TIA Patients Research Articles

What is the added value of CT-angiography in patients with transient ischemic attack?

BackgroundTransient ischemic attack (TIA) is an important predictor for a pending stroke. Guidelines recommend a workup for TIA-patients similar to that of stroke patients, including an assessment of the extra- and intracranial arteries for vascular pathologies with direct therapeutic implications via computed tomography angiography (CTA). Aim of our study was a systematic analysis of TIA-patients receiving early CTA-imaging and to evaluate the predictive value of TIA-scores and clinical characteristics for ipsilateral vascular pathologies and the need of an invasive treatment.MethodsWe analysed clinical and imaging data from TIA patients being admitted to a tertiary university hospital between September 2015 and March 2018. Following subgroups were identified: 1) no- or low-grade vascular pathology 2) ipsilateral high-risk vascular pathology and 3) high-risk findings that needed invasive, surgical or interventional treatment. We investigated established TIA-scores (ABCD2-, the ABCD3- and the SPI-II score) and various clinical characteristics as predictive factors for ipsilateral vascular pathologies and the need for invasive treatment.ResultsOf 812 patients, 531 (65.4%) underwent initial CTA in the emergency department. In 121 (22.8%) patients, ipsilateral vascular pathologies were identified, of which 36 (6.7%) needed invasive treatment. The ABCD2-, ABCD3- and SPI-II-scores were not predictive for ipsilateral vascular pathologies or the need for invasive treatment. We identified male sex (OR 1.579, 95%CI 1.049–2.377, p = 0.029), a short duration of symptoms (OR 0.692, 95% CI 0.542–0.884, p = 0.003), arterial hypertension (OR 1.718, 95%CI 0.951–3.104, p = 0.073) and coronary heart disease (OR 1.916, 95%CI 1.184–3.101, p = 0.008) as predictors for ipsilateral vascular pathologies. As predictors for the need of invasive treatment, a short duration of symptoms (OR 0.565, 95%CI 0.378–0.846, p = 0.006), arterial hypertension (OR 2.612, 95%OR 0.895–7.621, p = 0.079) and hyperlipidaemia (OR 5.681, 95%CI 0.766–42.117, p = 0.089) as well as the absence of atrial fibrillation (OR 0.274, OR 0.082–0.917, p = 0.036) were identified.ConclusionMore than every fifth TIA-patient had relevant vascular findings revealed by acute CTA. TIA-scores were not predictive for these findings. Patients with a short duration of symptoms and a vascular risk profile including coronary heart disease, arterial hypertension and hyperlipidaemia most likely might benefit from early CTA to streamline further diagnostics and therapy.

Rationale, Design and Methods of the Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA (PRODAST) Study.

BackgroundThe optimal timing of anticoagulation following acute ischaemic stroke or TIA in patients with atrial fibrillation (AF) is a frequent challenge. Early initiation of anticoagulation can reduce the risk for recurrent ischaemic events, but may lead to an increased risk for intracerebral haemorrhage.AimThe Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA (PRODAST) study was initiated to investigate outcome events under antithrombotic therapy after ischaemic stroke or TIA in patients with AF. The main objective is to compare the three-month rates of major haemorrhagic events between early (≤ 7 days) versus late (> 7 days) administration of dabigatran or treatment with vitamin-K antagonists started at any time. Occurrences of ischaemic and major haemorrhagic events will be evaluated to determine the optimal time point for initiation or resumption of anticoagulation.Design and MethodsPRODAST is a prospective, multicenter, observational, non-interventional post-authorization safety study. 10,000 patients with recent (≤ 1 week from index event) ischaemic stroke or TIA and non-valvular AF were recruited at 86 German sites starting in July 2015. The observational plan includes a baseline visit, documentation of data during hospitalization and a telephone-based, central follow-up at three months after the index event. The primary endpoint is the major bleeding rate within three months. Secondary endpoints include rates of recurrent ischaemic or haemorrhagic stroke, TIA, systemic embolism, myocardial infarction and death.SummaryPRODAST will provide important real-world data on safety and efficacy of antithrombotic therapy after acute stroke and TIA in patients with AF.

Abstract 9211: Utility of Transthoracic Echocardiography in Hospitalized Patients With Stroke or Transient Ischemic Attack

Background: Stroke is a leading cause of mortality in the US. The AHA/ASA Stroke Guidelines recommend echocardiography (ECHO) as part of cardiac evaluation for prevention of recurrent stroke. This study investigated the utility and associated cost of TTE as a diagnostic tool in stroke or TIA. Methods: A retrospective study of adults admitted with a diagnosis of stroke or TIA was conducted from 2016-2019 using the Trihealth EHR. Patient characteristics, comorbidities, TTE findings were analyzed using descriptive statistics. Hospital total cost & length of stay (LOS) were compared between patients with &without TTE using Mann-Whitney test. Results: There were 3,894 patients hospitalized with a stroke or TIA. A TTE was ordered for 2,435 (2,202 stroke, 233 TIA). Among stroke patients, the Median (IQR) age was 71 (60-81), 52% were female, 76% had hypertension, 57% history of tobacco & 39% had Diabetes. TTE abnormalities were found in 74% with LVH or LA dilation most common and MVP or PFO least common (figure 1). Ejection fraction was normal in 83%, borderline in 5.5% & reduced in 6.4%. Median (IQR) hospitalization cost was lower in the TTE group 7,153 [4,754-12,412] vs.7,733 [4,754-12,412], p=0.009, but not LOS, 3[2-5] vs. 3[2-6], p=0.212. Conclusion: Echocardiogram abnormalities were prevalent in patients hospitalized with stroke/TIA. Abnormalities ranged from LVH or LA dilatation being most common to MVP or PFO least common. The evaluation with TTE in stroke & TIA patients may be cost saving. Further investigation is necessary.

Priorities of medical rehabilitation of patients with recent experience of transient ischemic attack

Introduction.Transient ischemic attacks can be a predictor of a more severe cardiovascular event, the risk of which depends on many factors that requires a personalized approach. Neuropsychological disorders (cognitive, emotional) have a significant impact on quality of life and social activity and are often underestimated in patients with TIA. Comprehensive medical rehabilitation with the inclusion of antithrombotic therapy and psychocorrection measures may reduce the risk of recurrent cardiovascular events in patients with TIA.Purpose of the study: to substantiate the efficiency of complex medical and non-pharmacological rehabilitation in patients who underwent TIA by analyzing the characteristics of the main and leading concomitant diseases.Materials and methods. The morbidity of 351 TIA patients was studied and analyzed. The average age of the examined patients was 58.6 ± 2.2 years, there were 64.9% of women and 35.1% of men. All patients received an individualized medical rehabilitation program for 12 months with correction of identified neuropsychological disorders. Depending on background and concomitant diseases the antiplatelet or anticoagulants therapy was differently administrated.Results and dicussion. Psychological, cognitive, and physical disorders (based on subjective complaints) are common in patients with TIA. The prevalence of mental disorders in patients with TIA was 138.2 cases per 100 patients. The correction of cognitive impairment, depressive symptoms is associated with improved quality of life (p < 0.05). Repeated acute cerebrovascular events (TIA, ischemic stroke) were recorded during the first 6 months after TIA in 29 patients (10.4%) with severe stenosis of the brachiocephalic arteries, severe arterial hypertension and paroxysmal atrial fibrillation.Conclusion.The importance of comprehensive medical and social rehabilitation of patients with TIA is determined. The participation of a psychotherapist as a member of a multidisciplinary team is necessary. A significant role of the secondary prevention of acute cerebrovascular events is assigned to rational antithrombotic therapy.

Expedited and Comprehensive Management of Low-Risk TIA Patients in the Emergency Department is Safe and Less Costly

ObjectivesTransient ischemic attack (TIA) can be a warning sign of an impending stroke. The objective of our study is to assess the feasibility, safety, and cost savings of a comprehensive TIA protocol in the emergency room for low-risk TIA patients. Materials and MethodsThis is a retrospective, single-center cohort study performed at an academic comprehensive stroke center. We implemented an emergency department-based TIA protocol pathway for low-risk TIA patients (defined as ABCD2 score < 4 and without significant vessel stenosis) who were able to undergo vascular imaging and a brain MRI in the emergency room. Patients were set up with rapid outpatient follow-up in our stroke clinic and scheduled for an outpatient echocardiogram, if indicated. We compared this cohort to TIA patients admitted prior to the implementation of the TIA protocol who would have qualified. Outcomes of interest included length of stay, hospital cost, radiographic and echocardiogram findings, recurrent neurovascular events within 30 days, and final diagnosis. ResultsA total of 138 patients were assessed (65 patients in the pre-pathway cohort, 73 in the expedited, post-TIA pathway implementation cohort). Average time from MRI order to MRI end was 6.4 h compared to 2.3 h in the pre- and post-pathway cohorts, respectively (p < 0.0001). The average length of stay for the pre-pathway group was 28.8 h in the pre-pathway cohort compared to 7.7 h in the post-pathway cohort (p < 0.0001). There were no differences in neuroimaging or echocardiographic findings. There were no differences in the 30 days re-presentation for stroke or TIA or mortality between the two groups. The direct cost per TIA admission was $2,944.50 compared to $1,610.50 for TIA patients triaged through the pathway at our institution. ConclusionsThis study demonstrates the feasibility, safety, and cost-savings of a comprehensive, emergency department-based TIA protocol. Further study is needed to confirm overall benefit of an expedited approach to TIA patient management and guide clinical practice recommendations.

A study of short term and long term risk of ischemic stroke and other vascular events following early treatment of tia and minor stroke in a tertiary centre in North India

Transient ischemic attack and minor ischemic stroke are associated with early recurrence and deterioration respectively. There is a high risk of stroke after TIA ranging between 10-20% in the ensuing 90 days in the various studies. There are various clinical and imaging factors which predict the early risk of stroke after a TIA. To evaluate the short term and long term risk of ischemic stroke following early treatment of TIA and minor stroke. TIA is defined as sudden focal neurologic deficit of presumed vascular origin lasting less than 24 hours. Minor ischemic stroke is defined as National institute of Health Stroke scale score of ≤5. TIA mimics were excluded from the study. The patients were followed up till 1 year. In patients with minor ischemic stroke, a 2-point worsening in the NIHSS was considered as an event. Modified Rankin score at 3 months was assessed. Total 320 patients were analysed with a mean age of 60.6 ± 13.6 years. Out of the them 20.7% were females, 78% of patients had minor stroke. There is significant association of lacunar stroke in minor stroke patients (p&amp;#60;0.01), whereas most TIA patients, etiology remained undetermined. In multiple regression analysis, both diabetes [p&amp;#60;0.05] and significant vessel stenosis (&amp;#62;50%) [p&amp;#60;0.05] were found to be an independent predictor of recurrent stroke in TIA and minor stroke patients. Urgent treatment after TIA and minor ischemic stroke is associated with reduced risk of ischemic stroke recurrence. Both diabetes mellitus and significant vessel stenosis are independent predictor of stroke recurrence.

Intracranial arterial stenosis in Caucasian versus Chinese patients with TIA and minor stroke: two contemporaneous cohorts and a systematic review

BackgroundIntracranial arterial stenosis (ICAS) is an important cause of stroke worldwide. Separate reports in Caucasians and Asians with stroke/transient ischaemic attack (TIA) have suggested lower ICAS prevalence in Caucasians, but...

The Effect of the 2019 Novel Coronavirus Pandemic on Stroke and TIA Patient Admissions: Perspectives and Risk Factors.

Background: The 2019 novel coronavirus pandemic has generated concern from stroke specialist centres across the globe. Reductions in stroke admissions have been reported, despite many expecting an increase due to the pro-thrombotic nature of 2019 novel coronavirus. Aims: To assess the impact of the pandemic and subsequent lockdown on stroke admissions and transient ischaemic attack referrals at the Royal Victoria Infirmary, Newcastle-Upon-Tyne, and additionally on patient behaviours affecting modifiable risk factors or perspectives related to accessing healthcare. Methods: A single-centre retrospective data analysis was carried out on a “lockdown” cohort of suspected stroke patients admitted between 11 March to 26 May 2020 and a “pre-lockdown” cohort admitted in 2019. Differences in weekly admissions, weekly referrals, onset-to-presentation time and weekly thrombolysis cases were examined. Further analysis interrogated these cohorts separated by Bamford classification and stroke mimics (such as seizure/hemiplegic migraine/functional neurology). A binary-format questionnaire was separately administered to admitted patients from 15 April to 5 June 2020. Results: Significant reductions in weekly posterior circulation infarct (−43%, p = 0.017) and stroke-mimic (−47%, p < 0.001) admissions and weekly referrals diagnosed as non-transient ischaemic attack (−55%, p = 0.002) were observed in the lockdown cohort, with no differences in onset-to-presentation time. Over 25% of questionnaire respondents reported less physical activity, increased isolation and delaying their presentation due to the pandemic. Conclusions: This study provides evidence of reduced stroke-mimic and posterior circulation infarct admissions. Questionnaire findings suggest that patients need to be informed to ensure they appropriately seek medical advice. Significant communication at the stroke-primary care interface is needed to support referral pathways and management of modifiable risk factors.

Abstract P311: Outpatient Evaluation of Transient Ischemic Attack and Minor, Non-Disabling Stroke During the COVID-19 Pandemic

Introduction: Reductions in hospital visits for stroke have been seen during the COVID-19 pandemic, partly reflecting perceived risks of in-hospital care. We recently implemented an evidence-based protocol for outpatient rapid evaluation of transient and minor, non-disabling stroke symptoms for patients seeking care 24 hours after symptom onset. We present our early experience through the pandemic. Methods: We conducted a retrospective review of patients evaluated in the RESCUE-TIA ( R apid E valuation of minor S troke and C erebrovasc U lar E vents including TIA ) clinic from December 2019-August 2020. The clinic sees patients with TIA symptoms or with fixed, non-disabling deficits seeking care &gt; 24 hours after symptom onset. We introduced telemedicine in March 2020. Magnetic resonance brain and vascular imaging is available within 24 hours of visit. We summarized patient characteristics and quality data with standard descriptive statistics. Results: A total of 21 patients were seen in the RESCUE-TIA clinic, including 15 patients during the height of the pandemic in NY; 67% were seen by telemedicine. The median age was 75 years (interquartile range [IQR], 61-82), and 71% were women. The median NIH Stroke Score for patients with minor stroke was 0 (IQR, 0-1), and the median ABCD 2 score for TIA patients was 3 (IQR, 2-3). Median time from symptom onset to evaluation was 3 days (IQR, 2.5-17.5). Median time from evaluation to laboratory diagnostics was 8 hours (IQR, 2-21), and to completion of imaging was 1 day (IQR, 0-5). Outpatient telemetry commenced in a median of 5 days (IQR, 1-9), and echocardiography was completed in a median of 8 days (IQR, 0-10). One patient was referred to the emergency room for a carotid occlusion. Final diagnoses were TIA (n=12), ischemic stroke (n=5), transient global amnesia (n=2), migraine (n=1), and non-aneurysmal, distal subarachnoid hemorrhage (n=1). Secondary prevention was initiated or optimized in 94% of TIA and stroke patients. Recurrent TIA occurred in 1 patient after 67 days, and ischemic stroke occurred in 1 patient 55 days after TIA. Conclusion: Timely outpatient evaluation of patients with recent TIA and minor, non-disabling stroke is feasible and may be useful during the pandemic, especially during emergency room crowding.

Abstract P160: Characteristics of Telestroke Using Emergency Departments in a National Sample

Background: Most data on spoke emergency departments (EDs) using telestroke come from single academic hub-and-spoke networks. Our objective was to describe characteristics of EDs using telestroke in a national sample. Methods: We surveyed a convenience sample of 366 EDs among those who self-identified as using telestroke on the 2016 National ED Inventory (NEDI)-USA, which goes to all US EDs. Surveys were mailed to ED directors, with follow-up phone calls to non-responders. The survey characterized ED staffing, transfer patterns, in-person consultant availability, alteplase use, and frequency of telestroke consultations. Descriptive statistics are reported. Results: Of the 4,410 EDs responding to the NEDI-USA telemedicine question, 1,824 (41%) reported using telestroke. Compared to non-surveyed telestroke EDs (n=1458), the 366 surveyed EDs had lower annual ED visit volume, and were more often rural and critical access hospitals. Of these, 320 (91%) affirmed use of telestroke on our secondary survey. Many were rural (n=157, 49%); few were academic (n=4, 1%). Only 132 EDs (41%) reported that &gt; 80% of attending physicians were board certified or board eligible in emergency medicine. Joint Commission Stroke Center certification was reported by 101 EDs (32%) and alternative certification by another 53 (17%). Fifty-two EDs (16%) reported availability of an in-person neurologist, with 32 (10%) available within 30 minutes, and 29 (9%) available 24/7. Frequency of telestroke consultation varied (Figure). Most EDs administered alteplase in the past year (n=261, 82%); some reported alteplase administration without telestroke consultation (n=94, 30%). EDs frequently admitted TIA and stroke patients without thrombolysis (78% and 55% respectively), but fewer (24%) admitted alteplase-treated patients. Conclusions: Telestroke is frequently used in US EDs. Of those surveyed, many had non-emergency medicine attending staffing and use the technology regularly.

Abstract P224: Management of TIA Over Time in the Greater Cincinnati Northern Kentucky Stroke Study

Introduction: The availability of rapid tissue and vessel imaging for TIA has increased, but the utilization rates of these and other diagnostic and management strategies for TIA over time are unknown. Objective: To investigate trends in TIA diagnostic and management strategies over time in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS). Methods: The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio and Northern Kentucky. For this study, all physician-adjudicated, first-ever cases of TIA (defined clinically as sudden onset of focal symptoms lasting &lt; 24 hours) presenting to an emergency department over five study periods (1993/4, 1999, 2005, 2010, 2015) were included. Use of AHA-recommended aspects of TIA management as well as disposition of TIA patients (admission to hospital or discharge from ED) and length of stay were compared across study periods. Rates of acute infarct on MRI were also reported. Trends were examined using the Cochran-Armitage test for trend. Results: In total, over all study periods, there were 2251 first-ever TIAs. Overall, 14% (n=311) occurred in Black individuals, and 57% (n=1275) occurred in women. Utilization of diagnostic modalities [non-contrast CT brain, vascular imaging (CTA, MRA, or carotid dopplers), tissue imaging (MRI), and echocardiogram] increased significantly over time (all p&lt;0.0001). In terms of management, both admission to the hospital and discharge from the hospital on an antiplatelet agent increased over time (both p&lt;0.0001; Table). Conclusions: The management of TIA has changed significantly over time. Utilization of tissue and vessel imaging as well as echocardiogram during the hospital stay has increased; in 2015, the vast majority of patients with TIA in this population-based study received each of these testing modalities and were admitted to a hospital for TIA work-up. Further work is needed to understand the best practices for work-up of suspected TIA.

Migraine in transient global amnesia: a meta-analysis of observational studies.

PURPOSE: Although many studies have investigated the relationship between transient global amnesia (TGA) and migraine, to date, no meta-analysis has confirmed the existence and size of their association. Literature search involved MEDLINE, EMBASE, CENTRAL and PsycINFO. Observational controlled studies including TGA patients (Caplan, Hodges and Warlow) were retrieved. Quality evaluation was based on the Newcastle-Ottawa scale. The prevalence of migraine was compared in TGA patients vs. healthy controls (HC), as well as in TGA against TIA individuals. Data from case-control, cross-sectional and cohort studies were pooled separately. Literature search yielded 1178 articles, 12 of which were included in the present meta-analysis. Results from case-control (ten), cohort (one) and cross-sectional (one) studies were compatible with an association between TGA and migraine. The nationwide inpatient cross-sectional study was of lesser value due to its inpatient orientation. The high-quality, population-based, retrospective cohort (158,301 participants per group) determined a higher relative-risk (RR) of TGA for migraine vs. non-migraine individuals [RR = 2.48, 95%confidence-interval (95% CI) = (1.32, 4.87)]. Sensitivity testing based on stricter diagnostic criteria strengthened the estimated association [RR = 3.84, 95% CI = (1.57, 9.38)]. Additionally, pooled data from eight case-control studies (700 TGA, 746 HC) yielded similar results [Odds-Ratio, OR = 2.51, 95% CI = (1.85, 3.41)], with the association mainly driven by the three high-quality studies, rather than the five articles of moderate quality. Finally, pooled findings from four case-control studies of moderate-quality revealed a higher prevalence of migraine among TGA compared to TIA patients [OR = 1.82, 95% CI = (1.22, 2.73)]. A significant association between TGA and migraine was established. The underlying connecting mechanism remains undetermined, yet.

Author response: The dimension of preventable stroke in a large representative patient cohort.

We thank Dr. Goldstein for the valuable comment on our article.1 Diabetes is a major risk factor for ischemic stroke and every fifth patient with diabetes dies of stroke.2 Guidelines recommend target control for hypertension and use of statins, whereas the benefit of prophylactic antiplatelet therapy remains controversial.3,4 In our cohort of ischemic stroke and TIA patients, 321 (18.6%) had diabetes and 60 of them were newly diagnosed (3.5% of all stroke/TIA patients). Among diabetic patients, 47.6% had undertreated hypertension, which is similar to the situation in patients without diabetes (45.3%). However, the proportion of patients not receiving adequate antithrombotic therapy—based on previous cardiovascular disease or carotid stenosis—was higher among diabetics (34.6% vs 7.3%, p < 0.001) as was the proportion of inadequately treated hypercholesterolemia (63.6% vs 51.1%, p = 0.002). Overall, risk factor control in diabetic patients was even worse than in non-diabetic patients—the proportions of patients with at least one untreated or inadequately treated risk condition at the time of the index event: 93.8% vs 76.2%, p < 0.001. Substantial improvement in primary prevention is one of the over-arching goals in the Action Plan for Stroke in Europe 2018–2030,5 and concerted actions are required to reduce the worrisome proportion of preventable strokes.

Author response: The dimension of preventable stroke in a large representative patient cohort.

We thank Dr. Goldstein for the valuable comment on our article.1 Diabetes is a major risk factor for ischemic stroke and every fifth patient with diabetes dies of stroke.2 Guidelines recommend target control for hypertension and use of statins, whereas the benefit of prophylactic antiplatelet therapy remains controversial.3,4 In our cohort of ischemic stroke and TIA patients, 321 (18.6%) had diabetes and 60 of them were newly diagnosed (3.5% of all stroke/TIA patients). Among diabetic patients, 47.6% had undertreated hypertension, which is similar to the situation in patients without diabetes (45.3%). However, the proportion of patients not receiving adequate antithrombotic therapy—based on previous cardiovascular disease or carotid stenosis—was higher among diabetics (34.6% vs 7.3%, p < 0.001) as was the proportion of inadequately treated hypercholesterolemia (63.6% vs 51.1%, p = 0.002). Overall, risk factor control in diabetic patients was even worse than in non-diabetic patients—the proportions of patients with at least one untreated or inadequately treated risk condition at the time of the index event: 93.8% vs 76.2%, p < 0.001. Substantial improvement in primary prevention is one of the over-arching goals in the Action Plan for Stroke in Europe 2018–2030,5 and concerted actions are required to reduce the worrisome proportion of preventable strokes.

Evaluating the utility of fasting lipid panel in addition to random lipid panel in determining lipid-lowering therapy in acute ischemic stroke or TIA patients

BackgroundHyperlipidemia is one of the major risk factors for cerebrovascular disease and it is common practice to obtain fasting lipid profile prior to starting lipid lowering therapy (LLT). Recent AHA Guidelines published in 2018 allow for a non-fasting value to be used. ObjectiveTo determine if obtaining fasting lipid levels in addition to random lipid levels prompts changes in hyperlipidemia management of acute stroke patients. Methods206 patients met the study criteria which included a diagnosis of acute ischemic stroke or transient ischemic attack on admission and availability of both random and fasting LDL levels collected within 72 h of each other. Patients were divided into three groups based on random LDL at admission: Group A: LDL < 70, Group B: LDL 70−99, and Group C: LDL ≥ 100 mg/dL. The dataset was analyzed to conform to the 2018 AHA/ACC guidelines using an LDL cutoff of 70 mg/dL. ResultsIn 206 patients, statin management would change based on the fasting LDL level in 12 patients, 11 of whom were in Group B. Our data suggests that lipid management is more likely to change if the initial random LDL falls between 70−99 mg/dL as compared to a value outside of this range (P < 0.001). We present a decision algorithm to guide lipid management in acute stroke patients. ConclusionsForegoing a fasting lipid panel to guide LLT in patients with ischemic stroke is appropriate in most cases but for select patients with random LDL levels between 70 and 99, fasting lipid profile should be obtained prior to deciding upon LLT.

Screening for Obstructive Sleep Apnea in Stroke and TIA Patients using a Home Sleep Apnea Test vs. In-laboratory Polysomnography: A Randomized Controlled Trial (1116)

Screening for Obstructive Sleep Apnea in Stroke and TIA Patients using a Home Sleep Apnea Test vs. In-laboratory Polysomnography: A Randomized Controlled Trial (1116)

Abstract WP197: Patient-Reported Physical Outcomes Measures in Mild-to-Moderate Stroke and TIA Patients

Introduction: Mild-to-moderate stroke and TIA patients are discharged directly home, but may have residual physical disability. The purpose of this study was to compare distributions of three patient-reported outcome measures: PROMIS GPH, Stroke Impact Scale-16 (SIS-16), and simplified modified Rankin (Rankin). Methods: PROMIS GPH includes global ratings of physical activities, physical health, pain and fatigue, SIS-16 includes ADLs, IADLs, and physical activities, and Rankin includes ADLs, IADLs, and overall comparison of function to pre-stroke function. Outcomes were measured at 90-days post-hospital discharge in 1768 stroke and TIA patients discharged directly home in the COMprehensive Post-Acute Stroke Services Study. Ceiling effects (frequency of maximum score) were evaluated for each measure. Differences in SIS-16 and PROMIS GPH scores across levels of Rankin were compared using the Kruskal-Wallis test. Spearman correlation coefficients were calculated between PROMIS GPH, SIS-16, Rankin, and individual items of the PROMIS GPH. Results: At hospital baseline, patients were 68 ± 13 years of age, 50% female, 72% stroke, 28% TIA, and with mean ± SD NIHSS of 2.3 ± 3.6. At 90 days, mean ± SD were 45.8 ± 9.8 for PROMIS GPH, 82.1 ± 19.7 for SIS-16, and 1.2 ± 1.3 for Rankin. Ceiling effects for the PROMIS GPH were (3.1%), SIS-16 (24.8%) and Rankin (38.9%). PROMIS GPH and SIS-16 scores differed significantly (p &amp;lt; 0.0001) across categories of the Rankin. Correlations with Rankin were moderate for SIS-16 (r=-0.64; 95% CI -0.67, -0.62) and PROMIS GPH (r=-0.54; 95% CI -0.58, -0.51). Correlations between SIS-16 and PROMIS GPH items were strong for physical activities (r=0.75; 95% CI 0.63, 0.77) and moderate for physical health (r=0.55; 95% CI 0.52, 0.59), fatigue (r=0.50; 95% CI 0.47, 0.54) and pain (r=0.44; 95% CI 0.40, 0.48). Of 438 patients at SIS-16 ceiling, the mean ± SD for global assessment of physical activities, physical health, pain, and fatigue on a scale of 0-5 were 4.8 ± 0.6, 3.7 ± 0.9, 4.4 ± 0.9, and 4.2 ± 0.7, respectively. Conclusion: PROMIS GPH may better detect physical health differences in mild-to-moderate stroke and TIA patients. Variability in global assessments of physical health, pain, and fatigue contribute to the lower PROMIS GPH ceiling effects.

Abstract 85: Periodontal Disease Association With Large-Artery Atherothrombotic Stroke

Introduction: Periodontal disease (PD) is associated with incident and recurrent ischemic stroke. We investigated whether PD is associated with specific stroke subtype. Methods: In this cross-sectional study, PD was assessed in ischemic stroke and TIA patients. Moderate-severe PD was determined by full-mouth examination by a dentist. Clinical information including stroke etiological subtype (TOAST) was collected at admission. Based on vascular imaging, strokes caused by large-artery atherothrombosis were further analyzed to distinguish those caused by either intracranial atherosclerosis (ICAS) or extracranial atherosclerosis (ECAS). They were also classified as anterior or posterior circulation disease. Results: Consecutive patients (N=265) were enrolled (age 64 ± 12.8, 49% white, 46% black, 5% other and 56% male) between 2015-17. A third (N=87) were found to have PD. Twenty percent (N=42) of strokes were caused by large-artery atherothrombosis. In this group, there was a significantly higher proportion of patients with PD compared with those without PD (24% vs.12%, X 2 p=0.01). Patients with PD also had a significantly higher proportion (12% vs 5%) of stroke due to posterior circulation disease (crude OR 3.0, 95% CI 1.1-7.9, p=0.03), not anterior circulation disease (14% vs. 7%; crude OR 2.2, 95% CI 0.9-5.2, p=0.08). This association with posterior circulation disease persisted after adjustment for age, race, hypertension, diabetes, hyperlipidemia, smoking status, coronary artery disease, atrial fibrillation, and hemoglobin A1C (adjusted OR 3.1 95% CI 1.04-9.1, p=0.004). In addition, those with PD had a significantly higher rate of stroke due to ICAS compared to those without PD (20% vs. 8%; crude OR 2.6, 95% CI 1.3-5.6, p=0.01), while there was no significant difference between the groups for strokes due to ECAS (9% vs. 3%; crude OR 2.2, 95% CI 1.0-8.7, p=0.06). PD remained significantly associated with ICAS after adjustment for the same covariates (adjusted OR 2.6, 95% CI 1.1-5.8, p=0.004). Conclusion: We report a significantly higher proportion of stroke due to large-artery atherothrombosis in patients with PD compared to those without PD. We report an independent association between PD and ICAS, as well as posterior circulation disease.

Abstract TP71: Delayed Lesion on Diffusion-Weighted Image is Not Uncommon in Elderly and Severe Stroke-Suspected Patients

Introduction: No lesion on admission DWI but delayed appearance in the follow-up DWI are not uncommon in acute stroke. Our aim is to investigate clinical features of patients with delayed-high intensity area (DHIA) on follow-up DWI. Methods: We enrolled 1) TIA patients and 2) clinically suspected stroke patients sustaining a neurological deficit over 24 hours without ischemic lesion on initial DWI. Follow-up DWI was performed in 7 days after admission. We divided into two groups as follows; DHIA group and no hyper-intense lesion on initial and second DWI (NHIA group). Univariate and multivariate logistic regression analysis were conducted on backgrounds, clinical courses including time from onset to MRI, symptom duration, and favorable outcome (mRS 0-1) in 3 months in both groups. Results: One hundred seventy-two cases were identified (male 68%, median age 66 yo, median NIHSS score 1, delayed-HIA group; 48 patients) between October 2012 and March 2019. DHIA group was older (72 yo vs 64 yo, p&lt;0.001), higher NIHSS score on admission (1 vs 0, p=0.001), elevated serum BNP (42.5 pg/dL vs 15.6 pg/dL, p&lt;0.001), D-Dimer (0.8 μg/mL vs 0.6 μg/mL, p=0.023). Then, favorable outcome was frequently observed in NHIA group (72% vs 88%, p=0.019). Time from onset to initial DWI of DHIA group was similar with those of NHIA group (130 min vs 148 min, p=0.142). Age and NIHSS score on admission were independent factors for DHIA (Age: OR 1.03, 95%CI 1.01-1.06, p=0.021, NIHSS on admission: OR 1.21, 95%CI 1.04-1.40, p=0.011). Conclusion: Follow-up DWI may play an important role of outcome biomarker in TIA and initially suspected stroke. Repeated MRI should be performed for elder and severe neurological deficits.

Abstract WMP93: Risk of Early Ischemic Stroke After Transient Ischemic Stroke: A Systematic Review and Meta-Analysis

Objective: TIA is considered a heralding sign for stroke. Studies have reported a stroke risk of 12 to 20% within 90 days after an index TIA, of which 50% happen within 24 to 48 hours. In the current comprehensive meta-analysis, we calculated the pooled stroke risk at 2, 7, 30, and 90 days post TIA and compared the risk between two study cohorts with study population before and after 1999 (publication year of the consensus guidelines on the management of TIA). Methods: Considering PRISMA guidelines, all published studies of early stroke recurrence in TIA from 2000 to 2019 were included. We calculated risk of early stroke following index TIA event at 2, 7, 30, and 90 days. We excluded studies that had a combined early outcome of TIA and stroke, studies without independent encounter for the index TIA event or diagnosis of index TIA after patient encounter for early ischemic stroke. Patients with positive diffusion weighted imaging (DWI+ TIA), or low suspicious for TIA were also excluded. Results: In total, 82,292 (mean age: 69.7; man: %53.4) TIA patients out of 25 studies were included. Hypertension was the most common disease among population of the included studies followed by diabetes mellitus and coronary artery disease. Among included studies, the risk of stroke ranged from 0.1 % to 5.5%, 0.4 % to 8.0%, 1.5% to 11.5% and 0.6 % to 22.1% at 2, 7, 30 and 90 days, respectively. Total number of TIA patients included for meta-analysis at 2, 7, 30 and 90 days were 31,366, 29,634, 15,038, and 81,013 respectively. We calculated pooled estimation of stroke risk following index TIA event at 2, 7, 30, and 90 days, by application of random effect models (95% CI), as 1.5, 2.3, 4.0, and 4.4, respectively. These rates among three studies at 2, 30 and 90 days which studied a population before 1999 were 4.9, 5.7 and 15.0, respectively. Conclusion: Our study indicated that an early risk of stroke following an index TIA event at 2, 7, and 90 days is 1.5, 2.3, and 4.4, respectively. We also observed a stroke risk reduction among studies with recruited population after 1999.