Transient Ischemic Attack Symptoms Research Articles

Imaging and blood flow characteristics of cerebrovascular fenestration malformation and its relationship with the occurrence of ischemic cerebrovascular disease

ObjectiveTo explore the imaging and transcranial Doppler cerebral blood flow characteristics of cerebrovascular fenestration malformation and its relationship with the occurrence of ischemic cerebrovascular disease.MethodsA retrospective analysis was conducted on the imaging data of 194 patients with cerebrovascular fenestration malformation who visited the Heyuan People’s Hospital from July 2021 to July 2023. The location and morphology of the fenestration malformation blood vessels as well as the presence of other cerebrovascular diseases were analyzed. Transcranial Doppler cerebral blood flow detection data of patients with cerebral infarction and those with basilar artery fenestration malformation were also analyzed.ResultsA total of 194 patients with cerebral vascular fenestration malformation were found. Among the artery fenestration malformation, basilar artery fenestration was the most common, accounting for 46.08% (94/194). 61 patients (31.44%) had other vascular malformations, 97 patients (50%) had cerebral infarction, of which 30 were cerebral infarction in the fenestrated artery supply area. 28 patients with cerebral infarction in the fenestrated artery supply area received standardized antiplatelet, lipid-lowering and plaque-stabilizing medication treatment. During the follow-up period, these patients did not experience any symptoms of cerebral infarction or transient ischemic attack again. There were no differences in peak systolic flow velocity and end diastolic flow velocity, pulsatility index and resistance index between the ischemic stroke group and the no ischemic stroke group in patients with basal artery fenestration malformation (P > 0.05).ConclusionCerebrovascular fenestration malformation is most common in the basilar artery. Cerebrovascular fenestration malformation may also be associated with other cerebrovascular malformations. Standardized antiplatelet and statin lipid-lowering and plaque-stabilizing drugs are suitable for patients with cerebral infarction complicated with fenestration malformation. The relationship between cerebral blood flow changes in basilar artery fenestration malformation and the occurrence of ischemic stroke may not be significant.

Spiral time-of-flight magnetic resonance angiography for intracranial vascular imaging: performance compared to conventional Cartesian angiogram.

Computed tomography angiography (CTA) and digital subtraction angiography (DSA) usually raise the risk of potential malignancies with cumulative radiation doses. Current time-of-flight magnetic resonance angiography (TOF-MRA) (dubbed as cTOF), which is based on Cartesian sampling mode, may show limited diagnostic conspicuity at sinuous or branching regions. It is also prone to relatively high false positive diagnoses and undesirable display of distal intracranial vessels. This study aimed to use spiral TOF-MRA (sTOF) as a noninvasive alternative to explore possible improvement, such that the application of magnetic resonance angiography (MRA) can be extended to facilitate clinical examination or cerebrovascular disease diagnosis and follow-up studies. Initially, 37 patients with symptoms of dizziness or transient ischemic attack were consecutively recruited for suspected intracranial vascular disease examination from Zhongshan Hospital of Xiamen University between July 2020 and April 2021 in this cross-sectional prospective study. After excluding 1 patient with severe scanning artifacts, 1 patient whose scanning scope did not meet the requirement, and 1 patient with confounding tumor lesions, a total of 34 participants were included according to the inclusion and exclusion criteria. Each participant underwent intracranial vascular imaging with both sTOF and cTOF sequences on a 3.0 T MR scanner with a conventional head-neck coil of 16 channels. Contrast CTA or DSA was also performed for 15 patients showing pathology. Qualitative comparisons in terms of image quality and diagnostic efficacy ratings, quantitative comparisons in terms of signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), vessel length, and sharpness were evaluated. Pair-wise Wilcoxon test was performed to evaluate the imaging quality derived from cTOF and sTOF acquisitions and weighted Cohen's Kappa was conducted to assess the rating consistency between different physicians. Compared to cTOF, sTOF showed better performance with fewer artifacts. It can effectively alleviate false positives of normal vessels being misdiagnosed as aneurysm or stenosis. Improved conspicuity was observed in cerebral distal regions with more clearly identifiable vasculature at finer scales. Quantitative comparisons in selected regions revealed significant improvement of sTOF in SNR (P<0.01 or P<0.001), CNR (P<0.001), vessel length (P<0.001), and sharpness (P<0.001) as compared to cTOF. Besides, sTOF can depict details of M1 and M2 segments of middle cerebral artery (MCA) at metallic implant region, showing its resistance to magnetic susceptibility. The sTOF shows higher imaging quality and lesion detectability with reduced artifacts and false positives, representing a potentially feasible surrogate in intracranial vascular imaging for future clinic routines.

Retrospective Cohort Angiographic Analysis of Vertebral Artery Dominance, Stenosis Patterns, and Demographic Correlations.

Differences in dominance and stenosis in the complex vertebral artery (VA) network pose challenges in diagnosing and treating cerebrovascular diseases crucial for brain nutrition. This research examines these intricacies, highlighting the importance of detailed diagnosis and treatment methods. To analyze the prevalence of the dominant VA, evaluate the influence of gender and age on steno-occlusion, and explore the correlation between the dominant VA and stenosed VA segments. A retrospective study of 249 angiograms from patients with VA stenosed at King Abdullah University Hospital between August 2019 and December 2022. The patients presenting symptoms of vertigo, migraines, headaches, or transient ischemic attacks (TIA) were included, 182 cases were classified based on VA dominance and stenosis severity. The data were analyzed using IBM SPSS 27. Out of the 182 participants, 64.8% were male, with an average age of 61.3 years and 35.2% were female. The prevalence of stenosis was distributed as follows: 26.4% mild, 44.0% moderate, and 29.7% severe. Statistically significant correlations were observed between hypertension, smoking, hyperlipidemia, and the degree of stenosis (p < 0.05), but not with diabetes. The prevalence of left vertebral artery (VA) dominance was found to be 41.1%. Additionally, there was no gender connection observed in the distribution of steno-occlusion (p = 0.434). There is no notable correlation between the degree of stenosis and the dominant vertebral artery (p > 0.05). Angiographic findings reveal the complex relationship between the dominance of the VA, patterns of stenosis, and demographic factors. Individuals with a dominant VA had a greater likelihood of developing stenosis on the opposite non-dominant side. The high occurrence of severe stenosis highlights the need for tailored diagnostic and treatment approaches. Understanding vertebral stenosis as a multifaceted interaction of demographic, lifestyle, and anatomical variables is essential for enhancing treatment strategies.

Metagenomic Analysis of Bacterial Microflora in Dental and Atherosclerotic Plaques of Patients With Internal Carotid Artery Stenosis.

Internal carotid artery stenosis is primarily attributed to atherosclerosis in the carotid artery bifurcation. Previous studies have detected oral bacteria in atherosclerotic lesions, suggesting an association between oral bacteria and atherosclerosis. In this study, we compared the bacterial flora of the atherosclerotic plaque in the carotid artery and dental plaque of patients with internal carotid artery stenosis using 16S ribosomal RNA (16S rRNA) metagenomic sequencing. Fifty-four patients who underwent internal carotid endarterectomy for internal carotid artery stenosis at the Showa University Hospital between April 2016 and February 2018 were included. Polymerase chain reaction targeting the 16S rRNA gene detected bacterial DNA in the carotid plaques of 11 cases, of which only 5 could be further analyzed. Thereafter, DNA extracted from the carotid and oral plaques of these 5 cases were analyzed using metagenomic sequencing targeting 16S rRNA. In addition, their general condition and oral conditions were evaluated. The patients were classified into symptomatic and asymptomatic groups based on the presence or absence of symptoms of transient ischemic attack, and their bacterial flora was evaluated. The results demonstrated that the microflora of carotid plaques (n = 5) contained bacterial species from 55 families and 78 genera. In addition, 86.5% of the bacteria detected in the carotid plaques were also detected in oral plaques. Cariogenic and periodontopathic bacteria accounted for 27.7% and 4.7% of the bacteria in the carotid plaques, respectively. These results suggest that oral bacteria are directly or indirectly involved in the pathogenesis of atherosclerosis. More extensive studies of oral commensal bacteria detected in extra-oral lesions are warranted to comprehensively investigate the role of oral bacteria in the pathogenesis of systemic diseases.

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

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

Task-residual effective connectivity of motor network in transient ischemic attack

Transient ischemic attack (TIA) is a temporary episode of neurological dysfunction that results from focal brain ischemia. Although TIA symptoms are quickly resolved, patients with TIA have a high risk of stroke and persistent impairments in multiple domains of cognitive and motor functions. In this study, using spectral dynamic causal modeling, we investigate the changes in task-residual effective connectivity of patients with TIA during fist-closing movements. 28 healthy participants and 15 age-matched patients with TIA undergo functional magnetic resonance imaging at 7T. Here we show that during visually cued motor movement, patients with TIA have significantly higher effective connectivity toward the ipsilateral primary motor cortex and lower connectivity to the supplementary motor area than healthy controls. Our results imply that TIA patients have aberrant connections among motor regions, and these changes may reflect the decreased efficiency of primary motor function and disrupted control of voluntary movement in patients with TIA.

Rates of Stroke in Patients With Different Presentations of Carotid Artery Stenosis

Carotid artery stenosis may present without the classical symptoms of transient ischaemic attack or stroke but the rates of stroke for these presentations is unknown. The aim of this study was to examine the rates of stroke in patients with different presentations of carotid artery stenosis. A multicentre prospective cohort study was conducted across three Australian vascular centres with low rates of surgical treatment of patients without transient ischaemic attack or stroke. Patients with a 50 - 99% carotid artery stenosis presenting with non-focal symptoms (e.g., dizziness or syncope; n= 47), prior contralateral carotid endarterectomy (n= 71), prior ipsilateral symptoms more than six months earlier (n= 82), and no symptoms (n = 304) were recruited. The primary outcome was ipsilateral ischaemic stroke. Secondary outcomes were any ischaemic stroke and cardiovascular death. Data were analysed using Cox proportional hazard and Kaplan-Meier analyses. Between 2002 and 2020, 504 patients were enrolled (mean age 71 years, 30% women) and followed for a median of 5.1 years (interquartile range 2.5, 8.8; 2 981 person years). Approximately 82% were prescribed antiplatelet therapy, 84% were receiving at least one antihypertensive drug, and 76% were prescribed a statin at entry. After five years the incidence of ipsilateral stroke was 6.5% (95% confidence interval [CI] 4.3 - 9.5). There were no statistically significant differences in the annual rate of ipsilateral stroke among people with non-focal symptoms (2.1%; 95% CI 0.8 - 5.7), prior contralateral carotid endarterectomy (0.2%; 0.03 - 1.6) or ipsilateral symptoms > 6 months prior (1.0%; 0.4 - 2.5) compared with those with no symptoms (1.2%; 0.7 - 1.8; p= .19). There were no statistically significant differences in secondary outcomes across groups. This cohort study showed no large differences in stroke rates among people with different presentations of carotid artery stenosis.

Predicting transient ischemic attack risk in patients with mild carotid stenosis using machine learning and CT radiomics.

This study aims to establish a radiomics-based machine learning model that predicts the risk of transient ischemic attack in patients with mild carotid stenosis (30-50% North American Symptomatic Carotid Endarterectomy Trial) using extracted computed tomography radiomics features and clinical information. A total of 179 patients underwent carotid computed tomography angiography (CTA), and 219 carotid arteries with a plaque at the carotid bifurcation or proximal to the internal carotid artery were selected. The patients were divided into two groups; patients with symptoms of transient ischemic attack after CTA and patients without symptoms of transient ischemic attack after CTA. Then we performed random sampling methods stratified by the predictive outcome to obtain the training set (N = 165) and testing set (N = 66). 3D Slicer was employed to select the site of plaque on the computed tomography image as the volume of interest. An open-source package PyRadiomics in Python was used to extract radiomics features from the volume of interests. The random forest and logistic regression models were used to screen feature variables, and five classification algorithms were used, including random forest, eXtreme Gradient Boosting, logistic regression, support vector machine, and k-nearest neighbors. Data on radiomic feature information, clinical information, and the combination of these pieces of information were used to generate the model that predicts the risk of transient ischemic attack in patients with mild carotid artery stenosis (30-50% North American Symptomatic Carotid Endarterectomy Trial). The random forest model that was built based on the radiomics and clinical feature information had the highest accuracy (area under curve = 0.879; 95% confidence interval, 0.787-0.979). The combined model outperformed the clinical model, whereas the combined model showed no significant difference from the radiomics model. The random forest model constructed with both radiomics and clinical information can accurately predict and improve discriminative power of computed tomography angiography in identifying ischemic symptoms in patients with carotid atherosclerosis. This model can aid in guiding the follow-up treatment of patients at high risk.

Case report of intracranial large vessel occlusion in glioblastoma multiforme patient after radiation therapy.

Vasculopathy of the large arteries is a prominent complication of radiotherapy. Radiation-induced cerebral vasculopathy can cause arterial stenosis/occlusion, cerebral hemorrhage, and aneurysm formation. We report a cases of glioblastoma multiforme (GBM) with occlusive radiation vasculopathy (ORV). This 28-year-old patient who suffered from GBM had surgery for cytoreduction and received postoperative CCRT. We adopted the radiotherapy and oncology group radiation guideline. This patient had cerebrovascular accident episodes without any known risk. Therefore, ORV was highly suspected and vascular stenosis was confirmed using magnetic resonance angiography (MRA) or digital subtraction angiography. Extracranial-intracranial bypass was performed and patency was confirmed. The patient had not suffered from recurrent symptoms of transient ischemic attack or ischemic stroke for 1.5 years. This is the first article to report bypass surgery for GBM patients. Although the median survival rate of GBM is approximately 15 months, the short survival time may be sufficient for occlusive vasculopathy to occur. Regular follow-up magnetic resonance imaging assessments are recommended, as is MRA as a screening tool for the early diagnosis of ORV.The Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial focused on atherosclerotic intracranial arterial stenosis, revealing that aggressive medical management was superior to stenting for secondary stroke prevention; however, it did not mention radiation-induced vasculopathy. Bypass surgery has yielded some positive outcomes. In the absence of contraindications, antiplatelet or anticoagulation agents could be added, and bypass surgery could be performed because there was no stent in the distal intracranial arteries. MRA is a potential screening tool for ORV in GBM patients and bypass surgery could be performed to improve brain perfusion. Bypass surgery could help patient with occlusive radiation vasculopathy.

LBODP070 A Rare Neuroendocrine Tumor-Insulinoma

Abstract Introduction Insulinoma is a rare neuroendocrine tumor, which presents sporadically or as a complex of multiple endocrine neoplasia type 1 syndrome (MEN-1). Most Insulinoma cases present with fasting hypoglycemia and some with both fasting and postprandial hypoglycemia. Case Report A 48-year-old male with no significant past medical or surgical history presented for an evaluation of hypoglycemia. He was recently seen in the Emergency Room after having a transient ischemic attack-like episode. The patient reported that he was at a family gathering where he was found confused and his blood glucose was checked by a family member with diabetes, which was noted to be 39 mg/ dl. He reported having other such episodes of lesser severity, occurring once or twice a month for many years. His symptoms would typically wake him from sleep, especially during early mornings with diaphoresis. He would take a snack to resolve his symptoms. Except for being overweight, no other abnormal findings were detected on physical examination. Fasting blood work revealed glucose of 42 with elevated insulin, C-peptide, proinsulin levels, and negative beta-hydroxybutyrate and insulin antibodies. An MRI abdomen with contrast demonstrated a 1.2 cm pancreatic lesion in the uncinate process, suspicious for a neuroendocrine tumor. Endoscopic Ultrasound staged the mass in the uncinate process of the pancreas as T1 N0 M0. FNAC showed a few atypical monomorphic cells suggestive of neuroendocrine origin. Immunohistochemical stains on the sample were positive for CD45 while CAM5.2, synaptophysin, and Ki65 were negative. The patient ultimately underwent exploratory laparotomy and resection of the neuroendocrine tumor with partial pancreatectomy. Discussion The symptoms of hypoglycemia are classified into sympathoadrenal (palpitation, diaphoresis, tremulousness) or neuroglycopenic (confusion, blurry vision, change in behavior, seizures, and amnesia of hypoglycemic episode). The neuroglycopenic symptoms of hypoglycemia mimic transient ischemic attack (TIA). The diagnosis of insulinoma needs biochemical proof of endogenous hyperinsulinemia and localization of the tumor. Surgery is the treatment of choice in resectable tumors. Conclusion This case highlights insulinoma as a rare cause of hypoglycemia and shows the importance of detailed history taking and appropriate investigations in its diagnosis.

When Can an Emergency CTA Be Dispensed with for TIA Patients?

Background: Transient ischemic attacks (TIAs) and minor strokes are often precursors of a major stroke. Therefore, diagnostic work-up of the TIA is essential to reduce the patient’s risk of further ischemic events. Purpose: With the help of this retrospective study, we aim to determine for which TIA patients a CT angiography (CTA) is not immediately necessary in order to reduce radiation exposure and nephrotoxicity. Material and Methods: Clinical and imaging data from patients who presented as an emergency case with a suspected diagnosis of TIA at a teaching hospital between January 2016 and December 2021 were evaluated. The included 1526 patients were divided into two groups—group 1, with major pathologic vascular findings in the CTA, and group 2, with minor vascular pathologies. Results: Out of 1821 patients with suspected TIA on admission, 1526 met the inclusion criteria. In total, 336 (22%) had major vascular pathologies on CTA, and 1190 (78%) were unremarkable. The majority of patients with major vascular pathologies were male and had a history of arterial hypertension, coronary heart disease, myocardial infarction, ischemic stroke, TIA, atherosclerotic peripheral vascular disease, smoking, antiplatelet medication, had a lower duration of TIA symptoms, and had lower ABCD2 scores. Conclusions: We were able to demonstrate a direct correlation between major CTA pathologies and a history of smoking, age, hyperlipidemia, history of peripheral arterial disease, and a history of stroke and TIA. We were able to prove that the ABCD2 score is even reciprocal to CTA pathology. This means that TIA patients without described risk factors do not immediately require a CTA and could be clarified in the course of treatment with ultrasound or MRI.

Double Interatrial Septum and Patent Foramen Ovale in Woman With Transient Ischemic Attack.

A 47-year-old woman with a history of hypertension presented with symptoms of transient ischemic attack. Her blood pressure was normal. A 12-lead electrocardiogram and a 24-hour Holter monitor revealed sinus rhythm. Transthoracic echocardiograms showed normal left ventricular systolic function (ejection fraction, 66%), mild left ventricular hypertrophy, and a slightly enlarged left atrium. The apical 4-chamber view showed echo-free space between 2 atria in the center of the interatrial septum (IAS) with 2 parallel atrial-septal structures, raising suspicion of a persistent interatrial space (Fig. 1). With the patient in the Valsalva maneuver, we obtained a 2-dimensional transesophageal echocardiogram (TEE) with agitated saline contrast medium, which revealed a small communication from the interatrial space to the right atrium through a patent foramen ovale (PFO) at the midesophageal short-axis level of the aortic valve (Fig. 2). Real-time 3-dimensional TEE revealed a membrane, parallel to the IAS, that created a double IAS and an additional interatrial space (Figs. 3 and 4). No obstruction existed between the left atrial appendage and the normal pulmonary veins, mitral valve, or coronary sinus. A 2-dimensional TEE in color-flow Doppler mode showed flow into the additional chamber from the left atrium across the left-sided IAS. Previous reports suggest that a double IAS can cause emboli,1,2 so we considered our patient to be at high risk and the PFO to be the cause of her neurologic event. Device closure of the PFO was not attempted because of possible complications from catheter-based closure. The patient was prescribed anticoagulation therapy and was discharged from the hospital after a 5-day stay. At the 3-month follow-up visit, she had no neurologic complications; 4 years later, she remained asymptomatic.Double IAS, an extremely rare congenital cardiac anomaly, is characterized by the presence of 2 distinct interatrial septa enclosing an interatrial chamber. The accessory membrane lies parallel to the IAS, and the pulmonary veins continue to communicate freely with the mitral valve and left atrial appendage.2,3 Most patients are asymptomatic unless thromboembolic complications or cardioembolic events occur. Potential causes of double IAS are abnormal or incomplete fusion of the atrial septum primum with the septum secundum, and embryologic left venous valve derived from the embryologic sinus venosus.2,3 There is no preferred treatment or risk stratification for cardiac sources of embolism in double IAS associated with neurologic events. However, monitoring with 3-dimensional TEE is imperative.

Clinical manifestations, laboratorial findings and mechanisms of CADASIL: An integrative review

This integrative literature review study aimed to analyze the clinical and laboratory findings, in addition to the treatment of case reports of CADASIL from the last 5 years. The database used in the search was PubMed, with the following descriptors: “CADASIL”, “case report”, in addition to the use of the Boolean operator (AND). The final sample was 25 baseline studies. Although CADASIL is caused by a genetic mutation, there was a case in which COVID-19 infection was the beginner of the manifestations of a patient with a previous mutation. In the exams, most have shown damages in MRI, with confluent hypertensive foci, microinfarcts, stenosis and even brain atrophy. Cases were also recorded in which the disease presented parkinsonian syndrome, symptoms of atypical paraplegia, mood alterations and transient ischemic attack. In the study it was perceptive the manifestations in families with this genetic disease. The symptons can be manifested in hetero or homozygous, and may cause mental disorders, headache and stroke. The clinical variety shows its complexity, requiring studies to understand all its pathophysiology.There is no cure for this disease, so its treatments were mainly to control the symptoms.

FAST-IT: Find A Simple Test — In TIA (transient ischaemic attack): a prospective cohort study to develop a multivariable prediction model for diagnosis of TIA through proteomic discovery and candidate lipid mass spectrometry, neuroimaging and machine learning—study protocol

IntroductionTransient ischaemic attack (TIA) may be a warning sign of stroke and difficult to differentiate from minor stroke and TIA-mimics. Urgent evaluation and diagnosis is important as treating TIA early...

Timing of Carotid Intervention in Symptomatic Cerebrovascular Disease: Outcomes of a Single-Institution Experience

The optimal timing for carotid endarterectomy in patients with symptomatic cerebrovascular disease has remained unclear. We compared the clinical outcomes of carotid endarterectomy performed before and 2 weeks after symptom onset. A retrospective analysis was performed of patients who had presented to our institution with symptomatic cerebrovascular disease, defined by the presence of transient ischemic attack (TIA) or cardiovascular accident (CVA) symptoms, from January 2012 to February 2020. The data collected included demographics, National Institutes of Health stroke scale (NIHSS) and modified Rankin scale (mRS) scores, and postoperative complications, including recurrent TIA or CVA, myocardial infarction, and death during admission and at discharge. The patients were followed up for 1 year. The primary end points included NIHSS scores, mRS scores, and changes in the scores from baseline to 30 days, with the secondary end points extending to 90 days and 1 year. A total of 169 patients were included, of whom, 58.6% had undergone carotid endarterectomy within 2 weeks of symptom onset. The baseline demographic and clinical characteristics were similar between groups. No differences in the primary or secondary end points were demonstrated at any interval (P = 1.0, P = .77, and P = .4 for the 30-day NIHSS score, mRS score, and 30-day change in the mRS score, respectively; and P = .9, P = .22, and P = .07 for the 90-day NIHSS score, mRS score, and 1-year mRS score, respectively). We found a difference in postoperative complications, including recurrent TIA/CVA, myocardial infarction, and death. A subgroup analysis of interventional neurology involvement was performed; they had evaluated 44.4% of the patients. No further intervention was required for 42.7%, diagnostic cerebral arteriography was performed in 36.0%, and an additional intervention was required for 21.3%. Interventional neurology involvement demonstrated no differences in the primary or secondary end points. Carotid endarterectomy was safe if performed within 2 weeks of symptom onset with equivalent outcomes compared with delayed surgery. Involvement of interventional neurology did not affect the neurologic outcomes for early vs late operative timing.

Treatment of a rare recurrent pulmonary arteriovenous malformation after multiple embolization by robotic-assisted thoracoscopic surgery

Pulmonary arteriovenous malformations (PAVMs) are a rare pulmonary arteriovenous direct traffic vascular malformation, which directly connect the pulmonary artery to the pulmonary vein without pulmonary capillary bed. Currently, surgical resection and percutaneous transcatheter embolization are the main mode of treatment. Embolization is gradually becoming the preferred treatment for people with PAVMs, because it is less invasive and easy to repeat. We describe a case of PAVMs with hemoptysis that relapsed again after three times of embolization and then only presented new symptoms of transient ischemic attack. Finally, the patient was treated by Da Vinci robotic-assisted thoracoscopic surgery, and there were no obvious post-operative complications and recurrence. It is the first report of multiple recurrent complex PAVMs and we present our experience with the treatment of recurrent PAVMs.

Abstract WP206: Temporal Trends In Stroke Patients Who Had Prior Transient Ischemic Attack And Did Not Present To The Emergency Room: A Population Study

Background: Acute ischemic stroke (AIS) is a leading cause of disability worldwide, with up to 30% of cases preceded by transient ischemic attack (TIA). Urgent evaluation of TIA symptoms is recommended to reduce risk of stroke, but not all patients with TIA symptoms seek evaluation. Our goal was to assess temporal trends in the demographics of such patients. Methods: Using the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) for years 2005, 2010, and 2015, we selected patients with a diagnosis of AIS using ICD-9/10 codes in adults ≥18yrs of age presenting to the ED. We identified patients who had a preceding TIA based on symptoms within 60 days of presentation, as judged by an adjudicating physician. Demographics, histories, and proportion of patients with TIA were compared across study years using Wilcoxon rank sum test or chi-square test. Results: We identified 5977 patients presenting with AIS across three epochs. Of these 207 (3%) had prior suspected TIA and did not seek immediate medical attention; 56/1790 (3%) in 2005, 62/1993 (3%) in 2010, and 70/2194 (3%) in 2015 (p-value=0.99). Patients with suspected TIA had increasing rates of previously diagnosed HLD and DM over the three time periods. No other risk factors or demographics showed a change over time. Known HTN was consistently prevalent across epochs (Table 2). Conclusion: Over the three epochs, 3% of AIS patients consistently did not seek emergent medical attention for a recent preceding TIA. A substantial proportion of these patients were increasingly already diagnosed with DM and HLD over the study periods, and the majority were persistently diagnosed with HTN. This is an opportune cohort for future targeted outreach.

Neurological Prognostic Factors in Hospitalized Patients with COVID-19.

We aimed to search whether neurological symptoms or signs (NSS) and the MEWS (Modified Early Warning Score) score were associated with in-hospital mortality or oxygen requirement during the first 14 days of hospitalization in COVID-19 patients recruited at the University Hospital in Krakow, Poland. The detailed clinical questionnaires on twenty NSS were either filled out by patients prospectively or retrospectively assessed by neurologists based on daily medical records. NSS were considered high or low-risk if they were associated with increased or decreased mortality in the univariable analysis. This cohort study included 349 patients with COVID-19 (median age 64, interquartile range (51–77), women 54.72%). The presence of high-risk NSS (decreased level of consciousness, delirium, seizures, and symptoms of stroke or transient ischemic attack) or its combination with the absence of low-risk NSS (headache, dizziness, decreased mood, and fatigue) increased the risk of in-hospital mortality in SARS-CoV-2 infection 3.13 and 7.67-fold, respectively. The presence of low-risk NSS decreased the risk of in-hospital mortality in COVID-19 patients more than 6-fold. Death in patients with SARS-CoV-2 infection, apart from NSS, was predicted by older age, neoplasm, and higher MEWS scores on admission. High-risk NSS or their combination with the absence of low-risk NSS increased the risk of oxygen requirement during hospitalization in COVID-19 patients 4.48 and 1.86-fold, respectively. Independent predictors of oxygen therapy during hospitalization in patients with SARS-CoV-2 infection were also older age, male sex, neoplasm, and higher MEWS score on admission.

Arterial spin labeling as an ancillary assessment to postoperative conventional angiogram in pediatric moyamoya disease

Digital subtraction angiography (DSA) is commonly performed after pial synangiosis surgery for pediatric moyamoya disease to assess the degree of neovascularization. However, angiography is invasive, and the risk of ionizing radiation is a concern in children. In this study, the authors aimed to identify whether arterial spin labeling (ASL) can predict postoperative angiogram grading. In addition, they sought to determine whether patients who underwent ASL imaging without DSA had similar postoperative outcomes when compared with patients who received ASL imaging and postoperative DSA. The medical records of pediatric patients who underwent pial synangiosis for moyamoya disease at a quaternary children's hospital were reviewed during a 10-year period. ASL-only and ASL+DSA cohorts were analyzed. The frequency of preoperative and postoperative symptoms was analyzed within each cohort. Three neuroradiologists assigned a visual ASL grade for each patient indicating the change from the preoperative to postoperative ASL perfusion sequences. A postoperative neovascularization grade was also assigned for patients who underwent DSA. Overall, 21 hemispheres of 14 patients with ASL only and 14 hemispheres of 8 patients with ASL+DSA were analyzed. The groups had similar rates of MRI evidence of acute or chronic stroke preoperatively (61.9% in the ASL-only group and 64.3% in the ASL+DSA group). In the entire cohort, transient ischemic attack (TIA) (p = 0.027), TIA composite (TIA or unexplained neurological symptoms; p = 0.0006), chronic headaches (p = 0.035), aphasia (p = 0.019), and weakness (p = 0.001) all had decreased frequency after intervention. The authors found a positive association between revascularization observed on DSA and the visual ASL grading (p = 0.048). The visual ASL grades in patients with an angiogram indicating robust neovascularization demonstrated improved perfusion when compared with the ASL grades of patients with a poor neovascularization. Noninvasive ASL perfusion imaging had an association with postoperative DSA neoangiogenesis following pial synangiosis surgery in children. There were no significant postoperative stroke differences between the ASL-only and ASL+DSA cohorts. Both cohorts demonstrated significant improvement in preoperative symptoms after surgery. Further study in larger cohorts is necessary to determine whether the results of this study are validated in order to circumvent the invasive catheter angiogram.

Comparing Treatment Outcomes Between In-Hospital and Emergency Department Management of Patients With Transient Ischemic Attacks.

IntroductionA transient ischemic attack (TIA) is a medical emergency, as it is a sudden neurological episode caused by ischemia in a vascular territory in the brain, which lasts less than one hour. TIA definition has shifted from time-based to tissue-based according to modern literature. It is considered a warning sign for an impending stroke. Symptoms could range from weakness on one side of the body, diaphoresis, to slurred speech. In this study, we examined the differences in health outcomes, when patients diagnosed with TIA are treated and discharged home from the ED, versus when admitted to the hospital for additional care.MethodsThis is a descriptive and retrospective study. We examined all patients’ encounters from January 1, 2018 to December 31, 2019 at four emergency department locations. The cohort compared patients diagnosed with a TIA who takes medications (anti-lipid, antiplatelet drugs) versus patients diagnosed with a TIA who are not on any preventive medication. We compared the hospital readmission rate between these two group of patients and the need for additional medical treatments. Our study also considered hospital length of stay (LOS), admission rate, and its impact on patients with comorbidities.ResultsThere were 983 patients included in the study. The patients on TIA prophylactic medications prior to coming to the ED made up (60.7%), and (51.2%) in this group required additional medications during hospital admission. The remaining 162 (39.3%), p=0.001 patients, were not on TIA prophylactic medications prior to presenting in the ED. The patients who required additional medications while in the ED were significantly older (mean +/-SD, 68.6 +/-14.0 years versus 62.18 +/- 17.4 years, p=0.001). Following a multivariate analysis, age greater than 60 (CI: 3.52-3.91, p=0.001) and results of the head CT/MRI investigations for any signs of neurological damage, were all found to be independent predictors of longer hospital stay and treatment outcomes. There were no significant differences in the treatment outcome for patients with TIA based on longer hospital stay and extra medication administration in the ED.ConclusionIn our study, we observed that approximately, 75% of the patients who were on TIA prophylactic medications prior to presenting in the ED with symptoms of TIA were admitted to the hospital for further monitoring, compared to other group of patients who were not on TIA medications. We did also noted that there were no differences in mortality outcome between patients treated and discharged from the ED, versus patients admitted to the hospital for additional treatment. Lastly, patients who are 68 years and older, made up two-thirds of patient population admitted in the hospital and required additional medications, compared to younger patients.