Recurrent Transient Ischemic Attacks Research Articles

Successfully Procedure Endovascular Carotid Angioplasty Stent in a Case of Neck Stab Wound with Pseudoaneurysm, Recurrent Transient Ischemic Attack, and Horner Syndrome: A Case Report

Highlight: Uncommon Presentation and Diagnosis: The case report presents a unique and rare clinical scenario involving a 14-year-old boy who sustained a neck stab wound, leading to the development of a pseudoaneurysm within the common carotid artery. Multidisciplinary Approach to Treatment: The case highlights the complexity of managing such casesm where a multidisciplinary approach is paramount. The manuscript underscores the significance of involving neurology, interventional neurology, and vascular surgery teams to provide comprehensive and tailored patient care Efficacy of Endovascular Intervention: The successful outcome of the endovascular carotid angioplasty stent procedure highlights its effectiveness as a treatment option for addresing complex vascular conditions like pseudoaneurysm or dissection of the carotid artery. ABSTRACT Introduction: Neck stab wounds can lead to various vascular complications, including pseudoaneurysm or carotid artery dissection. Proper diagnosis and management can prevent recurrent strokes. Case: We reported a case of a 14-year-old boy with a previous left neck stab wound who developed recurrent transient ischemic attacks (TIAs) accompanied by Horner's syndrome and headache following a traumatic common carotid artery dissection. An angiographic examination revealed a pseudoaneurysm or dissection of the left common carotid artery. The patient was initially treated with oral anticoagulant therapy, but he continued to experience recurrent TIA. The patient was then treated endovascularly with a carotid angioplasty stent to restore the compromised carotid artery. Following the endovascular procedure, the patient experienced no complications, showed improvement in Horner syndrome, and had no headache. During the follow-up period, the patient had no more TIAs. Conclusion: Endovascular carotid angioplasty stents are an effective and safe way to treat pseudoaneurysm or dissection of the carotid artery, especially in cases presenting with recurrent TIAs and Horner syndrome. The observed clinical improvement following the procedure indicates significant benefits in enhancing the patient's quality of life and preventing complications from recurrent TIA episodes.

Changing or Retaining Direct Oral Anticoagulant After Ischemic Stroke Despite Direct Oral Anticoagulant Treatment.

The optimal antithrombotic strategies for patients with atrial fibrillation who experience ischemic stroke (IS) despite direct oral anticoagulant (DOAC) therapy remain inconclusive. This study compared outcomes for patients with DOAC treatment failure who changed or retained their prestroke DOAC. This retrospective cohort study analyzed data from the National Health Insurance Research Database from 2012 to 2020. Patients with atrial fibrillation who experienced IS during DOAC therapy were assigned to either (1) the DOAC-change group: changing prestroke DOAC or (2) the DOAC-retain group: retaining prestroke DOAC. The primary outcome was a composite of recurrent IS and transient ischemic attack. The secondary outcomes included intracranial hemorrhage, major bleeding, systemic thromboembolism, and all-cause death. Propensity score-based inverse probability of treatment weighting was applied to balance the baseline characteristics between the DOAC-change and DOAC-retain groups. The Cox proportional hazards model compared the risk of outcomes between the 2 groups. In total, 1979 patients were enrolled (609 DOAC-change patients and 1370 DOAC-retain patients). The incidence rates of recurrent IS or transient ischemic attack were 7.20 and 6.56 per 100 person-years in the DOAC-change and DOAC-retain groups, respectively (hazard ratio [HR], 1.07 [95% CI, 0.87-1.30]). A nonsignificantly higher incidence rate of intracranial hemorrhage was observed in the DOAC-change group compared with the DOAC-retain group (0.75 versus 0.53 per 100-person-years; HR, 1.49 [95% CI, 0.78-2.83]). The systemic thromboembolism, major bleeding, and death rates were comparable between the DOAC-change and DOAC-retain groups. Changing prestroke DOAC does not reduce the risk of recurrent cerebral ischemia in patients with atrial fibrillation who develop IS during DOAC therapy. However, future studies should continue to observe the potential trends of increased intracranial hemorrhage risk.

Recurrent Transient Ischemic Attack in the Elderly due to Asymptomatic Atrial Septal Defect: An Unusual Scenario

Atrial septal defects (ASD) are congenital cardiac anomalies, characterized by abnormal communication between the atria. These are commonly diagnosed in childhood and occasionally remain asymptomatic and undetected until the later stages of life. In ASD, there is communication between atria. Until the 4th decade of life, the majority of ASD are asymptomatic. Some exhibit the signs of exhaustion, syncope, exercise intolerance, and dyspnea with effort. Eisenmenger syndrome, paradoxical embolism, and atrial arrhythmias are among the problems that some people may later on develop. We describe a particular case of a 70-year-old male who arrived with a transient ischemic attack where he had left-sided upper limb weakness due to a paradoxical embolism due to ASD.

Angiographic Pattern of M1 Stenosis Predicts Territorial Stroke in Patients Receiving Aggressive Medication without Stenting

To evaluate the relationship between different angiographic patterns of middle cerebral artery M1 segment stenosis and related territorial stroke in patients receiving aggressive medical treatment without stenting. We retrospectively reviewed our patient registry database to identify ICAS patients diagnosed by digital subtraction angiography between January 2017 and December 2020 and identified 3 different angiographic patterns (normal, shift, and dilation) in 124 patients with M1 stenosis. The association between these patterns and recurrent ischemic stroke in the M1 territory was analyzed. The rates of recurrent M1 territorial stroke and transient ischemic attack in the normal group, shift group, dilation group and shift-dilation group were 34.5%, 35.0%, 78.3%, and 44.4% respectively. In patients with the shift pattern, the rate of recurrent stroke is significantly higher at a deflection angle ≥9.32° than at a deflection angle <9.32°(P < 0.05). In patients with dilation pattern, the rate of recurrent stroke is significantly higher than patients with non-dilation pattern (72.3% vs. 36.8%, P < 0.05). Angiographic patterns of M1 stenosis may predict recurrent territorial strokes, thus providing a surrogate marker to identify high-risk patients for potential endovascular treatment.

Bridge to Better Care: Investigating Transient Ischemic Attack (TIA) Management Expertise Among Primary Healthcare Providers in Al-Ahsa, Saudi Arabia.

Introduction Transient ischemic attacks (TIAs) are brief episodes of neurological impairment caused by reduced blood flow to the brain, spinal cord, or retina, typically lasting under an hour. Recent advances in neuroimaging suggest that some TIAs may actually be small strokes with resolved symptoms. This study focuses on assessing the knowledge and management of TIAs among primary care physicians and nurses in Al-Ahsa, Saudi Arabia. Methodology This isa cross-sectional study, conducted in Al-Ahsa, Saudi Arabia, during the period July to August 2023. Data were collected using an electronic questionnaire and was analyzed using IBM SPSS Statistics for Windows, version 27.0.1 (released 2020, IBM Corp., Armonk, New York, United States). Results Among the participants, 64.0% correctly identified TIA as an ischemic neurological deficit. However, only 20.2% provided correct responses for all TIA symptoms. Regarding diagnostic tests, 47.4% acknowledged the need for neuroimaging immediately after TIA, while 17.5% recognized the importance of ultrasonography of the supra-aortic trunks. In terms of TIA management, 38.6% preferred referral to the emergency service, and 41.2% correctly perceived the risk of TIA recurrence as similar to that of established cerebral ischemic stroke. Significant disparities were observed in the recognition of TIA symptoms, with physicians outperforming nurses, particularly in identifying motor deficits (82.4% vs. 65.2%) and speech alterations (86.8% vs. 76.1%, p = 0.004). However, nurses exhibited better knowledge in recognizing the need for a neuroimaging test (48.5% vs. 45.7%, p = 0.849) and the urgency of conducting a transcranial Doppler (TCD) (19.1% vs. 23.9%, p = 0.641). Conclusion A considerable proportion of healthcare providers demonstrate a good understanding of TIA definition and management. However, the lack of significant predictors for good knowledge and attitude suggests the need for more comprehensive strategies to enhance TIA management expertise across healthcare professionals.

Timing on patent foramen ovale closure: early versus delayed closure

Abstract Introduction Pivotal randomized clinical trials showed benefit in patent foramen ovale closure (PFOC) up to 9 months after a cryptogenic stroke or transient ischemic attack (TIA) [1-4]. It might be sensible to indicate PFOC also in non-recent cryptogenic strokes, but evidence is lacking. Purpose We aimed to compare the effectiveness of PFOC according to the time elapsed from the patient’s last episode of cryptogenic cerebrovascular event (CVE) or systemic embolism (SE). Methods A retrospective, international, multicentre, cohort study was performed to compare the outcomes of an early closure (EC, &amp;lt;9 months) or delayed closure (DC, ≥9 months) of patent foramen ovale (PFO) as secondary prevention after the index event. The primary end-point was recurrence of CVE or SE after PFOC. Results A total of 325 and 171 patients were classified in the EC and DC groups, with a median time to PFOC of 3.4 (IQR 1.9-5.5) and 17.5 (IQR 12.2-33.4) months, respectively. No significant differences were observed regarding the type of event indicating PFOC (stroke was the most frequent (77.8% in EC group vs 79.0% in DC group), followed by TIA (19.4% vs 18.7%)); neither about neuroanatomic localization of the lesions, nor contrast transcranial Doppler patterns, nor Risk of Paradoxical Embolism (RoPE) score (7 (IQR 5-8) vs 6 (IQR 5-7), p=0.077). Echocardiographic PFO characteristics of both groups were similar, except for a larger defect size (tunnel width) in the DC group (6 (IQR 4-14) vs 12 (IQR 6-16) mm, p=0.005)). PFOC device, procedural success (99.4 in EC vs 98.8% in DC group) and periprocedural complications (2.1 vs 0.8%) were comparable in both groups. Median follow-up was 2.0 (IQR 1.3-3.8) years in the EC group and 2.2 (IQR 1.2-4.9) in the DC group (p=0.721). No significant differences were observed concerning recurrence of stroke, TIA or SE (3.9% vs 2.6%, p=0.443), time from PFOC to recurrence (0.9 (IQR 0-2.1) vs 6.1 (2.5-8.8) years, p=0.090), death (1.4% vs 1.0%, p=0.697), residual shunt 12 months after PFOC, or antithrombotic treatment during follow-up (Figure 1). Moreover, a subanalysis considering those patients with a very delayed PFOC (≥24 months) after the index event also showed no differences in recurrence rate during follow-up compared to the earlier procedures (4.2% in the &amp;lt;24-month group vs 3.4% ≥24-month group, p=0.770). Conclusions No differences were observed regarding recurrences of CVE/SE in patients undergoing PFOC before and after 9 months from the index event. Despite the absence of evidence from randomized trials, this study suggests that the preventive benefit of PFOC after a cryptogenic CVE/SE may be extended beyond 9 months after the last event.Figure 1:Incidence of recurre

Abstract 16631: Isolated Cardiac Sarcoidosis Presenting as Recurrent Transient Ischemic Attacks

Background: Cardiac sarcoidosis (CS) is a rare disease that can present with a variety of clinical scenarios including, heart failure and sudden death. We present a case of isolated CS presenting as recurrent transient ischemic attacks (TIA) in a previously asymptomatic patient. Description of Case. A 54-year-old female with a history of two previous TIAs presented 30 minutes after the onset of left-sided facial droop and incomprehensible speech. CT and MRI brain did not show acute infarction. ECG showed a right bundle branch block pattern. Transthoracic echocardiogram (TTE) showed an abnormal global longitudinal strain of 12.8%, a left ventricular ejection fraction of 40%, segmental wall motion abnormalities involving the apex and basal inferior walls, and swirling of contrast at the apex. She had no previous history of cardiomyopathy. CTA was unrevealing for coronary artery disease but a cardiac MRI showed areas of late gadolinium enhancement and a RV wall aneurysm. PET scan revealed multifocal patchy nodular areas of FDG uptake within the myocardium. A diagnosis of isolated CS was made. At a three-month follow-up, TTE showed a new apical thrombus measuring 0.8cm x 0.6 cm. The patient was started on anticoagulation with the eventual resolution of the thrombus. She had no further ischemic events. Discussion. TIAs and ischemic stroke are extremely rare complications of CS and are largely attributed to cardioembolic phenomena, in the absence of systemic disease. Cardiac structural changes that lead to arrhythmias, hypokinesis, and stasis with clot formation largely explain embolic events in these patients. In addition, evidence suggests that the inflammatory cytokines, such as IFN gamma and IL-12, released by the sarcoid granuloma may also have an independent role in clot formation. The combination of stagnant flow in akinetic areas and a strong inflammatory bed of cytokines led to recurrent TIAs in this patient and the apical thrombus that was later identified.

Abstract 18826: Atrial Fibrillation, Atrial Myopathy, and the Risk of Recurrent Stroke or Transient Ischemic Attack After Cryptogenic Stroke

Background: The annual risk of recurrent stroke after cryptogenic stroke (CS) is estimated at 3-6%. Atrial myopathy, characterized by left atrial structural and electrophysiological remodeling, is associated with atrial fibrillation (AF) and stroke. Hypothesis: Atrial myopathy is associated with an increased risk of recurrent stroke or transient ischemic attack (rCVA) within one year. Methods: Patients with interpretable echocardiograms who received an implantable loop recorder for CS at a tertiary care medical center (2015-22) were included and followed for at least 1 year. Left atrial emptying fraction (LAEF) and reservoir strain (LARS) were calculated from two-dimensional transthoracic echocardiograms. Covariates including congestive heart failure, hypertension, age, diabetes, sex, stroke/transient ischemic attack, vascular disease, carotid artery stenosis, and rCVA were ascertained by review of hospital medical records. Incident AF post CS was obtained from review of loop recorder data. Odds ratios were calculated using logistic regression models. Two-sided student's T-test was used to compare means of continuous variables. Results: 159 patients (mean age 74.4 years, 52.1% female) were followed for at least one-year post CS. Patients with rCVA had significantly lower LAEF (p=0.012) and near-significantly lower LARS (p=0.088) compared to those who did not. The odds of rCVA were 4.82 (2.22, 7.11)-fold greater in those found to have new AF independent of LAEF, LARS, and remaining covariates including carotid artery stenosis. Patients on anticoagulation at time of rCVA had trends towards reduced stroke severity (p=0.184). Conclusions: Atrial myopathy characterized by AF or reduced LA function is associated with rCVA post CS.

Abstract 127: Delayed Thrombectomy In A Patient With Recurrent MCA Strokes

Introduction Prior research has demonstrated mechanical thrombectomy (MT) to be a safe and effective treatment for stroke patients with a large vessel occlusion (LVO).1 However, MT has generally only been studied in a time window of less than 24 hours.2 To the best of the authors' knowledge, this case report is the first publication of a MT done months after the initial stroke event, in a patient with recurrent strokes and an evolving occlusion visualized in the middle cerebral artery (MCA). Methods The patient is a 55‐year‐old man with a past medical history of a left‐sided MCA stroke 2 months prior to current admission with multiple transient ischemic attacks (TIAs) on dual antiplatelet therapy (DAPT), with no persistent residual deficits. His first stroke was preceded by about 1 week of intermittent confusion and right arm tingling. MRI at the time showed an acute embolic infarct in left MCA territory, and a CTA showed a sub‐occlusive thrombus vs. atherosclerotic plaque in the superior branch of the left MCA. He was discharged on DAPT, but his prior symptoms began to recur on a weekly basis, lasting for a few minutes each time. The patient eventually presented on this admission to the ED with persistent dysarthria and word finding difficulties. Within 4 hours, his exam improved to an NIHSS of 0. An MRI without contrast showed a new acute punctate infarct in the posterior left lateral temporal cortex. CT angiogram showed a persistent left M2 occlusion which was confirmed by the diagnostic cerebral angiogram. CT Perfusion also showed a large penumbra in the same region. The decision was made to perform MT, and complete recanalization was achieved. On 2‐month follow‐up, the patient continues to report no new symptoms since the time of MT. Results The patient’s positive outcome thus far at 60 day follow up indicates that MT can prove safe and efficacious even in significantly delayed time windows. This also shows that the decision to proceed with MT ought not to depend on time interval and degree of collaterals alone, but also on the pattern of symptoms the patient is exhibiting. The recurrent TIAs and strokes our patient was having indicates that, although collaterals had formed in response to his sub‐occlusive thrombus in the MCA, they were still unable to provide full compensation for this lost blood flow, leading to the patient’s intermittent symptoms. Conclusion This report demonstrates that MT can be safely and effectively utilized even in significantly delayed time windows in patients with recurrent TIAs or strokes.

Abstract 101: Ophthalmic Artery Aneurysm Embolization Resulting in Resolution of Headaches and Visual Symptoms

Introduction Cerebral aneurysms are a rare cause of headaches and visual symptoms. Most common locations include anterior communicating artery, internal carotid arteries (ICAs), middle cerebral arteries, and tip of the basilar artery. While most unruptured aneurysms are asymptomatic, when symptoms do occur, they are most often headaches, cranial nerve palsies, or bilateral temporal hemianopsia due to compression of surrounding nerves or the optic chiasm. Rarely, thrombus formation within an aneurysm can lead to symptoms via distal embolization and infarction. The literature is limited regarding repeated aneurysmal microembolism formation or transient alterations in blood flow dynamics leading to episodic symptoms. Methods We report the case of a 55 year‐old woman with Ehlers‐Danlos syndrome and syringomyelia who presented to the hospital with one week of intermittent left eye visual disturbances, characterized by either complete transient monocular vision loss or blurriness lasting for 30 seconds at a time and occurring multiple times per day. These symptoms were also associated with pressure‐like headaches that originated around the left eye and radiated to the left side of her head. Results Neurological and ophthalmological examinations were notable for normal cranial nerve function, including intact visual acuity, visual fields, color vision and extraocular movements in each eye. On a dilated fundoscopic exam, there were no retinal or optic disc abnormalities. The rest of the neurological exam was normal. Head and neck CTA and subsequent digital subtraction angiography (DSA) showed multiple bilateral ICA aneurysms, as well as a 4 millimeter left ophthalmic artery aneurysm. Brain and orbits MRI with contrast showed no acute abnormalities, including no evidence of infarction or intracranial hemorrhage. She was started on clopidogrel due to concern for recurrent retinal transient ischemic attacks as well as escalating doses of nortriptyline for empiric treatment of possible ocular migraines. In follow‐up three months later, she continued to have the same visual and headaches symptoms. She underwent a successful elective flow diversion embolization of the ophthalmic artery aneurysm with subsequent resolution of her symptoms Conclusion Here we describe a case of a patient who presented with episodic monocular vision changes and headaches ipsilateral to an ophthalmic artery aneurysm, who experienced complete resolution of these symptoms following flow diversion embolization of the aneurysm. Although the precise pathophysiological relationship between the aneurysm and her visual symptoms is unclear, potential mechanisms include aneurysmal microthrombus formation with retinal embolization and dissolution, hemodynamic retinal blood flow changes related to the aneurysm, or recurrent ocular migraines triggered by the ophthalmic artery aneurysm.

Long-term clinical outcomes for patients with uncrossable patent foramen ovale.

Patent foramen ovale (PFO) closure is performed in selected patients with cryptogenic stroke to prevent recurrence. The prognosis of patients with uncrossable PFO after failed guidewire or catheter passage during the procedure remains unknown. We compared the long-term prognosis between uncrossable PFO and successful PFO closure in patients with high-grade PFO shunts. We analyzed patients who underwent PFO closure for stroke or transient ischemic attack (TIA) prevention at Gachon University Gil Medical Center between April 2010 and March 2022. The primary outcome was a composite of recurrent stroke or TIA. Secondary outcomes included stroke, TIA, all-cause death, and a composite of stroke, TIA, and all-cause death. Of 286 patients, 245 were included in the analysis after excluding those with transseptal puncture technique usage or concurrent atrial septal defect. Among them, 82 had uncrossable PFO, and 163 underwent successful PFO closure. Large shunts were more prevalent in the PFO closure group compared to the uncrossable PFO group (62.0% vs. 34.1%, P < 0.001), and resting shunts were also more common in the PFO closure group (17.8% vs. 2.4%, P < 0.001). Stroke or TIA occurred in 2 patients (2.4%) in the uncrossable PFO group and 8 patients (4.9%) in the PFO closure group (hazard ratio, 1.44; 95% confidence interval, 0.30-6.81; P = 0.647). Additionally, no disparities in the occurrence of stroke or TIA were found in subgroups divided by baseline characteristics, RoPE score, or shunt grade. Clinical outcomes for patients with uncrossable PFO seem similar to those with successful PFO closure.

Independent external validation of a stroke recurrence score in patients with embolic stroke of undetermined source

BackgroundEmbolic stroke of undetermined source (ESUS) accounts for a substantial proportion of ischaemic strokes. A stroke recurrence score has been shown to predict the risk of recurrent stroke in patients with ESUS based on a combination of clinical and imaging features. This study aimed to externally validate the performance of the ESUS recurrence score using data from a randomized controlled trial.MethodsThe validation dataset consisted of eligible stroke patients with available magnetic resonance imaging (MRI) data enrolled in the PreDAFIS sub-study of the MonDAFIS study. The score was calculated using three variables: age (1 point per decade after 35 years), presence of white matter hyperintensities (2 points), and multiterritorial ischaemic stroke (3 points). Patients were assigned to risk groups as described in the original publication. The model was evaluated using standard discrimination and calibration methods.ResultsOf the 1054 patients, 241 (22.9%) were classified as ESUS. Owing to insufficient MRI quality, three patients were excluded, leaving 238 patients (median age 65.5 years [IQR 20.75], 39% female) for analysis. Of these, 30 (13%) patients experienced recurrent ischaemic stroke or transient ischemic attack (TIA) during a follow-up period of 383 patient-years, corresponding to an incidence rate of 7.8 per 100 patient-years (95% CI 5.3–11.2). Patients with an ESUS recurrence score value of ≥ 7 had a 2.46 (hazard ratio (HR), 95% CI 1.02–5.93) times higher risk of stroke recurrence than patients with a score of 0–4. The cumulative probability of stroke recurrence in the low-(0–4), intermediate-(5–6), and high-risk group (≥ 7) was 9%, 13%, and 23%, respectively (log-rank test, χ2 = 4.2, p = 0.1).ConclusionsThis external validation of a published scoring system supports a threshold of ≥ 7 for identifying ESUS patients at high-risk of stroke recurrence. However, further adjustments may be required to improve the model’s performance in independent cohorts. The use of risk scores may be helpful in guiding extended diagnostics and further trials on secondary prevention in patients with ESUS.Trial registration: Clinical Trials, NCT02204267. Registered 30 July 2014, https://clinicaltrials.gov/ct2/show/NCT02204267.

Diagnostic value of ABCD2 and ABCD3-I risk scoring systems in determining one-month risk of stroke in patients with transient ischemic attack: An observational study

Objective: To compare the diagnostic value of the ABCD2 and ABCD3-I scoring systems in predicting the development of a 30-day neurological event in adult patients with transient ischemic attack (TIA) presenting to the emergency department. Methods: The study was observational and prospective and was conducted in a single center. The diagnostic values of the ABCD2 and ABCD3-I scores in predicting a neurological event within one month were compared in patients diagnosed with TIA in the emergency department. Results: A statistically significant difference was observed between groups with or without stroke within one month in terms of both the ABCD2 and ABCD3-I scores (P=0.044 and P=0.029, respectively). There was no statistically significant difference between the patients with and without a recurrent TIA within one month in relation to the ABCD2 score (P=0.934), but a statistically significant difference was found in the ABCD3-I scores of these groups (P&lt;0.001). Conclusions: Both the ABCD2 and ABCD3-I scoring systems could predict ischemic stroke within 30 days of TIA, the ABCD3-I score is more effective than the ABCD2 score in the prediction of TIA recurrence.

Multimodal MRI study of the relationship between plaque characteristics and hypoperfusion in patients with transient ischemic attack.

Transient ischemic attack is a significant risk factor for acute cerebral infarction. Previous studies have demonstrated that hypoperfusion in patients with transient ischemic attack was associated with the recurrence of transient ischemic attack, stroke, and persistent worsening of neurological symptoms. Moreover, transient ischemic attack patients classified as high-risk group according to the ABCD2 score have a higher incidence of stroke. Therefore, the objective of this study was to investigate the plaque characteristics of transient ischemic attack patients with concomitant cerebral hypoperfusion using multimodal MRI, as well as hemodynamic changes in the high-risk group with transient ischemic attack patients. A total of 151 patients with transient ischemic attack were prospectively recruited for this study. All enrolled patients underwent multimodal MRI, including DWI, TOF-MRA, HR-VWI, and DSC-PWI. Finally, 56 patients met the inclusion criteria. Based on DSC-PWI images, patients were divided into two groups: hypoperfusion (n = 41) and non-hypoperfusion (n = 15). Clinical baseline characteristics and plaque characteristics were analyzed between the two groups. Furthermore, within the hypoperfusion group, patients were further classified into low-risk (n = 11) and high-risk (n = 30) subgroups based on the ABCD2 score. Hemodynamic differences between these subgroups were also analyzed. Compared with the non-hypoperfusion group, the hypoperfusion group had a significantly higher prevalence of hypertension (68.3% vs. 33.3%, p = 0.019) and hyperhomocysteinemia (65.9% vs. 33.3%, p = 0.029). Moreover, the hypoperfusion group exhibited more significant luminal stenosis degree [41.79 31.36 vs. 17.6213.62, p = 0.006] and greater NWI (57.1%20.47% vs. 40.21% 21.56%, p = 0.009) compared to the non-hypoperfusion group. In addition, the high-risk group identified by the ABCD2 score had a higher rMTT [117.6(109.31-128.14) vs. 108.36(100.67-119.92), p = 0.037]. Transient ischemic attack patients with hypoperfusion exhibited a higher prevalence of hypertension and hyperhomocysteinemia, as well as higher luminal stenosis degree, and greater NWI. Furthermore, Transient ischemic attack patients in the high-risk group demonstrated higher MTT.

Ticagrelor plus aspirin vs clopidogrel plus aspirin in mild non-cardioembolic ischemic stroke: A protocol of a randomized, controlled, active comparator arm, outcome assessor blind, feasibility study

Background &amp; Objectives: The risk of recurrence after a transient ischemic attack (TIA) or minor stroke is high especially within three months after first event. The aim of study is assessing the efficacy of ticagrelor plus aspirin in reduction of mild non-cardioembolic ischemic stroke or high risk TIA recurrence during first 3 months. Methods: This is a randomized, controlled, active comparator arm, outcome assessor blind, parallel group, feasibility study design on 90 patients with diagnosis of non-cardioembolic minor ischemic stroke or high risk TIA admitted in Bou-Ali Sina Hospital, Sari, Iran. After meeting all inclusion and exclusion criteria, patients will be randomized to ticagrelor 90 mg BID plus aspirin (ASA) 80 mg daily or clopidogrel 75 mg daily plus ASA 80 mg daily (1:1 ratio) until 21 days and then ASA 80 mg daily. Participants will be visited at month one and three. Any adverse events, serious side effects and outcome events will be recorded. The primary outcome is defined as ischemic stroke recurrence. Conclusion: Ticagrelor plus ASA is expected to be effective for prevention of recurrence in mild non-cardioembolic stroke and high risk TIA. Trial Registration: ClinicalTrials.gov: NCT04738097

Association between vertebrobasilar artery geometry and vertebrobasilar stenosis, recurrence, and death in posterior circulation stroke and transient ischemic attack

BackgroundIntracranial atherosclerosis is one of the primary causes of posterior circulation stroke and transient ischemic attack (TIA), particularly in people of South and East Asian heritage. Focal vessel geometry may play a role in atherosclerosis progression. Thus, we investigated the relevance of vertebrobasilar artery (VBA) geometry and vertebrobasilar atherosclerotic stenosis, recurrence, and death in posterior circulation stroke and TIA. MethodsFour hundred and twenty patients with posterior circulation ischemic stroke or TIA were included. The VBA geometric features, comprising the geometric configurations (Tuning fork, Walking, Lambda, and No confluence), vascular bends (multi-bending and oligo-bending), and VBA stenosis degrees, were defined based on computed tomography angiography (CTA) images. Recurrence of stroke or TIA and death were assessed through a 1-year follow-up. Additionally, the relationship between VBA geometric features, VBA stenosis, and prognosis were analyzed. ResultsWalking type and vascular multi-bending showed significant associations with more severe VBA stenosis and distribution, and these were also more frequently observed in patients with large-artery atherosclerosis (LAA) stroke (all P < 0.05). Sixty-four patients exhibited recurrent stroke or TIA, and 31 died during the 1-year follow-up. In the binary logistic regression analysis, Walking type (P = 0.018), Lambda type (P = 0.021), and multi-bending type (P = 0.004) were found to be independently associated with stroke recurrence, while No confluence type was independently associated with death (P = 0.010). ConclusionsThe geometric characteristics of the VBA are associated with vertebrobasilar stenosis, LAA stroke, 1-year recurrence, and death in posterior circulation stroke and TIA. VBA geometry may be used to stratify the risk of stroke and TIA in the posterior circulation.

Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy (CADASIL) with Rare Exon 7 Mutation in Pakistan: A Clinico-Genetic Correlation

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an autosomal dominant hereditary small vessel arteriopathy with a genetic predilection for early strokes and vascular dementia. CADASIL is a result of NOTCH3 gene mutation on chromosome 19. Typical manifestations range from migraine with aura, relapsing transient ischemic attacks (TIAs) and strokes to psychiatric symptoms, seizures and progressive dementia. This report identifies the first case of a rare C379S mutation in exon 7 of NOTCH3 in a Pakistani patient, presenting with initial symptoms of vertigo and dizziness and later with recurrent TIAs, subjective memory problems and migraines, hence expanding the spectrum of this condition.

Intracerebral hemorrhage and ischaemic stroke due to Moyamoya disease in young patients: a case report

Link of Video Abstract: https://youtu.be/DWVi34rPNOg Background: Moyamoya disease (MMD) is a non-atherosclerotic cerebrovascular disorder characterized by progressive stenosis of the distal part of the internal carotid artery (ICA), thus forming an abnormal vascular network in the base of the brain. MMD is often found in women. The common symptoms of MMD are migraine, epilepsy, recurrent transient ischemic attack (TIA), ischemic stroke, and intracerebral hemorrhage. Stroke at young onset has challenges in looking for risk factors and etiology. A detailed examination is needed to prevent recurrent strokes. Case Presentation: Male 17-year-old complained of a throbbing headache on the right side for 5 months, with a numeric rating scale (NRS) 4. The headache duration was 24-72 hours, with a frequency of 1-2 times a month. Complaints are exacerbated by activity and improve when taking over medication. 2 months after the first onset, he felt severe headache with NRS 7, accompanied by weakness and tingling on the left side. All his laboratory results were within normal limits. Cerebral Digital Subtraction Angiography (DSA) results showed severe stenosis at the base of the right ICA bifurcation segment accompanied by slow flow at the right middle cerebral artery (MCA) and severe stenosis at the base of the left ICA accompanied by cross-filling to the contralateral anterior cerebral artery (ACA). Cortico-cortical collaterals were obtained from the posterior cerebral artery (PCA) branch covering the MCA area. The patient was diagnosed with MMD. Conclusion: MMD is a rare cerebrovascular disease that can be a risk factor for stroke at a young age. Diagnosis and evaluation of the collateral system need to be carried out through cerebral angiography so that the selection and consideration of appropriate management of recurrent stroke attacks can be carried out.

In praise of pioglitazone: An economically efficacious therapy for type 2 diabetes and other manifestations of the metabolic syndrome.

Pioglitazone improves glycaemic control, not only by lowering insulin resistance, but also by improving beta cell function. Because of the improved beta cell function the glycaemic control that occurs with pioglitazone is prolonged. Pioglitazone has positive effects not only on cardiac risk factors and surrogate measures of cardiovascular disease, it also lowers the incidence of cardiac events in patients with diabetes. The recurrence of transient ischaemic attack and ischaemic stroke is also reduced in non-diabetic, insulin-resistant subjects. Utilized at preclinical stages (but not later) of heart failure, pioglitazone improves diastolic function and avoids progression to heart failure. Pioglitazone, through suppression of atrial remodelling, also decreases the incidence of atrial fibrillation. The manifestations of diseases associated with insulin resistance (non-alcoholic steatohepatitis and polycystic ovary disease) are also improved with pioglitazone. Pioglitazone may possibly improve psoriasis and other dermopathies. Pioglitazone is therefore an inexpensive and efficacious drug for the insulin-resistant subject with diabetes that is underutilized because of biases that have evolved from the toxicities of other thiazolidinediones.

Endovascular revascularization of chronically occluded common carotid artery for symptomatic cerebral hypoperfusion.

Endovascular recanalization is increasingly being utilized in symptomatic patients with chronically occluded carotid arteries.1 In carefully selected patients, endovascular recanalization has shown to lower the risk of ischemic events when compared to medical management alone.1 However, successful endovascular revascularization is technically challenging and not without risk.1, 2 In this video, we demonstrate a case of a 64-year-old woman who presented with recurrent transient ischemic attacks. On imaging she was found to have a chronic total occlusion of the common carotid artery from the arch. After obtaining informed consent, the patient underwent a successful endovascular recanalization and stenting of a chronically occluded left common carotid artery with aid from an intravascular guided re-entry catheter. Post operatively the patient developed a neck hematoma which improved and she returned to her neurological baseline. She reported no further symptoms on her three month follow up.