confirmation by manual review of the medical record in all instances of reported recurrent stroke or TIA. Ischemic stroke in the territory of the symptomatic stenotic artery was the primary outcome. We calculated 30-day rate of stroke in the territory of the stenotic artery and 95% confidence intervals using the Wald method and compared it with that reported in the SAMMPRIS trial. Results: Among 36 patients who met study criteria, 13 (36.1%) were female and mean age was 65.4 (± 9.7) years. Median initial NIHSS score was 4 (interquartile range 0-17). Symptomatic ICAD was localized to the anterior circulation in 21 (58%) patients and posterior circulation in 15 (41.7%). At 30 days, 3 of the 36 patients (8.3%, 95% CI 2.1-22.6%) had recurrent stroke compared to 5.8% in the medical arm of SAMMPRIS (p=0.47). An additional 3 patients (8.3%) experienced TIA within 30 days. Conclusions: In a single-center observational cohort study, we found that AMM in patients with symptomatic ICAD yielded similar rates of recurrent stroke at 30-days as observed in the SAMMPRIS trial. Our study provides “real-world” confirmation of the potential benefits of AMM in this high-risk stroke subtype.

English

Moyamoya disease is a rare cerebrovascular disease characterized by progressive occlusive cerebral arteritis affecting the distal internal carotid arteries near the circle of Willis. A collateral circulation develops around the blocked vessels which appear as a puff of smoke. Incidence is variable depending on the geographical location. The clinical features of Moyamoya disease are recurrent transient ischemic attacks (TIAs), strokes, sensorimotor paralysis, convulsions and/or migraine-like headaches. Magnetic resonance imaging (MRI) and MR Angiogram (MRA) should be performed for the diagnosis and follow-up of Moyamoya disease. Neurosurgical proceures like Encephalo myo synangiosis (EMS), multiple burr holes and some direct procedures are useful to reestablish new circulation after a few weeks. The long term outlook for patients with treated Moyamoya seems to be good. Once major stroke or bleeding take place, even with treatment, the patient may be left with permanent loss of function. So it is very important to treat this condition promptly. Herewith, we are reporting a 15 month old child with history of right focal adversive seizures, 34 events a month followed by post ictal drowsiness. Imaging studies revealed a vascular insult with infarct in the left fronto parietal lobes as well as multiple infarcts in other regions of the brain. MR Angio Brain revealed Moya moya disease. Child was successfully managed by prompt referral to Neurosurgical Centre where he underwent EMS and he is under their follow up.

Meta-Analysis of Net Long-Term Benefit of Different Therapeutic Strategies in Patients With Cryptogenic Stroke and Patent Foramen Ovale

We pooled available data on follow-up events in patients with patent foramen ovale and cryptogenic stroke to evaluate the net clinical benefit of different therapeutic strategies (percutaneous closure vs antiplatelet vs anticoagulant therapy). MEDLINE/PubMed and Cochrane databases and reviewed cited references to identify relevant studies were used; 3,311 patients from 21 clinical studies, both observational and randomized, with follow-up ≥12 months were overall included. Net clinical benefit was evaluated considering the cumulative incidence of both stroke and/or transient ischemic attack and major bleeding events. Anticoagulant therapy was more effective than antiplatelet therapy in preventing recurrent stroke and/or transient ischemic attack (event rates: 7.7% vs 9.8%, respectively, p = 0.03), but at the price of more than sixfold greater risk of major bleeding (7.1% vs 1.3%; odds ratio 6.49, 95% confidence interval 3.25 to 12.99, p <0.00001). Patent foramen ovale closure was associated over the long term with significant net clinical benefit versus both antiplatelet and anticoagulant therapy; such benefit was driven by 50% relative reduction of stroke and/or transient ischemic attack versus antiplatelet therapy and by 82% relative reduction of major bleeding versus anticoagulant therapy. In conclusion, results of this large study-level meta-analysis may influence practice patterns in patients with patent foramen ovale and cryptogenic stroke; an individualized approach tailored on both the risk of recurrent cerebral events and the bleeding risk should be used to identify the best therapeutic option (percutaneous closure vs antiplatelet therapy vs anticoagulant therapy).

Ivy Sign on Fluid-Attenuated Inversion Recovery Images in Moyamoya Disease: Correlation with Clinical Severity and Old Brain Lesions.

PurposeLeptomeningeal collateral, in moyamoya disease (MMD), appears as an ivy sign on fluid-attenuated inversion-recovery (FLAIR) images. There has been little investigation into the relationship between presentation of ivy signs and old brain lesions. We aimed to evaluate clinical significance of ivy signs and whether they correlate with old brain lesions and the severity of clinical symptoms in patients with MMD.Materials and MethodsFLAIR images of 83 patients were reviewed. Each cerebral hemisphere was divided into 4 regions and each region was scored based on the prominence of the ivy sign. Total ivy score (TIS) was defined as the sum of the scores from the eight regions and dominant hemispheric ivy sign (DHI) was determined by comparing the ivy scores from each hemisphere. According to the degree of ischemic symptoms, patients were classified into four subgroups: 1) nonspecific symptoms without motor weakness, 2) single transient ischemic attack (TIA), 3) recurrent TIA, or 4) complete stroke.ResultsTIS was significantly different as follows: 4.86±2.55 in patients with nonspecific symptoms, 5.89±3.10 in patients with single TIA, 9.60±3.98 in patients with recurrent TIA and 8.37±3.39 in patients with complete stroke (p=0.003). TIS associated with old lesions was significantly higher than those not associated with old lesions (9.35±4.22 vs. 7.49±3.37, p=0.032). We found a significant correlation between DHI and motor symptoms (p=0.001).ConclusionBecause TIS has a strong tendency with severity of ischemic motor symptom and the presence of old lesions, the ivy sign may be useful in predicting severity of disease progression.

Duration of symptom and ABCD2 score as predictors of risk of early recurrent events after transient ischemic attack: a hospital-based case series study.

BackgroundThe aim of this study was to refine clinical risk factor stratification and make an optimal intervention plan to prevent ischemic stroke.Material/MethodsClinical data, including diffusion-weighted imaging (DWI) findings, were collected in a cohort of hospitalized transient ischemic attack (TIA) patients from January 2010 to December 2011. Recurrent cerebrovascular events after TIA, including recurrent TIA, minor stroke, and major stroke, were identified by face-to-face follow-up. A multivariate, ordinal, logistic regression model was used to determine significant predictors of recurrent events.ResultsOf 106 TIA patients, 24 (22.6%) had recurrent TIA and 20 (18.9%) had a stroke within 7 days. Hypertension, dyslipidemia, a history of ischemic stroke or TIA, and ABCD2 score were significantly associated with the recurrent events after TIA (P<0.001, P=0.02, P<0.001, P=0.02). Hypertension (RR=9.21; 95% CI, 3.07–27.61, P<0.001) and duration of symptom (RR=1.10; 95% CI, 1.02–1.17, P=0.01) as an item of ABCD2 score were highly predictive of the severity of recurrent events, whereas ABCD2 score as a whole (P=0.18) proved to be less strongly predictive.ConclusionsA history of hypertension and long duration of symptom independently and significantly predict severe recurrent events after TIA within 7 days, but a high ABCD2 score was less strongly predictive of severe recurrent events.