Onset Of Transient Ischemic Attack Research Articles

Abstract WP136: Clinical, Laboratory, and Imaging Characteristics Oof Transient Ischemic Attack Caused by Large Artery Lesion: A Comparison Between Carotid and Intracranial Artery

Background: The purpose of this study was to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions. Methods: Among 445 patients admitted to our stroke care unit within 48 hours of TIA onset between April 2008 and December 2013, 85 patients (63 men, 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 days and 90 days after TIA onset. Results: Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared to those in the extracranial group. Eleven patients in the extracranial group and no patient in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2% vs. 0%, p = 0.044) and 90-day risk (17.1% vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group. Conclusions: Patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions among our patients with TIA caused by large artery disease. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

Computed tomography perfusion imaging may predict cognitive impairment in patients with first-time anterior circulation transient ischemic attack.

To determine whether computed tomography perfusion imaging (CTPI)-derived parameters are associated with vascular cognitive impairment (VCI) in patients with transient ischemic attack (TIA). Patients with first-time anterior circulation TIA (diagnosed within 24h of onset) and normal cognition, treated between August 2009 and August 2014 at the Department of Neurology of Chengdu Military General Hospital, China, were analyzed retrospectively. Patients underwent whole-brain CTPI within 1week of TIA to detect cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT) and time to peak (TTP) in the ischemic region. Based on cognitive function assessment 4weeks after TIA, using the Montreal cognitive assessment (MoCA) and mini mental state examination, the patients were divided into control and VCI groups. CTPI parameters and other clinical data were compared between groups, and Spearman's correlation analysis used to identify associations between cognitive scores and CTPI parameters in the VCI group. 50 patients (25 per group; aged 55-72years) were included. Patient age, gender, smoking status, alcohol consumption, educational level, time from TIA onset to admission, time from TIA onset to CTPI, and prevalence of hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation and hyperhomocysteinemia did not differ between groups. Both groups showed TTP and MTT prolongation, CBF reduction, but no change in CBV in the ischemic region; these changes were significantly larger in the VCI group (P<0.05). MTT correlated negatively with MoCA score (r=-0.51, P=0.009). CTPI could facilitate early diagnosis of VCI in patients with anterior circulation TIA.

Clinical, Laboratory, and Imaging Characteristics of Transient Ischemic Attack Caused by Large Artery Lesions: A Comparison between Carotid and Intracranial Arteries

Background/Aims: The aims of this study were to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions. Methods: Among 445 patients admitted to our stroke care unit within 48 h of TIA onset between April 2008 and December 2013, 85 patients (63 men, mean age 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 and 90 days after TIA onset. Results: Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared with those in the extracranial group. Eleven patients in the extracranial group and none in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2 vs. 0%, p = 0.044) and the 90-day risk (17.1 vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group. Conclusions: Among our patients with TIA caused by large artery disease, patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

Abstract T P164: New ABC (Age, Blood Pressure, and Clinical Features) Score Can Predict Early Ischemic Stroke After Transient Ischemic Attack

Background and Purpose: Several clinical scales, such as the ABCD2 score, were developed for predicting early stroke after transient ischemic attack (TIA). We aimed to derive a new score from our TIA registry. Methods: The PROMISE-TIA registry was a multicenter prospective study in Japan. From June 2011 to December 2013, 1353 patients within 7 days of TIA onset were enrolled. Among them, we analyzed 1277 patients (822 men, 69.5 ± 12.4 years) who completed followed-up at 90 days after TIA onset. The components of the score were determined by the multivariate Cox proportional hazards model. We included them into the analysis if the p-value was under 0.1. The accuracy of our score was compared to that of the ABCD2, ABCD3, and ABCD3-I scores by using the C-statistics. Results: Cox hazard model showed that age≧80 years (HR: 1.91; 95%CI: 0.95-3.61, p=0.069), systolic blood pressure (SBP)≧160 or diastolic blood pressure (DBP)≧90 at presentation (HR: 4.05; 95%CI: 2.01-9.05, p&lt;0.001), hemiparesis (HR: 4.05; 95%CI: 1.23-8.27, p=0.0124), and speech disturbance (HR: 2.68; 95%CI: 1.39-5.57, p=0.0026) were related to ischemic stroke within 7 days. One point was given for each of the following factors : age≧80, SBP≧160 or DBP≧90, hemiparesis, and speech disturbance. The sum of these scores was defined as “ABC score”. The 7-day ischemic stroke risk was 0% for ABC score of 0, 1.37% (0.52-3.62) for 1, 2.06% (1.14-3.67) for 2, 6.36% (4.19-9.56) for 3, 16.7% (8.15-31.0) for 4. The 90-days ischemic stroke risk was 2.50% (0.63-9.45), 3.44% (1.86-6.29), 3.74% (2.43-5.73), 9.70% (6.94-13.4), and 16.7% (8.15-31.0), respectively. The incidence of ischemic stroke was significantly higher in patients with a score of 3-4 than those with a score of 0-2; HR being 3.27 (1.19-11.5) for 7 days and 2.76 (1.35-6.20) for 90 days. The C-statistics of the ABC score was significantly higher than that of the ABCD2, ABCD3, or ABCD3-I score (vs. ABCD2: 0.721 vs. 0.596, p=0.0011, vs. ABCD3: 0.721 vs. 0.597, p=0.0087, vs. ABCD3-I: 0.720 vs. 0.566, p=0.0050). Conclusions: Our ABC score can be useful for predicting risk of ischemic stroke within 7 days and 90days after TIA onset.

Incidence and Predictors of Ischemic Stroke Events during Hospitalization in Patients with Transient Ischemic Attack

Background: The purpose of this study was to elucidate the incidence and predictors of ischemic stroke or recurrent transient ischemic attack (TIA) during acute hospitalization in patients with TIA. Methods: We carried out a multicenter retrospective study to clarify the characteristics of in-patients with TIA. The subjects of this study were TIA patients admitted to 13 stroke hospitals within 7 days after onset between 2008 and 2009. TIA was defined as focal neurologic symptoms ascribable to a vascular etiology lasting less than 24 h. We investigated the incidence and predictors of ischemic events including ischemic stroke or recurrent TIA during hospitalization. Results: A total of 464 patients with TIA (292 men, 69 ± 13 years) were registered. Of those, 400 (86.2%) were admitted within 24 h of TIA onset. The mean length of hospital stay was 13 days. During hospitalization, 8 patients had ischemic strokes and 26 had recurrent TIAs. The leading subtype of 8 ischemic strokes was small vessel disease (n = 3) followed by cardioembolism (n = 2). Multiple logistic regression analysis showed that hypertension (OR: 3.41; 95% CI: 1.23-12.3), MRI-diffusion-weighted image positivity (OR: 2.49; 95% CI: 1.15-5.25), and hemiparesis (OR: 2.30; 95% CI: 1.02-5.88) were independently associated with ischemic events during hospitalization. Conclusions: In this study, 1.7% of patients with TIA had ischemic stroke during acute hospitalization, and the most common subtype was small vessel disease. Subsequent ischemic stroke and recurrent TIA were associated with hypertension, positive DWI findings, and hemiparesis.

Abstract W P141: Cerebral Microbleeds and White Matter Hyperintensities as Predictors for Early Stroke Recurrences in Transient Ischemic Attack: Korean TIA eXpression Study

Background: Patients within 24 hours from symptom onset of transient ischemic attack (TIA) are particularly at high risk of early recurrent stroke. Neuroimaging variables are increasingly recognized to help better identify patients at high risk. The Korean TIA eXpression study aimed to determine the risk of early recurrent stroke and its clinical and imaging predictors. Methods: We conducted a hospital-based, multi-center prospective cohort study. TIA was defined by transient focal neurological deficits which result from ischemia and last less than 24 hours. Inclusion criteria were: 1) patients who admitted within 24 hours after symptom onset, 2) those who underwent magnetic resonance imaging and angiography, and 3) age of 45 years or older. We collected baseline data of demographics, vascular risk factors, clinical manifestation, potential mechanism of TIA, neuroimaging findings of acute ischemic lesions, white matter changes, microbleeds, vascular status, and laboratory test results. The primary endpoint was recurrent stroke within 90 days. Results: A total of 500 patients (mean age 64.4, male 58%, mean ABCD2 score 4.3 ± 1.4) were enrolled and completed 90-day follow-up. The primary endpoint of recurrent stroke developed in 25 (5.0%) patients within 90 days. From univariable analyses, we identified the following potential predictors (p &lt; 0.20) of recurrent stroke within 90 days: ABCD2 scores, crescendo TIA, lacunar TIA, symptomatic extracranial occlusion, old lacune, white matter hyperintensities, and cerebral microbleeds. In a multivariable logistic regression analysis, crescendo TIA (adjusted odds ratio (OR) 4.4, 95% confidential interval (CI) 1.3-14.7), lacunar TIA (OR 2.5, 95% CI 1.1-6.1), white matter hyperintensities (OR 2.4, 95% CI 1.1-5.4), and cerebral microbleeds (OR 4.9, 95% CI 1.9-12.8) were independently associated with recurrent stroke within 90 days. Conclusion: In conclusion, the current study suggests that microangiopathy may be a predictor for early recurrent strokes after TIA. Our novel findings need to be validated in future studies.

Abstract T P364: Longitudinal Evaluation of Functional Magnetic Resonance Imaging on Working Memory in Patients after Transient Ischemic Attack

OBJECTIVE: Transient ischemic attack (TIA) can increase the risk of cognitive decline, especially in attention-executive-psychomotor functioning. However, whether TIA patients have altered patterns of brain activation during this function, and whether there is a dynamic change on cerebral activity patterns, have not been examined to date. This study is designed to using functional magnetic resonance imaging (fMRI) to investigate longitudinal changes in brain activation during a verbal working memory (VWM) task in patients with TIA. METHODS: The current study included 25 patients with first-ever TIA in right hemisphere and 25 healthy volunteers. N-Back VWM task-related fMRI were conducted one week and three months after TIA onset. The brain activity evoked by n-back task in the patients was assessed and compared with that of the controls. Significant changes in cerebral activation over time were also observed in TIA patients. RESULTS: The groups did not differ on any demographic, cognitive and task performance variables. Compared with healthy subjects, patients at one week after TIA demonstrated increased activity in bilateral inferior frontal gyrus (IFG), right dorsolateral prefrontal cortex (DLPFC), insula, inferior parietal lobe (IPL) and cerebellum during the task. However, at 3-month follow-up, the task-related brain activity in patients was clearly less recruited, and only right IFG still exhibited increased activity. Moreover, a direct comparison of fMRI data between one week and three months after TIA showed that there was increased activation in bilateral middle temporal gyrus (MTG), right DLPFC, IPL, cerebellum and left IFG in patients at one week after TIA. CONCLUSIONS: These findings support the hypotheses that the patterns of brain activity during VWM performance may change for a period of time post-TIA despite the cessation of clinical symptoms. They also provide evidence of a progressive normalization of the VWM activation pattern after transient episodes of ischemia in patients with first-ever TIA.

The value of diffusion-weighted imaging in prediction of outcome of transient ischemic attacks

Objective The aim of the study was to study the clinical significance of diffusion-MRI in the prediction of outcome of transient ischemic attacks (TIAs) and its relation to the risk factors and TIA clinical presentations. Background Diffusion-weighted imaging (DWI) observations in TIA patients led to the proposal for a new definition of TIA, which is called the 'tissue-based' TIA definition, so that patients with clinical symptoms of focal brain with acute DWI-lesions, irrespective of the neurological signs duration, had a stroke rather than TIA. Patients and methods The participants in this study were classified into two groups: patient group (group I) and control group (group II) ( n = 20) of normal individuals. The patients in group I ( n = 35) were those who had had recent TIAs for the first time for whom an initial brain DWI was performed within 48 h after the onset of TIA and a follow-up one 3 months later for those with initial positive DWI. Results Initial DWI lesions were detected in nine (25.7%) patients; it was found that those with TIA duration 1 h or more, with mainly AF or carotid artery stenosis more than 50% and presenting clinically with aphasia or motor manifestations, had lesions on DWI. Conclusion TIA patients with duration of symptoms 1 h or more, atrial fibrillation or carotid artery stenosis more than 50% risk factors, and presenting clinically with motor deficits or aphasia had DWI positivity and thus an increased risk of developing stroke.

Reduction in Early Stroke Risk in Carotid Stenosis With Transient Ischemic Attack Associated With Statin Treatment

Statins reduce stroke risk when initiated months after transient ischemic attack (TIA)/stroke and reduce early vascular events in acute coronary syndromes, possibly via pleiotropic plaque stabilization. Few data exist on acute statin use in TIA. We aimed to determine whether statin pretreatment at TIA onset modified early stroke risk in carotid stenosis. We analyzed data from 2770 patients with TIA from 11 centers, 387 with ipsilateral carotid stenosis. ABCD2 score, abnormal diffusion weighted imaging, medication pretreatment, and early stroke were recorded. In patients with carotid stenosis, 7-day stroke risk was 8.3% (95% confidence interval [CI], 5.7-11.1) compared with 2.7% (CI, 2.0%-3.4%) without stenosis (P<0.0001; 90-day risks 17.8% and 5.7% [P<0.0001]). Among carotid stenosis patients, nonprocedural 7-day stroke risk was 3.8% (CI, 1.2%-9.7%) with statin treatment at TIA onset, compared with 13.2% (CI, 8.5%-19.8%) in those not statin pretreated (P=0.01; 90-day risks 8.9% versus 20.8% [P=0.01]). Statin pretreatment was associated with reduced stroke risk in patients with carotid stenosis (odds ratio for 90-day stroke, 0.37; CI, 0.17-0.82) but not nonstenosis patients (odds ratio, 1.3; CI, 0.8-2.24; P for interaction, 0.008). On multivariable logistic regression, the association remained after adjustment for ABCD2 score, smoking, antiplatelet treatment, recent TIA, and diffusion weighted imaging hyperintensity (adjusted P for interaction, 0.054). In acute symptomatic carotid stenosis, statin pretreatment was associated with reduced stroke risk, consistent with findings from randomized trials in acute coronary syndromes. These data support the hypothesis that statins started acutely after TIA symptom onset may also be beneficial to prevent early stroke. Randomized trials addressing this question are required.

Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack

BackgroundStroke is common during the first few weeks after a transient ischemic attack (TIA) or minor ischemic stroke. Combination therapy with clopidogrel and aspirin may provide greater protection against subsequent stroke than aspirin alone.MethodsIn a randomized, double-blind, placebo-controlled trial conducted at 114 centers in China, we randomly assigned 5170 patients within 24 hours after the onset of minor ischemic stroke or high-risk TIA to combination therapy with clopidogrel and aspirin (clopidogrel at an initial dose of 300 mg, followed by 75 mg per day for 90 days, plus aspirin at a dose of 75 mg per day for the first 21 days) or to placebo plus aspirin (75 mg per day for 90 days). All participants received open-label aspirin at a clinician-determined dose of 75 to 300 mg on day 1. The primary outcome was stroke (ischemic or hemorrhagic) during 90 days of follow-up in an intention-to-treat analysis. Treatment differences were assessed with the use of a Cox proportional-hazards model, with study center as a random effect.ResultsStroke occurred in 8.2% of patients in the clopidogrel–aspirin group, as compared with 11.7% of those in the aspirin group (hazard ratio, 0.68; 95% confidence interval, 0.57 to 0.81; P<0.001). Moderate or severe hemorrhage occurred in seven patients (0.3%) in the clopidogrel–aspirin group and in eight (0.3%) in the aspirin group (P=0.73); the rate of hemorrhagic stroke was 0.3% in each group.ConclusionsAmong patients with TIA or minor stroke who can be treated within 24 hours after the onset of symptoms, the combination of clopidogrel and aspirin is superior to aspirin alone for reducing the risk of stroke in the first 90 days and does not increase the risk of hemorrhage. (Funded by the Ministry of Science and Technology of the People's Republic of China; CHANCE ClinicalTrials.gov number, NCT00979589.)

Urgent Carotid Endarterectomy in Patients with Acute Neurological Symptoms: The Results of a Single Center Prospective Nonrandomized Study.

To evaluate the feasibility and the safety of performing urgent (within 24 hours) carotid endarterectomy in patients with carotid stenosis presenting with repetitive transient ischemic attacks or progressing stroke. Thirty consecutive patients underwent urgent carotid endarterectomy for repetitive transient ischemic attacks (N = 12) or progressing stroke (N = 18) according to the following criteria: two or more transient ischemic attacks or a fluctuating neurological deficit over a period of less than 24 hours (progressing stroke), no impairment of consciousness, no cerebral infarct larger than 1.5 cm in diameter on computed tomography and a carotid artery stenosis of 70% or more on the appropriate side, diagnosed by echodoppler ultrasonography and/or arteriography. Patients with cerebral hemorrhage were excluded. All patients were examined pre- and postoperatively by the same neurologist and surgery was performed by the same vascular surgeon. All the patients underwent a cerebral CT scan within 5 days after surgery. There were 19 men and 11 women. The mean age was 71 ± 7.6 years. The time delay of surgery after the onset of transient ischemic attacks or progressing stroke averaged 19.4 ± 11.5 hours. For patients suffering progressive stroke, one developed a fatal ischemic stroke 24 hours after surgery, five showed no improvement of their neurological status after surgery, but none worsened. Twelve patients experienced significant improvement of their neurological status with an European Stroke Scale of 77.9 ± 25.2 at admission and 95.8 ± 4.6 at discharge, and all but one of those patients had a Barthel's index value over 85/100 at discharge. The 12 patients with repetitive transient ischemic attacks had an uneventful postoperative outcome. The mean duration of follow-up was 3.4 ± 1.2 years. No patient developed another transient ischemic attack or ischemic stroke during the follow-up period. The results of our series documented the feasibility and the safety of performing urgent (within 24 hours) carotid endarterectomy in patients presenting with repetitive transient ischemic attacks or progressing stroke. This procedure seems to us to be justified by the fact that waiting for surgery may lead to the development of a more profound deficit or another stroke in these neurologically unstable patients whose only chance for neurological recovery is in the early phase.

Knowledge of Transient Ischemic Attack among the Japanese

Stroke is often preceded by a transient ischemic attack (TIA). To properly recognize TIA and take prompt initial action, all citizens should be fully educated about TIA. Our objective is to evaluate how much knowledge of TIA has spread among Japanese citizens. As a preliminary study with this goal, we conducted an Internet-based questionnaire survey of 30,000 Japanese citizens aged 20 years or more, excluding health care professionals, from across Japan to investigate their awareness and knowledge of stroke and TIA. Valid responses were obtained from 11,121 Japanese citizens, aged 44.8 ± 13.1 (mean ± SD) years. The most frequent response pertaining to initial action at TIA onset was "visit the family doctor" (41.8%), followed by "immediately call an ambulance" (22.4%). Tokushima, Kagawa, and Kumamoto were the top 3 prefectures with the highest ambulance request rates. Factors contributing to immediately calling an ambulance were respondents' confidence about the involvement of stroke (odds ratio [OR] 2.290, 95% confidence interval [CI] 1.250-4.318, P = .009) and knowledge of the importance of initiating treatment within 3 hours of symptom onset (OR 2.273, 95% CI 1.923-2.825, P = .000). Although television was the primary source of information about stroke for all groups of age, older respondents obtained more information from newspapers than younger respondents. The results showed that many Japanese citizens would fail to call an ambulance in response to TIA, and diagnosis by a primary care physician appears to be the main triage system for the treatment of TIA. Rather than instituting a nationally uniform strategy of education for the promotion of TIA awareness among Japanese citizens, education programs should account for age-specific and regional differences among citizens.

Occluded middle cerebral artery vascular stump mimicking aneurysm: Case report and review of literature

The stump of an occluded middle cerebral artery (MCA) is a rare but important aneurysm mimic. A 57-year-old male was admitted due to recurrent onset of transient ischemic attack. Computed tomography angiography (CTA) and digital subtraction angiography (DSA) showed a total obstruction in the right MCA with moyamoya phenomenon at distal trunks and a protruding lesion in the left MCA bifurcation. The patient was diagnosed with left MCA bifurcation aneurysm. Intraoperatively, the lesion was found to be an occluded right MCA stump. Encephalomyoarteriosynangiosis was performed, and the patient remained symptom-free at the 6-month follow-up. The possibility of a vascular stump should be considered when an aneurismal lesion is present at the MCA bifurcation with moyamoya phenomenon at distal trunks.

Abstract TP387: Abcd 2 Score Predicts The Long-term Risk Of Stroke After Transient Ischemic Attack: Fukuoka Stroke Registry

Background and Purpose— ABCD 2 score has been developed to predict the early risk of stroke after transient ischemic attack (TIA). The aim of this study was to clarify whether ABCD 2 score predicts the occurrence of stroke in the long term after TIA. Methods— Fukuoka Stroke Registry (FSR) is a multicenter epidemiological study database on acute stoke. From June 2007 to June 2011, 496 (305 males, 70 ± 13 years of age) patients who had suffered from TIA and were hospitalized in the 7 stroke centers within 7 days after the onset of TIA were enrolled in this study. The patients were divided into three groups according to the risk: low-risk (ABCD 2 score 0-3; n=72), moderate-risk (4-5; n=229) and high-risk group (6-7; n=195). They were followed up prospectively for up to 3 years. Cox proportional hazard regression model was used to elucidate whether ABCD 2 score was a predictor for stroke after TIA after adjusting for confounding factors. Results— Among three groups, there were significant differences in age, hypertension, diabetes mellitus and the decrease in estimated glomerular filtration rate (P&lt;0.01, significantly). During a mean follow-up of 1.3 years, Kaplan-Meier analysis demonstrated that the stroke rate in TIA patients was significantly lower in low-risk group than in moderate-risk or high-risk group (log rank test, p&lt;0.001). The adjusted hazard ratios for stroke in patients with TIA increased with moderate-risk group (Hazard ratio [HR]: 3.47, 95% CI: 1.03-21.66, P&lt;0.05) and high-risk group (HR: 4.46, 95% CI: 1.31-27.85, P&lt;0.05), compared to low-risk group. Conclusions— The ABCD 2 score is able to predict the long-term risk of stroke after TIA.

Examination Timing and Lesion Patterns in Diffusion-weighted Magnetic Resonance Imaging of Patients with Classically Defined Transient Ischemic Attack

This study investigated factors associated with the presence of acute ischemic lesions after transient ischemic attack (TIA), using diffusion-weighted imaging (DWI) data from a multicenter retrospective, observational study. Of the 464 patients admitted to 13 stroke centers in Japan within 7 days after TIA onset, 458 patients underwent a DWI examination in this registry. Patients were divided into those with acute ischemic lesions and those without. We analyzed associations between DWI lesions and baseline characteristics, including age, sex, comorbidities, large artery atherosclerosis (LAA), type and duration of symptoms, the presence of multiple occurrences of TIA within 90 days before hospital visits (multiple TIAs) and the time from symptom onset to DWI examination (time-to-DWI). Among the 458 patients (291 men, 68.4±13.2 years old), 374 (81.7%) underwent a DWI examination within the initial 24 hours after the symptom onset. DWI lesions were found in 96 patients (21.0%), and divided into a single lesion (56 patients, 12.2%) or multiple lesions (40 patients, 8.7%). The presence of DWI lesions had an association with male sex (odds ratio [OR] 1.84; 95% confidence interval [CI] 1.07-3.29), time-to-DWI longer than 24 hours (OR 2.96; CI 1.57-5.52), and intracranial LAA (OR 1.99; CI 1.02-3.79). The presence of a single DWI lesion had an association with atrial fibrillation (OR 2.70; CI 1.41-5.03), and multiple DWI lesions did with time-to-DWI longer than 24 hours (OR 6.20; CI 2.60-15.20), multiple TIAs (OR 3.04; CI 1.35-6.76), intracranial LAA (OR 3.63; CI 1.44-8.89), and extracranial LAA (OR 3.53; CI 1.08-10.78). Acute ischemic lesions on DWI were associated with time-to-DWI and LAA in patients with classically defined TIA. Additionally, we identified some differences in relating factors between patients with single and multiple DWI lesions. These results indicate that time-to-DWI and DWI lesion pattern may be important for the diagnosis and management of TIA.

Juxtacortical Spots on Fluid-Attenuated Inversion Recovery Images in Cryptogenic Transient Ischemic Attack

Background and PurposeJuxtacortical spots are detected frequently on fluid-attenuated inversion recovery (FLAIR) images, but have not been extensively researched in patients with transient ischemic attack (TIA). We hypothesized that juxtacortical spots on FLAIR images are partly associated with right-to-left shunt (RLS) in TIA without clear etiology. The possibility of an association between the presence of RLS and juxtacortical spots on FLAIR images in patients with TIA without clear etiology was investigated, and the imaging findings of patients with and without RLS were compared.MethodsThis was a retrospective study of TIA patients who visited our tertiary stroke center consecutively within 72 hours of TIA onset. Cryptogenic TIA was defined as no clear etiology despite a routine diagnostic workup. The presence of RLS was examined by transcranial Doppler with an agitated saline test or transesophageal echocardiography. Juxtacortical spots were defined as small and round hyperintensities in the juxtacortex on FLAIR images, excluding white-matter hyperintensities.ResultsOf the 132 patients with cryptogenic TIA examined for this study, 70 (53.0%) had RLS. Juxtacortical spots on FLAIR images were detected more frequently in patients with RLS than in those without. The independent factors for the presence of juxtacortical spots were RLS [odds ratio (OR)=3.802, 95% confidence interval (95% CI)=1.74-8.2; p=0.001] and age (OR=1.058, 95% CI=1.01-1.10; p=0.004) by multivariate analysis. The number of juxtacortical spots was significantly higher among patients with a moderate-to-large RLS than in those with a small or no RLS.ConclusionsThe findings of the present study demonstrate a significant association between the presence of RLS and the occurrence of juxtacortical spots on FLAIR images in patients with cryptogenic TIA.

Abstract 2867: Factors Relating To An Early Visit To A Stroke Center In Patients With Transient Ischemic Attack: Analyses Of Data From A Multicenter Retrospective Study

Purpose: As transient ischemic attack (TIA) is a medical emergency associated with a high risk of early recurrent stoke, an immediate seeking medical attention is essential to reduce a risk of stroke after TIA. The purpose of this study was to investigate factors relating to an early visit to a stroke center in patients with TIA, using data of a multicenter retrospective study. Methods: The subjects of this study were TIA patients admitted to 13 stroke centers within 7 days after onset between 2008 and 2009. The diagnosis of TIA was made in this study if clinical symptoms lasted less than 24 hours, regardless of imaging findings. We compared baseline characteristics between patients visiting a stroke center within 3 hours of TIA onset (early visit, EV group) and those after the initial 3 hours (late visit, LV group), using Chi-square tests. Results: Four hundred sixty-four patients (292 men, mean age of 69 years) were registered. Of them, 240 patients (52%) belonged to the EV group and 220 (47%) used an ambulance. One hundred twenty-seven patients (27.4%) were referred from some other medical facility and 23 patients (5.0%) were from another department within the hospital. As compared to patients in the LV group, those in the EV group more commonly had motor symptoms (p &lt; 0.0001) and consciousness disturbance (p = 0.0027), and were less commonly referred from some other medical facility (p &lt; 0.0001) or from another department (p = 0.0057). Patients were less likely to have a past history of TIA in the EV group than in the LV group, but not significantly (p = 0.065). Conclusions: Almost half of TIA patients visited a stroke center within 3 hours after onset. Motor symptoms and consciousness disturbance were related to an early visit. Referrals from some other medical facility or department were associated with delay in a contact to stroke specialists.

Temporal Profile of De Novo Development of Moyamoya Vasculopathy in an Adult

A 46-year-old woman developed transient ischemic attack (TIA) caused by progressive moyamoya vasculopathy in the right hemisphere. She had presented with minor cerebellar infarction due to left vertebral artery dissection 7 years prior to the onset of TIA. Initial carotid angiography at the onset of vertebral artery dissection demonstrated absence of steno-occlusive changes in the anterior circulation. During the next 7 years, she had been strictly followed up with magnetic resonance angiography every 6 months, which demonstrated the asymptomatic development of steno-occlusive change in the proximal right middle cerebral artery, finally involving the terminal internal carotid artery. Carotid angiography at the onset of TIA showed terminal internal carotid artery stenosis with abnormal vascular network at the right base of the brain, indicating a definitive diagnosis of moyamoya vasculopathy with unilateral involvement. She underwent right superficial temporal artery-middle cerebral artery anastomosis without complication one month later. TIA completely disappeared after surgery, and no cerebrovascular events occurred during the follow-up period of 6 months. De novo formation of moyamoya vasculopathy is extremely rare in adulthood. The present case demonstrated the entire temporal profile of the development of this rare entity in adulthood. The previous presentation of vertebral artery dissection before the development of moyamoya vasculopathy as well as the initiation of steno-occlusive change at the middle cerebral artery is apparently unique.

Differences in Brain Natriuretic Peptide Value between Transient Ischemic Attack and Stroke Patients with Atrial Fibrillation

Purpose: The present study investigated clinical characteristics including plasma brain natriuretic peptide (BNP) among transient ischemic attack (TIA) and stroke patients with atrial fibrillation (AF). Methods: We prospectively enrolled 227 consecutive patients with AF within 24 h of onset of TIA or stroke, and plasma BNP was measured on admission. Patients were divided into 2 groups: TIA and stroke groups. The factors associated with TIA were investigated by multivariate logistic regression analysis. Results: 21 patients (9.3%) were diagnosed with TIA, and 206 patients (90.7%) with stroke. The plasma BNP level of the TIA group was significantly lower than that of the stroke group [median (interquartile range) 86.5 (72.7–189.0) pg/ml vs. 269.0 (146.0–432.0) pg/ml, p = 0.0002]. The optimal cutoff level, sensitivity, and specificity of BNP levels to distinguish the TIA group from the stroke group were 120 pg/ml, 79.1 and 66.7%, respectively. Multivariate logistic regression analysis demonstrated that pre-admission warfarin use (OR 3.7; 95% CI 1.178–11.570, p = 0.0250), glucose of ≤120 mg/dl (OR 5.1; 95% CI 1.629–16.238, p = 0.0052) and a plasma BNP of ≤120 pg/ml (OR 6.1; 95% CI 1.967–18.931, p = 0.0017) were independently associated with TIA. Conclusions: In AF patients, the BNP value on admission is lower in those with TIA than in those with stroke. Thus, cardiac function may be associated with neurological severity at the onset of TIA and stroke.

Prevalence of sleep-disordered breathing in acute ischemic stroke as determined using a portable sleep apnea monitoring device in Korean subjects

It has been suggested that there is a strong association between sleep-disordered breathing (SDB) and stroke. However, this connection has not been studied in Korean subjects. Sixty-one patients with acute cerebral infarction (ACI) and 13 patients with transient ischemic attack (TIA) were consecutively enrolled. SDB was evaluated within 48 h of stroke or TIA onset using a portable screening device, which allowed incidents of apnea, hypopnea, and snoring to be automatically analyzed. Clinical and sleep-related variables, including body mass indices (BMI), cardiovascular risk factors, stroke severity and disability, and Epworth sleepiness scale, Stanford sleepiness scale, and Berlin questionnaire scores were assessed. Sixty-four age-matched patient's spouses or family members with no history of physician-diagnosed stroke were enrolled as controls. Mean apnea-hypopnea index (AHI) was significantly higher in TIA (14.6 ± 10.4) and ACI (15.6 ± 14.7) patients than in the controls (7.8 ± 7.0; p = 0.001). The prevalences of SDB were 69.2% in TIA and 50.8% in ACI patients and 32.8% in controls. BMI and systolic blood pressure (SBP) were significantly higher in patients with SDB than in patients without SDB. Sleep-related stroke onset occurred in 17 patients (22.9%), and these patients had significantly higher AHIs. Multiple logistic regression analysis showed that BMI (odds ratio, 1.293; p = 0.027) and SBP (odds ratio, 1.030; p = 0.004) were found to independently predict SDB in patients with TIA or ACI. SDB is prevalent during the 48 h following ACI or TIA in Korean subjects. The authors recommend that SDB be evaluated after an ACI or TIA, especially in those with a high BMI and an elevated SBP.