Transient Ischemic Attack Symptoms Research Articles

Referral pathways for patients with TIA avoiding hospital admission: a scoping review

ObjectiveTo identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital.DesignScoping review.Data...

Ongoing impairments following transient ischaemic attack: retrospective cohort study.

Clinical management after transient ischaemic attack (TIA) is focused on stroke prevention; however, a number of small studies suggest that patients may experience ongoing residual impairments. This was a retrospective matched-cohort study using anonymized electronic primary care records from The Health Improvement Network database, which covers approximately 6% of the UK population. Adults (≥ 18 years old) who experienced a first TIA between 2009 and 2013 were matched in a ratio of 1:5 to controls by age, sex and general practice. The time to first consultation for fatigue, psychological impairment or cognitive impairment was estimated by Kaplan-Meier survivor functions and adjusted hazard ratios. A total of 9419 TIA patients and 46 511 controls were included. The Kaplan-Meier curves showed that TIA patients were more likely than controls to consult for all three impairments (P < 0.0001). Within 7.1 months (95% confidence interval (CI), 6.2-8.2), 25% of TIA patients consulted for psychological impairment compared with 23.5 months (95% CI, 22.5-24.6) for controls. Hazard ratios for TIA patients were 1.43 (95% CI, 1.33-1.54) for consulting for fatigue, 1.26 (95% CI, 1.20-1.31) for psychological impairment and 1.45 (95% CI, 1.28-1.65) for cognitive impairment. Transient ischaemic attack is associated with significantly increased subsequent consultation for fatigue, psychological impairment and cognitive impairment. These findings suggest that impairments exist after initial symptoms of TIA have resolved, which should be considered by clinicians when treating TIA patients.

Differences in Clinical Characteristics between Patients with Transient Ischemic Attack Whose Symptoms Do and Do Not Persist on Arrival

Symptoms of transient ischemic attack (TIA) persist on arrival and subsequently resolve in some patients admitted to hospitals early after onset. Differences in clinical characteristics between patients with acute TIA whose symptoms do and do not persist on arrival remain unclear. We retrospectively extracted data of consecutive TIA patients with an onset-to-door time (ODT) of 24 hours or less and without a history of stroke from a multicenter TIA database. Clinical characteristics were compared between patients with and without persisting symptoms on arrival. Two hundred sixty-six patients (158 men, 68.0 ± 12.9 years) were included. Of the total number of patients, 105 (39.5%) had persisting symptoms with a mean National Institutes of Health Stroke Scale score of 2.4 (median, 1.0). Patients with persisting symptoms were more likely to have sensory disorder, ambulance-transported admission, long-duration TIA (≥60 minutes), and shorter ODT than those without. Multivariate analysis showed that sensory disorder (odds ratio [OR] 2.52, 95% confidence interval [CI] 1.35-4.77), ambulance-transported admission (OR 1.80, 95% CI 1.00-3.28), and long-duration TIA (OR 3.96, 95% CI 2.12-7.71) were positively associated and that an ODT of more than 12 hours (OR .18, 95% CI .04-.63) was inversely associated with the presence ofpersisting symptoms. Patients with persisting symptoms were more likely to be examined by a stroke physician at first (69% versus 57%, P = .049) and then hospitalized in a stroke unit (59% versus 43%, P = .010). Clinical manifestations and management after admission might differ between patients with acute TIA whose symptoms do and do not persist on arrival.

Depressive symptoms following stroke and transient ischemic attack: is it time for a more intensive treatment approach? results from the TABASCO cohort study.

To examine whether depressive symptoms after a stroke or a transient ischemic attack (TIA) increase the risk of cognitive impairment and functional deterioration at 2-year follow-up. Participants were survivors of first-ever, mild-to-moderate ischemic stroke or TIA from the TABASCO prospective cohort study who underwent 3T magnetic resonance imaging and were examined by a multiprofessional team 6, 12, and 24 months after the event using direct interviews, depression scales, and neurologic, neuropsychological, and functional evaluations. The main outcome was the development of cognitive impairment, either mild cognitive impairment (MCI) or dementia. MCI was diagnosed by a decline on at least 1 cognitive domain (≥ 1.5 SD) of the Montreal Cognitive Assessment score and/or on the computerized neuropsychological battery, as compared with age- and education-matched published norms. Dementia was diagnosed by a consensus forum that included senior neurologists specializing in memory disorders and a neuropsychologist. Data were obtained from 306 consecutive eligible patients (mean age: 67.1 ± 10.0 years) who were admitted to the department of emergency medicine at the Tel Aviv Medical Center from April 1, 2008, to December 1, 2011, within 72 hours from onset of symptoms of TIA or stroke. Of these patients, 51 (16.7%) developed cognitive impairment during a 2-year follow-up. Multivariate regression analysis showed that a Geriatric Depression Scale (GDS) score ≥ 6 at admission and at 6 months after the event was a significant independent marker of cognitive impairment 2 years after the stroke/TIA (OR = 3.62, 95% CI, 1.01-13.00; OR = 3.68, 95% CI, 1.03-13.21, respectively). A higher GDS score at 6 months was also related to a worse functional outcome (P < .001). Our results support depression screening among stroke and TIA survivors as a tool to identify patients who are prone to have a worse cognitive and functional outcome. These patients may benefit from closer medical surveillance and a more intensive treatment approach. ClinicalTrials.gov identifier: NCT01926691.

Transient loss of voice during labour analgesia.

Sir, A 30-year-old full term American Society of Anesthesiologists 1 primigravida patient was administered labour analgesia (LA) on demand at 4-5 cm cervical dilation employing combined spinal epidural (CSE) technique. In sitting position, assuring asepsis, 18 g epidural catheter was sited in L2-3 space threaded up to 10 cm, checked and fixed. After that, 1cc of 0.125% preservative free isobaric bupivacaine (1cc of 0.25% preservative free bupivacaine double diluted with sterile normal saline) and 10 μg fentanyl was injected intrathecally via 26 g Quincke needle at L3-4 space. Maternal and foetal vital parameters remained stable. She had satisfactory pain relief in 10 min and was chatting comfortably when suddenly after 12 min, we noticed loss of voice (she was unable to talk). Other than that there was no neurodeficit or dyspnoea. Spinal level was limited to T6. She was fully awake, oriented and continued communication with us by writing. All maternal and foetal vital parameters remained normal. She was pain free and her labour progressed normally. She was worried but not hysterical. No further abnormality was revealed in neurology consultation. As no further deterioration was noted, we counselled the patient and relatives regarding this event being a rare but reversible drug side effect and reassured them about both maternal and foetal well-being. Epidural bolus was held off, which otherwise would be given at 30 min after spinal injection. By 45 min of the event the phonation started returning and by 1 h she was able to speak normally. Simultaneously cervix was found to be fully dilated and she went on to have a normal vaginal delivery. Ten millilitre 0.25% bupivacaine was given epidurally for episiotomy suturing. The epidural catheter was removed after suturing. The post-operative recovery, hospital stay and follow up for 3 months was uneventful. Cerebral complications of preeclampsia, thrombo-embolic phenomena, absence seizure or high spinal can mimic symptoms of transient ischaemic attack in a parturient. However, our patient did not fit into any of these categories. Kuczkowski and Goldsworthy[1] reported a case of a previously healthy parturient who received 10 μg of fentanyl combined with 2.5 mg of bupivacaine intrathecally as a part of CSE technique for LA and At 4 min after intrathecal injection she suddenly developed transient aphonia and aphagia. The pinprick sensory level of analgesia was found to be at T3 and her symptoms resolved in 20 min. Gupta et al.[2] reported aphonia and aphagia in a male patient posted for lower limb debridement at 3 min after receiving 12.5 mg heavy bupivacaine with 25 μg fentanyl intrathecally which recovered spontaneously in 10-15 min. In both cases the authors believe extensive cephalad spread of fentanyl through the Cerebrospinal fluid (CSF) as the cause for neurological symptoms. There has been a study which noted rapid cephalad spread of fentanyl in the cervical CSF after lumbar administration.[3] Sudden onset, life-threatening respiratory depression have been reported following administration of intrathecal fentanyl for labour analgesia which suggest that lipophilic opioids may move rapidly from lumbar cistern to brainstem level via CSF.[4] There may be more rapid rise in CSF concentrations of drug due to pregnancy related changes. Rapid clearance of fentanyl from the CSF might explain the transient nature of symptoms. Some cases have been reported where similar side effects were noted to be reversed using opioid antagonists naloxone and nalbuphine[5] supporting the cause to be the opioid. Many similar unreported incidences may have been attributed to over anxious and hysterical nature of patients. CSE using fentanyl is one of the established techniques for labour analgesia with minimal side effects. It is necessary to be aware of this rare side effect and maintain composure, provide reassurance to patient and reverse drug effect if needed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Risk factors of transient ischemic attack: An overview.

Transient ischemic attack (TIA) is a transient episode of neurologic dysfunction caused due to loss of blood flow to the brain or spinal cord without acute infarction. Depending on the area of the brain involved, symptoms of TIA vary widely from patient to patient. Since the blockage period in TIA is very short-lived, there is no permanent damage. Risk factors for TIA include family history of stroke or TIA, age above 55 years or older, higher risk of TIA in males than females, high blood pressure, diabetes mellitus, and tobacco smoking. Genetics, race, and imbalance in lipid profile are other risk factors of TIA. TIA is usually diagnosed after taking a thorough history and a physical examination. Several radiological tests such as computed tomography and magnetic resonance imaging are useful in the evaluation of patients who have had a TIA. Ultrasound of the neck and an echocardiogram of the heart are other tests useful in the diagnosis and evaluation of the attack. The treatment following acute recovery from a TIA depends on the underlying cause. Patients who have more than 70% stenosis of the carotid artery, removal of atherosclerotic plaque is usually done by carotid endarterectomy surgery. One-third of the people with TIA can later have recurrent TIAs and one-third can have a stroke because of permanent nerve cell loss. Having a TIA is a risk factor for eventually having a stroke. Educating the patients and inculcating lifestyle modifications in them are initial steps to minimize the prevalence of transient ischemic attack.

Clinical Effect of edaravone on serum superoxide dismutase and malondialdehyde levels in elderly transient ischemic attack

Objective To investigate the clinical effect of Edaravone on transient ischemic attack and serum superoxide dismutase and malondialdehyde levels in the elderly. Methods Ninety eight cases with transient ischemic attack treated in our hospital were chosen as the objects, which were randomly divided into observation group and control group (n=49 for each). Patients in observation group were treated with Edaravone combined with conventional therapy, and patients in control group were treated with conventional therapy. The clinical effect and levels of SOD and MDA were analyzed and compared between the two groups. Results The effective rate and total efficiency were higher in observation group than in control group (79.6% vs. 55.1%, 95.9% vs. 83.7%, χ2=6.914 and 4.354, P=0.008 and 0.032). The SOD level was higher and the MDA level was lower in observation group than in control group (both P<0.001) after treatment. Conclusions Edaravone could improve the symptoms of transient ischemic attack in the elderly, and increase the activity of SOD and reduce MDA level, which is helpful to reduce lipid peroxides, alleviate free radical toxicity, and improve the anti-oxidation ability. Key words: Ischemic attack, transient; Free radical scavengers; Superoxide dismutase; Malondialdehyde

Stroke prevention following modified endoscopic ablation and appendectomy for atrial fibrillation.

We reported the results of stroke prevention following modified endoscopic procedure for atrial fibrillation. 82 patients underwent modified endoscopic procedure for atrial fibrillation (AF), in whom 47 had paroxysmal, 28 had persistent, and 7 had long-standing atrial fibrillation. CHA2DS2VASC median score was 3 (range from 0 to 8). The procedure was performed on the beating heart, through 3 ports on the left chest wall. Pulmonary vein isolation and ablation of the left atrium were achieved by bipolar radiofrequency ablation. Left atrial appendage (LAA) was excluded by stapler. Brain CT, cardiac CT and 24-h Holter monitoring were performed following the procedure. The procedure was successfully completed for all patients. The mean duration was 122±40.1min. LAA was excluded after appendectomy and checked by intraoperative transesophageal echocardiography. The mean follow-up duration was 24.3±3.5months. No patients showed signs and symptoms of transient ischemic attack or stroke. No new positive findings were demonstrated by recurring brain CT scan performed after the procedure. Cardiac CT confirmed the absence of LAA and thrombosis in the left atrium. 87.8% (72/82) of all patients were in sinus rhythm. Our results demonstrate that the modified endoscopic procedure is a safe, effective, and appropriate treatment for AF, which restores sinus rhythm and may be associated with the prevention of AF-related stroke.

Endovascular Management of Long-Segmental Petrocavernous Internal Carotid Artery (Carotid S) Occlusion.

Background and PurposeLong-segmental thrombotic occlusion of the distal internal carotid artery (ICA) sparing the cervical segment proximally and the supraclinoid segment distally, which could be termed ’Carotid S occlusion’, has an unusual clinical presentation. However, endovascular management of this lesion is challenging. The purpose of our study is to report our endovascular treatment clinical experience of the disease.MethodsFrom March 2008 to June 2013, we could identify 14 patients (average age: 62.1, median age: 62, range: 50-79) with ‘Carotid S occlusion’, who underwent endovascular recanalization procedures. Patient’s clinical presentations were collected and the imaging findings also analyzed. The technical success rate, 24-hour and follow-up imaging outcome, and the clinical outcome using the 90-day mRS (modified Rankin scale) score were evaluated.ResultsPatients presented with gradually progressing (n = 8), fluctuating (n = 3), transient ischemic attack (n = 2) and stationary (n = 1) symptoms. DWI showed internal and external border-zone lesions in six patients, only internal ICA border-zone lesions in three patients, and only external border-zone lesions in two patients. Underlying distal ICA stenosis was noted in 12 patients. The technical success rate was 92.8% (13/14). Luminal patency was noted in all patients (100%) after 24 hours and in nine of 10 (90%) on long-term follow-up (median: 6.5, average: 15.1, range: 1-39 months). A 90-day, good functional outcome (mRS ≤ 2) was noted in 13 of 14 patients (92.8%).Conclusions‘Carotid S occlusion’ usually presented with border-zone infarction and endovascular management of the lesions was feasible. A relatively successful clinical outcome could be achieved after successful revascularization.

Stroke prevention in asymptomatic carotid artery disease: revascularization of carotid stenosis is not the solution.

Asymptomatic carotid stenosis (ACS) exceeding 50% is present in about 2% of 60-year-old patients and an even higher fraction of older individuals. The major independent risk factors include advancing age, male sex, tobacco smoking, and a history of vascular disease. The best available evidence does not support either population screening for ACS or routine carotid revascularization when ACS is discovered. There is an urgent need to identify patients with ACS and a sufficiently high risk of ipsilateral stroke (despite contemporary medical management) to warrant invasive treatment. The mainstays of medical management are antiplatelet therapy (usually low-dose aspirin), high-dose statins, blood pressure control, and smoking cessation. Patients with ACS should be periodically educated about symptoms of transient ischemic attack and stroke that require emergent medical attention. Current guidelines vary widely in recommendations regarding revascularization (ie, endarterectomy or carotid stenting). The benefits of revascularization strategies remain uncertain for patients with ACS who receive contemporary medical management.

Detectability of Ischemic Lesions on Diffusion-Weighted Imaging Is Biphasic after Transient Ischemic Attack

Experimental studies of transient focal ischemia indicate biphasic detectability of lesions by diffusion-weighted imaging (DWI); poorly detectable phase exists at 1-12 hours after reperfusion. The present study aimed to clarify whether poorly detectable phase also exists in DWI of transient ischemic attack (TIA) patients. A retrospective study was conducted in 144 consecutive TIA patients who underwent magnetic resonance imaging (MRI) within 2 weeks after carotid TIA. Patients were classified into 9 groups according to time from disappearance of TIA symptoms to DWI: intraischemic period, 0-1 hour, 1-12 hours, 12-24 hours, 1-2 days, 2-3 days, 3-7 days, 7-10 days, and 10-14 days after the end of TIA. Lesions were detected in 33 of 144 patients (22.9%). The frequency of positive lesions was 20% in the intraischemic period and 30.8% at 0-1 hour after the end of TIA; it markedly decreased to 8.7% at 1-12 hours after end of TIA. Thereafter, it increased to 21.7%, 30.8%, 36.4%, 37.0%, 38.5%, and 30% at 12-24 hours, 1-2 days, 2-3 days, 3-7 days, 7-10 days, and 10-14 days after the end of TIA, respectively. In 7 patients, MRI was repeated twice, at 1-12 hours and then at 5-13 days after the end of TIA. Lesions were never detected on the first MRI but were clearly demonstrated in 4 of 7 patients on the second MRI. The detectability of ischemic lesions may be biphasic after TIA as indicated by experimental studies.

Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial

Extracranial carotid and vertebral artery dissection is an important cause of stroke, especially in young people. In some observational studies it has been associated with a high risk of recurrent stroke. Both antiplatelet drugs and anticoagulant drugs are used to reduce risk of stroke but whether one treatment strategy is more effective than the other is unknown. We compared their efficacy in the Cervical Artery Dissection in Stroke Study (CADISS), with the additional aim of establishing the true risk of recurrent stroke. We did this randomised trial at hospitals with specialised stroke or neurology services (39 in the UK and seven in Australia). We included patients with extracranial carotid and vertebral dissection with onset of symptoms within the past 7 days. Patients were randomly assigned (1:1) by an automated telephone randomisation service to receive antiplatelet drugs or anticoagulant drugs (specific treatment decided by the local clinician) for 3 months. Patients and clinicians were not masked to allocation, but investigators assessing endpoints were. The primary endpoint was ipsilateral stroke or death in the intention-to-treat population. The trial was registered with EUDract (2006-002827-18) and ISRN (CTN44555237). We enrolled 250 participants (118 carotid, 132 vertebral). Mean time to randomisation was 3·65 days (SD 1·91). The major presenting symptoms were stroke or transient ischaemic attack (n=224) and local symptoms (headache, neck pain, or Horner's syndrome; n=26). 126 participants were assigned to antiplatelet treatment versus 124 to anticoagulant treatment. Overall, four (2%) of 250 patients had stroke recurrence (all ipsilateral). Stroke or death occurred in three (2%) of 126 patients versus one (1%) of 124 (odds ratio [OR] 0·335, 95% CI 0·006-4·233; p=0·63). There were no deaths, but one major bleeding (subarachnoid haemorrhage) in the anticoagulant group. Central review of imaging failed to confirm dissection in 52 patients. Preplanned per-protocol analysis excluding these patients showed stroke or death in three (3%) of 101 patients in the antiplatelet group versus one (1%) of 96 patients in the anticoagulant group (OR 0·346, 95% CI 0·006-4·390; p=0·66). We found no difference in efficacy of antiplatelet and anticoagulant drugs at preventing stroke and death in patients with symptomatic carotid and vertebral artery dissection but stroke was rare in both groups, and much rarer than reported in some observational studies. Diagnosis of dissection was not confirmed after review in many cases, suggesting that radiographic criteria are not always correctly applied in routine clinical practice. Stroke Association.

Pregnancy outcomes in women with moyamoya disease: experiences at a single center in Korea.

PurposeMoyamoya disease (MMD) occurs predominantly in Korean and Japanese women. The aim of this study was to investigate clinical features and pregnancy outcomes in women with MMD.Materials and MethodsWe conducted a retrospective chart review of women with MMD who visited our Department of Obstetrics and Gynecology between January 2005 and October 2013. For all study subjects, clinical features, demographic characteristics, and perinatal outcomes were recorded.ResultsWe identified 28 pregnancies in 22 patients who had been diagnosed with MMD. The mean maternal age at delivery was 31.9±3.5 years old. The mean gestational age at delivery was 38.0±0.9 weeks. Among the 28 pregnancies, 25 (92.5%) underwent cesarean section; 19 (76.0%) of them were performed under regional anesthesia and six (24.0%) under general anesthesia. The mean newborn weight was 3233.7±348.2 g. The 5-minute Apgar score in 85% of the newborns was higher than 8, with no other apparent complications. During the puerperal period, transient ischemic attack symptom or seizure occurred in 4 cases, although patients recovered within a few days.ConclusionFor pregnant women with MMD, it is important to control blood pressure and prevent hyperventilation during the intrapartum period, and the best methods of delivery and anesthesia should be considered to avoid unfavorable sequelae. Additionally, a multidisciplinary approach (i.e., neurosurgery) is necessary to constantly manage underlying diseases.

Patients' responses to transient ischaemic attack symptoms: a cross-sectional questionnaire study in Australian general practices.

Consensus guidelines for transient ischaemic attack (TIA) recommend urgent investigation and management, but delays in management occur and are attributable to patient and health system factors. To establish general practice patients' anticipated responses to TIA symptoms, and associations of appropriate responses. A cross-sectional questionnaire-based study in Australian general practices. Consecutive patients attending general practices completed questionnaires that contained the Stroke Action Test (STAT) adapted for TIA about demographic, health system use, and stroke risk factors. STAT elicits appropriate or inappropriate anticipated responses to 28 symptom complexes. Anticipated actions in-hours and out-of-hours were elicited. Associations of independent variables with adapted-STAT scores were tested with multiple linear regression. There were 854 participants (response rate 76.9%). Urgent healthcare-seeking responses to transient neurological symptoms ranged from 96.8% for right-sided weakness with dysphasia to 59.1% for sudden dizziness. Associations of higher adapted-STAT scores were older age, Indigenous status, previous after-hours services use, self-perception of health as poor, and familiarity with a stroke public awareness campaign. A personal or family history of stroke, smoking status, and time of event (in-hours/out-of-hours) were not significantly associated with adapted-STAT scores. Most general practice attendees expressed intentions to seek health care urgently for most symptoms suggestive of TIA, with highest levels of urgency observed in high stroke-risk scenarios. Intentions were not associated with a number of major risk factors for TIA and might be improved by further educational interventions, either targeted or at population level.

Left-Sided Strokes Are More Often Recognized Than Right-Sided Strokes

Left-sided strokes are reported to be more common than right-sided strokes, but it is unknown whether they occur more often or are simply recognized more easily by clinicians. In a large unselected community-dwelling population, we examined the frequency of clinical left- and right-sided strokes and transient ischemic attacks (TIAs) and compared it with the frequency of left- and right-sided infarcts on MRI. This study was conducted within the population-based Rotterdam Study. Between 1990 and 2012, 13 894 participants were followed up for first-ever stroke and TIA. MRI scans were performed within a random subgroup of 5081 persons and were rated for the presence of supratentorial cortical and lacunar infarcts. We compared frequencies of left- and right-sided strokes, TIAs, or MRI infarcts using binomial and Fisher exact tests. After a mean follow-up of 9.6 (±6.0) years, 1252 patients had a stroke, of which 704 were ischemic, and 799 participants had a TIA. Within the subgroup with MRI, we identified 673 infarcts. Ischemic strokes were more frequently left-sided (57.7%; 95% confidence interval, 53.7-61.6) than right-sided, similar to TIAs (57.8% left-sided; 53.4-62.3). In contrast, we found no left-right difference in distribution of infarcts on MRI (51.9% left-sided; 48.1-55.6). Clinical ischemic strokes and TIAs are more frequently left-sided than right-sided, whereas this difference is not present for infarcts on MRI. This suggests that left-sided strokes and TIAs are more easily recognized. Consequently, there should be more attention for symptoms of right-sided strokes and TIAs.

Screening for asymptomatic carotid artery stenosis: U.S. Preventive Services Task Force recommendation statement.

Update of the 2007 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for carotid artery stenosis. The USPSTF commissioned a systematic review to synthesize the evidence on the accuracy of screening tests, externally validated risk-stratification tools, the benefits of treatment of asymptomatic carotid artery stenosis with carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAAS), the benefits from medications added to current standard medical therapy, and the harms of screening and treatment with CEA or CAAS. This recommendation applies to adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms. The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. (D recommendation).

Delay in seeking medical help following Transient Ischemic Attack (TIA) or "mini-stroke": a qualitative study.

BackgroundPrompt treatment following Transient Ischemic Attack (TIA) can reduce the risk of subsequent stroke and disability. However, many patients delay in making contact with medical services. This study aimed to explore TIA patients' accounts of delay between symptom onset and contacting medical services including how decisions to contact services were made and the factors discussed in relation to delay.MethodsTwenty interviews were conducted with TIA patients in England. Using a previous systematic review as an initial framework, interview data were organised into categories of symptom recognition, presence of others and type of care sought. A thematic analysis was then conducted to explore descriptions of care-seeking relevant to each category.ResultsDelay in contacting medical services varied from less than an hour to eight days. Awareness of typical stroke symptoms could lead to urgent action when more severe TIA symptoms were present but could lead to delay when experienced symptoms were less severe. The role of friends and family varied widely from deciding on and enacting care-seeking decisions to simply providing transport to the GP practice. When family or friends played a greater role, and both made and enacted care-seeking decisions, delays were often shorter, even when patients themselves failed to identify symptoms. Healthcare professionals also impacted on patients' care-seeking with greater delays in seeking further care for the same episode described when patients perceived a lack of urgency during initial healthcare interactions.ConclusionsThis study provides new information on patients' decisions to contact medical services following TIA and identifies overlapping factors that can lead to delay in receiving appropriate treatment. While recognition of symptoms may contribute to delay in contacting medical services, additional factors, including full responsibility being taken by others and initial healthcare interactions, can over-ride or undermine the importance of patients' own identification of TIA.

The natural history of asymptomatic severe carotid artery stenosis

Although level 1 evidence supports carotid endarterectomy (CEA) for stroke prevention in patients with asymptomatic severe carotid artery stenosis (ASCAS; >70%), medical therapy alone has been promulgated by some as equally effective. The goal of this study was to determine the natural history of medically treated patients with ASCAS. Patients with ASCAS from 2005 to 2006 were identified in a health network database. Patients were included if the initial therapeutic plan involved medical therapy alone (usually because of comorbidities or patient preference). Study end points included: ipsilateral neurologic symptoms (INS) of transient ischemic attack and/or stroke, death, and INS and/or death. There were 126 carotid arteries identified in 115 patients. Using standard duplex velocity criteria, 88 (70%) had severe (70%-89%) and 38 (30%) had very severe stenoses (VSS; 90%-99%). The average age was 73.5years, demographic characteristics included: 66% hypertension, 64% coronary artery disease, 30% diabetes, 5% chronic kidney disease (CKD), and 86% were taking a statin drug (28% had a low-density lipoprotein level<100mg/dL). There were 31 patients (24.6%) who developed INS during a mean follow-up of 27months; most (23 of 31; 74%) occurred within 12months of the initial duplex ultrasound examination; 14 (45%) were strokes. The 5-year actuarial freedom from INS was 70.1± 5%. Multivariate predictors of INS included: VSS (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.56-6.76; P= .002), CKD (HR, 6.25; 95% CI, 2.05-19.2; P= .001), and age (HR, 0.94; 95% CI, 0.91-0.98; P= .001). There were 41 patients (33%) who underwent eventual carotid revascularization (32 CEA, nine stent); 23 of 41 (56%) were performed for INS and 18 (44%) for plaque progression. Overall 5-year actuarial survival was 69.8%± 4.1%. Multivariate predictors of death included: age (HR, 1.06; 95% CI, 1.03-1.1; P= .0001), chronic obstructive pulmonary disease (HR, 1.92; 95% CI, 1.08-3.41; P= .03), and diabetes (HR, 5.08; 95% CI, 2.86-9.01; P< .0001). The 5-year actuarial freedom from INS and/or death was 54± 4.4%. Multivariate predictors of INS and/or death were: VSS (HR, 1.98; 95% CI, 1.22-3.23; P= .006), CKD (HR, 5.46; 95% CI, 2.12-14.08; P= .0004), and diabetes (HR, 2.6; 95% CI, 1.59-4.24; P= .0001). Statin use was not protective against INS or death in this cohort. Medically managed patients with ASCAS develop INS early, especially in patients with VSS. Medical therapy with aspirin and statins failed to control ASCAS, thus validating the role of CEA in these patients as promulgated in multiple current treatment guidelines.

The glycolytic switch in the development and progression of colorectal cancer

The glycolytic switch in the development and progression of colorectal cancer

Focus on: transient ischaemic attack

Transient ischaemic attack (TIA) is a common and important condition affecting 46 000 new patients each year in the UK. It is strongly predictive of future stroke, with the risk being greatest in the first few days after the event. Prompt recognition, early specialist assessment and robust treatment of TIA are therefore vital. However, there is frequent confusion regarding the symptoms of TIA among both patients and health professionals. Additionally, patients often delay seeking help following a TIA and fail to use emergency access routes to care. Further public health initiatives are urgently required to address these issues and to ensure that TIA is recognised as a medical emergency.