To Transient Ischemic Attack Research Articles

Transient Global Amnesia (TGA): Influence of Acute Hypertension in Patients Not Adapted to Chronic Hypertension

Objective: Transient global amnesia (TGA) is defined by an acute memory disturbance of unclear etiology for a period of <24 h. Several studies showed differences in vascular risk factors between TGA compared to transient ischemic attack (TIA) or healthy controls with varying results. This retrospective and cross-sectional study compares the cardiovascular risk profile of TGA patients with that of acute stroke patients.Methods: Cardiovascular risk profile and MR imaging of 277 TGA patients was retrospectively analyzed and compared to 216 acute ischemic stroke patients (26% TIA).Results: TGA patients were significantly younger and predominantly female compared to stroke patients. A total of 90.6% of TGA patients underwent MRI, and 53% of those showed hippocampal diffusion-weighted imaging (DWI) lesions. Scores for cerebral microangiopathy were lower in TGA patients compared to stroke patients. After statistical correction for age, TGA patients had higher systolic and diastolic blood pressure, higher cholesterol levels, lower HbA1c, as well as blood glucose levels, and lower CHA2DS2-VASc scores. Stroke patients initially displayed higher CRP levels than TIA and TGA patients. TGA patients without DWI lesions were older and showed higher CHA2DS2-VASc scores compared to TGA patients with DWI lesions.Conclusion: This study revealed significant differences between TGA and stroke patients in regard to the cardiovascular risk profile. Our main findings show a strong association between acute hypertensive peaks and TGA in patients not adapted to chronic hypertension, indicating a vascular cause of the disease.

Asymptomatic Females Are at Higher Risk for Perioperative TIA/Stroke and Males Are at Higher Risk for Long-Term Mortality after Carotid Artery Stenting: A Vascular Quality Initiative Analysis.

The study aims to review the sex differences with respect to transient ischemic attack (TIA)/stroke and death in the perioperative period and on long-term follow-up among asymptomatic patients treated with carotid stenting (CAS) in the vascular quality initiative (VQI). All cases reported to VQI of asymptomatic CAS (ACAS) patients were reviewed. The primary end point was risk of TIA/stroke and death in the in-hospital perioperative period and in the long-term follow-up. The secondary end point was to evaluate predictors of in-hospital perioperative TIA/stroke and mortality on long-term follow-up after CAS. There were 22,079 CAS procedures captured from January 2005 to April 2019. There were 5,785 (62.7%) patients in the ACAS group. The rate of in-hospital TIA/stroke was higher in female patients (2.7 vs. 1.87%, p = 0.005) and the rate of death was not significant (0.03 vs. 0.07%, p = 0.66). On multivariable logistic regression analysis, prior/current smoking history (odds ratio = 0.58 [95% confidence interval or CI = 0.39-0.87]; p = 0.008) is a predictor of in-hospital TIA/stroke in females. The long-term all-cause mortality is significantly higher in male patients (26.9 vs. 15.7%, p < 0.001). On multivariable Cox-regression analysis, prior/current smoking history (hazard ratio or HR = 1.17 [95% CI = 1.01-1.34]; p = 0.03), coronary artery disease or CAD (HR = 1.15 [95% CI = 1.03-1.28]; p = 0.009), chronic obstructive pulmonary disease or COPD (HR = 1.73 [95% CI = 1.55-1.93]; p < 0.001), threat to life American Society of Anesthesiologists (ASA) class (HR = 2.3 [95% CI = 1.43-3.70]; p = 0.0006), moribund ASA class (HR = 5.66 [95% CI = 2.24-14.29]; p = 0.0003), and low hemoglobin levels (HR = 0.84 [95% CI = 0.82-0.86]; p < 0.001) are the predictors of long-term mortality. In asymptomatic carotid disease patients, women had higher rates of in-hospital perioperative TIA/stroke and a predictor of TIA/stroke is a prior/current history of smoking. Meanwhile, long-term all-cause mortality is higher for male patients compared with their female counterparts. Predictors of long-term mortality are prior/current smoking history, CAD, COPD, higher ASA classification of physical status, and low hemoglobin level. These data should be considered prior to offering CAS to asymptomatic female and male patients and careful risks versus benefits discussion should be offered to each individual patient.

The Association Between an Antecedent of Transient Ischemic Attack Prior to Onset of Stroke and Functional Ambulatory Outcome.

Background:Specific clinical risk factors linked to transient ischemic attack (TIA) could affect functional ambulatory outcome following thrombolytic therapy in patients having ischemic stroke with a prior TIA (TIA-ischemic stroke). This issue was investigated in this study.Methods:We retrospectively analyzed data from 6379 ischemic stroke patients of which 1387 presented with an antecedent TIA prior to onset of stroke. We used logistic regression model to identify demographic and clinical risk factors that are associated with functional ambulatory outcome in patients with TIA-ischemic stroke treated with thrombolytic therapy.Results:In a population of TIA-ischemic stroke who received recombinant tissue plasminogen activator, patients with a history of stroke (odds ratio [OR] = 3.229, 95% confidence interval [CI] = 1.494-6.98, P = .003) were associated with increasing odds of improvement in functional ambulation, while the female gender (OR = 0.462, 95% CI = 0.223-0.956, P = .037) was associated with reducing odds of improvement. In the non-TIA group, dyslipidemia (OR = 1.351, 95% CI = 1.026-1.781, P = .032) and blood glucose (OR = 1.003, 95% CI = 1.0-1.005, P = .041) were associated with the increasing odds of improvement while older patients (OR = 0.989, 95% CI = 0.98-0.999, P = .029) with heart failure (OR = 0.513, 95% CI = 0.326-0.808, P = .004) and higher lipid level (OR = 0.834, 95% CI = 0.728-0.955, P = .009) were associated with reducing odds of improvement in ambulation.Conclusion:In a population of TIA-ischemic stroke with thrombolytic therapy and a clearly defined TIA without focal ischemic injury, regardless of associated clinical risk factors, a TIA prior to a stroke is not associated with reducing odds of improved ambulatory outcome, except in female patients with TIA-ischemic stroke.

New diagnostic criteria for headache attributed to transient ischemic attacks

BackgroundThe International Classification of Headache Disorders diagnostic criteria for Headache Attributed to Transient Ischemic Attack (TIA) and many other secondary headaches are based primarily on the opinion of experts. The aim of this study was to field test, for the first time, the diagnostic criteria for headache attributed to TIA of the International Classification of Headache Disorders, 3rd edition (ICHD-3) and in case of their weaknesses to propose new diagnostic criteria.MethodsConsecutive patients with Transient Ischemic Attack and a simultaneous control group were extensively interviewed soon after admission. Data were collected on previous headaches, headaches around the time of Transient Ischemic Attack and characteristics of the TIA using validated neurologist conducted semi-structured interview forms. The evidence of relevant infarction were excluded in patients with Transient Ischemic Attack using magnetic resonance imaging with diffusion-weighted imaging (n = 112) or computed tomography (n = 8).ResultsOne hundred twenty patients with Transient Ischemic Attack and 192 controls were included. A new type of headache occurred within 24 h in 16 (13%) of patients with Transient Ischemic Attack and in no controls, a preexisting type of headache with altered characteristics occurred in 9 (7.5%) of patients with Transient Ischemic Attack and no in controls, headache without altered characteristics occurred in 8 (6.6%) of patients with Transient Ischemic Attack and in 9 (4.6%) controls. Only 24% of the headaches in patients with Transient Ischemic Attack (8 of 33 patients) fulfilled the diagnostic criteria of International Classification of Headache Disorders-3 and no control patients. We propose new criteria fulfilled by 94% of the headaches. Specificity remained excellent as only one of 192 controls had a headache fulfilling the proposed criterion C.ConclusionsExisting diagnostic criteria for headache attributed to TIA of the International Classification of Headache Disorders are too insensitive. We suggest new diagnostic criteria with high sensitivity and preserved specificity.

Deep Learning Natural Language Processing Successfully Predicts the Cerebrovascular Cause of Transient Ischemic Attack-Like Presentations.

Background and Purpose- Triaging of referrals to transient ischemic attack (TIA) clinics is aided by risk stratification. Deep learning-based natural language processing, a type of machine learning, may be able to assist with the prediction of cerebrovascular cause of TIA-like presentations from free-text information. Methods- Consecutive TIA clinic notes were retrieved from existing databases. Texts associated with cerebrovascular and noncerebrovascular diagnoses were preprocessed before classification experiments, using a variety of classifier models, based on only the free-text description of the history of presenting complaint. The primary outcome was area under the curve (AUC) of the receiver operator curve. The model with the greatest AUC was then used in classification experiments in which it was provided with additional clinical information. Results- Of the classifier models trialed on the history of presenting complaint, the convolutional neural network achieved the greatest predictive capability (AUC±SD; 81.9±2.0). The effects of additional clinical information on AUC were variable. The greatest AUC was achieved when the convolutional neural network was provided with the history of presenting complaint and magnetic resonance imaging report (88.3±3.6). Conclusions- Deep learning-based natural language processing, in particular convolutional neural networks, based on medical free-text, may prove effective in prediction of the cause of TIA-like presentations. Future research investigating the role of the application of deep learning-based natural language processing to the automated triaging of clinic referrals in TIA, and potentially other specialty areas, is indicated.

Abstract WP223: Ischemic Stroke After Emergency Department Discharge for Symptoms of Transient Neurological Attack

Introduction: Compared to transient ischemic attack (TIA), little is known about the risk of ischemic stroke after the nonspecific symptoms of a transient neurological attack (TNA). Methods: Using administrative claims data, we identified patients discharged from emergency departments (ED) in New York State between 2006 and 2012 with a primary discharge diagnosis of a TNA symptom, defined as in prior work as altered mental status, generalized weakness, and sensory changes. The primary outcome of ischemic stroke was identified using validated ICD-9-CM diagnosis codes. We used Kaplan-Meier survival statistics to calculate cumulative rates, and Cox regression to compare stroke risk after TNA versus after TIA (positive control) or renal colic (negative control) while adjusting for demographics and vascular risk factors. We performed subgroup analyses stratified by age. In sensitivity analyses, TNA was limited to cases of altered mental status or sensory changes, as these were more commonly associated with stroke in prior work, or limited to discharges without neuroimaging, to assess whether limited evaluation was associated with increased risk. Results: Of 499,369 patients diagnosed with a TNA symptom and discharged from the ED, 7,756 were hospitalized for ischemic stroke over 4.7 (±1.9) years. At 90 days, the cumulative stroke rate was 0.29% (95% confidence interval [CI], 0.28-0.31%) after TNA symptoms versus 2.08% (95% CI, 1.89-2.28%) after TIA and 0.03% (95% CI, 0.02-0.04%) after renal colic. The hazard of stroke was higher after TNA than after renal colic (hazard ratio [HR], 2.13; 95% CI, 1.90-2.40). However, the risk was lower than after TIA (HR, 0.47; 95% CI, 0.44-0.50). Compared to TIA, TNA was less strongly associated with stroke among patients under 60 years of age (HR, 0.22; 95% CI, 0.19-0.25) than in those over 60 years of age (HR, 0.50; 95% CI, 0.47-0.53) ( P &lt;0.001 for interaction). Our results were unchanged in sensitivity analyses limiting TNA diagnoses to patients with altered mental status or sensory changes or to those who did not undergo neuroimaging. Conclusions: Patients discharged from the ED with TNA symptoms faced a higher risk of ischemic stroke than low risk controls, but the magnitude of stroke risk was low, particularly in comparison to TIA.

Distinct inflammatory responses differentiate cerebral infarct from transient ischaemic attack

We previously reported on a 26-year-old patient who presented early during a large and eventually fatal cerebral infarct. Microarray analysis of blood samples from this patient demonstrated initially up-regulated and subsequently down-regulated Granzyme B (GzmB) expression, along with progressive up-regulation of genes for S100 calcium binding protein A12 (S100A12) and matrix metalloproteinase 9 (MMP-9). To confirm these findings, we investigated these parameters in patients with suspected stroke presenting within 6h of symptom onset to a single centre. Blood samples were taken at enrolment, then 1h, 3h and 24h post-enrolment for the examination of cellular, protein and genetic changes. Patients with subsequently confirmed ischaemic (n=18) or haemorrhagic stroke (n=11) showed increased intracellular concentrations of GzmB in all cell populations investigated (CD8+, CD8− and Natural Killer [NK] cells). Infarct patients, however, demonstrated significantly reduced GzmB gene expression and increased circulating MMP-9 and S100A12 levels in contrast to transient ischaemic attack (TIA) patients or healthy controls. Furthermore, a pronounced neutrophilia was noted in the infarct and haemorrhage groups, while TIA patients (n=9) reflected healthy controls (n=10). These findings suggest a spectrum of immune response during stroke. TIA showed few immunological changes in comparison to infarct and haemorrhage, which demonstrated inhibition of GzmB production and a rise in neutrophil numbers and neutrophil-associated mediators. This implies a greater role of the innate immune system. These markers may provide novel targets for inhibition and reduction of secondary injury.

The determination of copeptin levels helps management decisions among transient ischaemic attack patients.

Most approaches to transient ischaemic attack (TIA) triage use clinical scores and vascular imaging; however, some biomarkers have been suggested to improve the prognosis of TIA patients. Serum levels of copeptin, adiponectin, neopterin, neuron-specific enolase, high-sensitivity C-reactive protein, IL-6, N-terminal pro-B-type natriuretic peptide, S100β, tumour necrosis factor-alpha and IL-1α as well as clinical characteristics were assessed on consecutive TIA patients during the first 24 h of the onset of symptoms. Among 237 consecutive TIA patients, 12 patients (5%) had a stroke within 7 days and 15 (6%) within 90 days. Among all candidate biomarkers analysed, only copeptin was significantly increased in patients with stroke recurrence (SR) within 7 days (P = 0.026) but not within 90 days. A cut-off point of 13.8 pmol/l was established with a great predictive negative value (97.4%). Large artery atherosclerosis (LAA) [hazard ratio (HR) 12.7, 95% CI 3.2-50.1, P < 0.001] and copeptin levels ≥13.8 pmol/l (HR 3.9, 95% CI 1.01-14.4, P = 0.039) were independent predictors of SR at the 7-day follow-up. LAA was the only predictor of 90-day SR (HR 7.4, 95% CI 2.5-21.6, P < 0.001). ABCD3I was associated with 7- and 90-day SRs (P = 0.025 and P = 0.034, respectively). The association between copeptin levels and LAA had a diagnostic accuracy of 90.3%. Serum copeptin could be an important prognostic biomarker to guide management decisions among TIA patients. Therefore, TIA patients with copeptin levels below 13.8 pmol/l and without LAA have an insignificant risk of 7-day SR and could be managed on an outpatient basis.

AKT Answer Relating to Transient Ischaemic Attack (TIA) and Advice on Driving

AKT Answer Relating to Transient Ischaemic Attack (TIA) and Advice on Driving

AKT Question Relating to Transient Ischaemic Attack (TIA) and Advice on Driving

AKT Question Relating to Transient Ischaemic Attack (TIA) and Advice on Driving

Epidemiological Aspects of Referral to TIA Clinics in Glasgow

A retrospective cohort study was carried out of new referrals to transient ischaemic attack (TIA) clinics in Glasgow. The aims of the study were to describe the profile of referrals and to assess the odds ratios for TIA, minor stroke or amaurosis fugax of both cardiovascular risk factors and clinical features. In total, data were collected for 813 new referrals in a period of six months. Thirteen point eight percent of referrals were from other Health Boards. The overall referral rate among residents of Greater Glasgow NHS Board was 165.6 per 100,000 per year. About 20% of referrals were made by clinicians in secondary care. The specialties from which referrals were most commonly made were accident and emergency, general medicine, ophthalmology and geriatric assessment. The most common risk factors in patients referred were hypertension (52.9%), smoking (31.7%), ischaemic heart disease (22.7%) and former smokers (22.4%). The most common clinical features were hemiparesis (13.3%), weakness of an upper limb (8.7%), vertigo (7.9%) and dysphasia (7.3%). In 48.7% of cases, a non-cerebrovascular diagnosis was made. Separate multivariate models were established for risk factors and clinical features. In the model for risk factors, five factors were significant for risk of TIA, stroke or amaurosis fugax. These were hyperlipidaemia, age over 64 years, hypertension, smoking and ex-smoking. In the model for clinical features, five factors were also significant. These were visual field defect, speech defact, facial weakness and hemiparesis.

Early seizures after acute stroke: a study of 1,640 cases.

We evaluated prospectively the occurrence of seizures within 15 days of a first stroke or transient ischemic episode in 1,640 patients to study relation between seizures and type of stroke. Seizures occurred in 90 patients (5.4%), including 36 (4.4%) of 814 with infarct owing to atheroma, 21 (16.6%) of 126 with infarct owing to cardiogenic embolus, 3 (1%) of 273 owing to lacunar infarct, 5 (1.9%) of 259 owing to transient ischemic attack (TIA), 21 (16.2%) of 129 owing to supratentorial hematoma, and 4 (16.6%) of 24 owing to subarachnoid hemorrhage. Thirteen (14.6%) of 89 subcortical infarcts were associated with seizures. Seizures were the initial sign of stroke in 80 (89%) of 90 cases and were usually single and partial. Seizure symptoms were most often motor, sensory, or visual.

An epidemiologic study of cerebrovascular disease in western Japan: with special reference to transient ischemic attacks.

The prevalence and incidence ratios of cerebrovascular disease, with special reference to transient ischemic attack (TIA), were studied in the towns of Daisen and Ama in western Japan. There have been no previous reports on this subject in Japan. The prevalence ratios of TIA were estimated to be 4.4 in Daisen and 2.0 in Ama per 1,000 people over 40 years old. The ratio of carotid arterial system TIA to vertebrobasilar arterial system TIA was about 1 to 1. The incidence ratios of stroke were 319.6 in Daisen and 314.5 in Ama per 100,000 people of all ages. The prevalence ratios of stroke were estimated to be 14.8 in Daisen and 13.5 in Ama per 1,000 people of all ages. The prevalence ratio of TIA in Japan is about one-third to one-half of that in Western countries. However, the prevalence of complete stroke is much higher in Japan compared with that in Western countries. Therefore, the ratio of TIA to stroke is much lower in Japan than in Western countries. The obstruction of small intracranial arteries, in addition to heart disease, might play an important role in TIA in Japan, whereas in Western countries TIA might be mostly caused by heart disease or the atherosclerosis of extracranial arteries.