Transient Ischemic Attack Symptoms Research Articles

Delay to Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis

In patients with recently symptomatic carotid artery stenosis, guidelines recommend carotid revascularization within 2 weeks of the index event. The "index event" may be defined as either the first or the most recent event. The delay between the index event and carotid endarterectomy (CEA) over a period of 6 years in a single centre was evaluated and the effect of defining the index event as either the first or the most recent event was assessed. Observational study. 555 consecutive patients with symptomatic carotid stenosis ≥ 50% treated with CEA between 2007 and 2012 were assessed. In 2010, changes to the in-hospital process of care to reduce delays in referral and CEA were introduced. These changes included, for example, improving access to physicians, imaging, and operating rooms. The delay from symptoms to surgery was expressed in days. The median time between the first event and surgery was reduced from 53 days (interquartile range [IQR] 30-78) in 2007 to 21 days (IQR 12-45) in 2012, and between the most recent event and CEA from 45 days (IQR 28-67) to 17 days (IQR 9-28). Patients referred directly by their general practitioner more often underwent CEA within 2 weeks than patients referred by specialists from other hospitals. Compared to patients with transient ischaemic attack or ocular symptoms, patients with ischaemic stroke more often underwent CEA within 2 weeks. A small change in the process of care significantly reduced the delay from the index event to CEA, but in 2012 it still exceeded 14 days in the majority of patients. The definition of the "index event" has a large impact on the total duration of delay, and should therefore be uniform across studies.

Magnetic resonance imaging in patients with transient ischemic attack.

Magnetic resonance imaging in patients with transient ischemic attack.

Commentary on “Comparison of Cognitive Function after Carotid Artery Stenting versus Carotid Endarterectomy”

predictable: no differences could be demonstrated. 1 Cognitive function includes memory, attention, mood, and language. Therefore, any possible initiative towards improving dysfunction is welcomed. At the same time, the risk of cognitive deterioration associated with interventions performed with the intention of preventing future stroke should be taken into account. Today, it is recommended that carotid intervention in patients with symptoms of transient ischemic attack or stroke is performed very early after the index symptom. 2,3 To manage evaluating the level of cognitive function (which requires advanced and time-consuming neuropsychological tests) prior to carotid intervention may therefore be the number one challenge of future studies. Clarifying the underlying pathophysiology (embolic or hemodynamic?) in patients with impaired cognitive function seems urgent. Thereafter, the influence of carotid intervention upon cognitive function may be easier to evaluate. Vascular surgeons should look forward to, but must await the results from, such studies and keep to established guidelines when selecting patients for carotid intervention. 3,4 And until further notice, CEA as well as CAS must continue to be regarded solely as (secondary) stroke prophylaxis.

The use of Cincinnati Prehospital Stroke Scale during telephone dispatch interview increases the accuracy in identifying stroke and transient ischemic attack symptoms.

BackgroundTimely and appropriate hospital treatment of acute cerebrovascular diseases (stroke and Transient Ischemic Attacks - TIA) improves patient outcomes. Emergency Medical Service (EMS) dispatchers who can identify cerebrovascular disease symptoms during telephone requests for emergency service also contribute to these improved outcomes. The Italian Ministry of Health issued guidelines on the management of AC patients in pre-hospital emergency service, including Cincinnati Prehospital Stroke Scale (CPSS) use.We measured the sensitivity and Positive Predictive Value (PPV) of EMS dispatchers’ ability to recognize stroke/TIA symptoms and evaluated whether the CPSS improves accuracy.MethodsA cross-sectional multicentre study was conducted to collect data from 38 Italian emergency operative centres on all cases identified with stroke/TIA symptoms at the time of dispatch and all cases with stroke/TIA symptoms identified on the scene by the ambulance personnel from November 2010 to May 2011.ResultsThe study included 21760 cases: 18231 with stroke/TIA symptoms at dispatch and 9791 with symptoms confirmed on the scene. The PPV of the dispatch stroke/TIA symptoms identification was 34.3% (95% CI 33.7-35.0; 6262/18231) and the sensitivity was 64.0% (95% CI 63.0-64.9; 6262/9791). Centres using CPSS more often (>10% of cases) had both higher PPV (56%; CI 95% 57–60 vs 18%; CI 95% 17–19) and higher sensitivity (71%; CI 95% 87–89 vs 52%; CI 95% 51–54).In the multivariate regression a centre’s CPSS use was associated with PPV (beta 0.48 p = 0.014) and negatively associated with sensitivity (beta -0.36; p = 0.063); centre sensitivity was associated with CPSS (beta 0.32; p = 0.002), adjusting for PPV.ConclusionsCentres that use CPSS more frequently during phone dispatch showed greater agreement with on-the-scene prehospital assessments, both in correctly identifying more cases with stroke/TIA symptoms and in giving fewer false positives for non-stroke/TIA cases. Our study shows an extreme variability in the performance among OCs, highlighting that form many centres there is room for improvement in both sensitivity and positive predictive value of the dispatch. Our results should be used for benchmarking proposals in the effort to identify best practices across the country.

Diagnostic and Prognostic Value of Multimodal MRI in Transient Ischemic Attack

The clinical diagnosis of transient ischemic attack is highly subjective, and the risk prediction after transient ischemic attack using the clinical parameters still remains unsatisfactory. We aimed to investigate the diagnostic and prognostic value of multimodal magnetic resonance imaging in transient ischemic attack patients. We prospectively performed diffusion-weighted imaging, perfusion-weighted imaging, and intracranial and extracranial magnetic resonance angiogram within 72 h of symptom onset in 162 transient ischemic attack patients defined by the classical time-based definition. Follow-up diffusion-weighted imaging was obtained three-days later in patients who did not exhibit lesions on the initial diffusion-weighted imaging. The occurrence of clinical events (transient ischemic attack or stroke) three-months after the initial transient ischemic attack was recorded, and the ABCD2 and ABCD3-I scores were calculated. The clinical and imaging parameters were compared between patients with and without initial diffusion-weighted imaging lesion, clinical events, and follow-up diffusion-weighted imaging lesions. Abnormalities were present on diffusion-weighted imaging, perfusion-weighted imaging, and magnetic resonance angiogram in 38·9%, 44·1%, and 51·9% of patients, respectively. Diffusion-weighted imaging plus perfusion-weighted imaging explained 64·8%, and the addition of magnetic resonance angiogram explained 74% of the transient ischemic attack symptoms. The initial diffusion-weighted imaging positivity was associated with longer time from symptom onset to magnetic resonance imaging examination (odds ratio, 1·039; 95% confidence interval, 1·008-1·071; P=0·013). On follow-up diffusion-weighted imaging, new lesions were found in 46·7% of the patients who initially showed normal diffusion-weighted imaging findings. Initial perfusion-weighted imaging abnormality predicted the appearance of follow-up diffusion-weighted imaging lesion (chi-square=7·774, P=0·005). During the three-months follow-up, 23 patients (14·2%) experienced subsequent transient ischemic attack (n=16) or stroke (n=7). Symptomatic magnetic resonance angiogram abnormality (odds ratio, 12·667; 95% confidence interval, 2·859-56·110; P=0·001) was the only independent factor associated with clinical events with a sensitivity of 91·3% and specificity of 54·7% (C statistics, 0·73). None with initially normal multimodal magnetic resonance imaging findings developed subsequent clinical events. Approximately three-quarter of transient ischemic attack is associated with multimodal magnetic resonance imaging abnormality. Initial perfusion-weighted imaging abnormality predicts newly developed diffusion-weighted imaging lesions, and symptomatic magnetic resonance angiogram abnormality seems to be the most important predictor for subsequent clinical events. Multimodal magnetic resonance imaging appears to be useful in assessing transient ischemic attack and predicting outcome in these patients.

Clinical Practice, Resource Utilization, and Outcomes of Device Closure of Patent Foramen Ovale in Pediatrics

BackgroundThere are few data on patent foramen ovale closure and its outcome in children. In this study, we evaluated the current clinical practice, resource utilization, and outcome of device closure of patent foramen ovale in children. We hypothesized that patent foramen ovale closure would not result in a demonstrated benefit in children. MethodsWe undertook a prospective survey of all consecutive patients (<20 years) who underwent patent foramen ovale closure in our metropolitan area between 1995 and 2010. Differences in proportions were tested using the chi-square test or Fisher's exact test where appropriate. Differences in group medians were tested using Wilcoxon signed-rank test. ResultsA total of 153 patients (104 girls), median age 16 years (range 7-19) were studied. Indications for patent foramen ovale closure included: (1) migraine headache (104; 68%), (2) nonmigraine headache (24; 16%), (3) visual symptoms (110; 72%), (4) transient ischemic attack symptoms (42; 28%), and (5) stroke-like symptom (24; 16%). Patent foramen ovale was closed with an Amplatzer septal occluder in 115 (75%) and a Helex septal occluder in 47 (30%). The mean length of hospital stay was 18 ± 11 hours; the mean hospital charge was $24,126 ± $5808. The median duration of follow-up was 12 months, and 80 patients responded to the study survey. On follow-up, symptoms improved in 143 (93%), of which 29 (19%) had a residual shunt. None of the patient or treatment parameters predicted lack of improvement on follow-up. ConclusionsDespite the lack of proven benefit, children undergo closure of the patent foramen ovale for a variety of reasons, with the vast majority (92%) of patients reporting significant improvement in their symptoms. However, patent foramen ovale closure is an expensive procedure with serious potential complications. Symptomatic improvement even in the presence of a residual shunt suggests a strong placebo effect.

Acute brain infarction detected by CCT and stroke risk in patients with transient ischemic attack lasting

Background and purpose: This study aimed to determine the frequency and associated factors of acute brain infarction (ABI) detected by noncontrast cranial computed tomography (CCT) in patients with transient ischemic attack (TIA) of symptom duration <1 h and to investigate the association between evidence of ABI and short-term risk of stroke. Methods: During a 54-month period (starting November 2007), consecutive patients with TIA (symptom duration <1 h) admitted and imaged with CCT were prospectively evaluated. Adjusted logistic regression was used to estimate odds ratios (ORs). Results: Of 1021 patients (mean age, 74.5 ± 11 years; 52% female) with TIA (symptom duration <1 h) imaged with CCT at admission, 68 patients (6.7%; 95% CI, 5.3–8.3%) exhibited TIA-related ABI. Adjusted logistic regression showed that ABI was independently correlated with atrial fibrillation (AF) (OR, 3.3; 95% CI, 1.4–7.9; p = 0.006) and time between onset and CT assessment >6 h (OR, 2.5; 95% CI, 1.1–6.1; p = 0.034). During hospitalization (5 ± 3 d), 22 patients (2.2%; 95% CI, 1.4–3.1%) developed a stroke. Patients with ABI had higher stroke rates than those without (10.3% and 1.6%, respectively; p < 0.001). Adjusted logistic regression revealed that stroke risk was independently correlated with ABI (OR, 5.3; 95% CI, 1.8–15.0; p = 0.002) and AF (OR, 2.6; 95% CI, 1.1–6.4; p = 0.026). Conclusions: Detection of ABI by CCT in TIA patients with symptom duration <1 h may depend on timing of CCT assessment and presence of AF. Evidence of ABI indicates an elevated stroke risk during hospitalization.

Features of Patients with Transient Monocular Blindness: A Multicenter Retrospective Study in Japan

Transient monocular blindness (TMB) is associated with a transient ischemic attack (TIA). The purpose of this study was to investigate the features of TMB in the Japanese population using data from a multicenter retrospective study of TIA. The subjects were consecutive TIA patients admitted to 13 stroke centers within 7 days after symptom onset. We compared clinical characteristics of patients with TMB and those without TMB who had other symptoms of cerebral TIA. A total of 464 patients were registered between January 2008 and December 2009, and 444 patients (283 men, mean age: 68.5 years) were included in the analysis. Thirteen patients (2.9%) presented with TMB. Patients with TMB were less likely to arrive at the specialized stroke center quickly than those without TMB (P = .013). Stenotic lesions in the extracranial internal carotid artery were more common in patients with TMB (33.3% versus 9.1%, P = .022). TMB was not common in our TIA inpatients. This study suggests that patients with TMB should immediately undergo a diagnostic workup, including brain and vessel imaging, and cardiac evaluation, as is performed in patients with other cerebral TIA symptoms. A larger, prospective cohort is needed to confirm the risks and outcomes of patients with TMB in the Japanese population.

Nursing Swallow Screens

The speech-language pathologist (SLP) standardized a Nursing Bedside Swallowing Screen (NBSS) tool for all patients admitted to the hospital. The adults engaged in the NBSS before oral intake (i.e., medication included) as part of the Brain Attack Pathway for patients with neurological symptoms. If the patient failed the NBSS in the emergency department (ED), then the screen was repeated again after the patient had been admitted before the SLP dysphagia evaluation. Fifty-three male and female patients ranging from 34 to 96 years old with an initial diagnosis of stroke or transient ischemic attack (TIA) admitted during an 8-week time period from April 25, 2010, to June 19, 2010, were included in this study. There were 32 women and 17 men including 27 strokes and 22 TIAs tested. As a whole, the NBSS and SLP dysphagia evaluation results were consistent with each other for 40 of 46 patients (86.96% perfect agreement). The NBSS had 74% of sensitivity (34 of 46) with the nursing and the speech pathologist in agreement with the patients passing the swallow screen. Accurate identification of aspiration with the patients failing the NBSS was evident with the nursing and speech pathology assessment, which resulted in 83% of sensitivity (10 of 12). The positive predictive value with the corresponding identification of aspiration with the staff was 96% (44 of 46). The naturalistic observation of the patients exhibited internal consistency reliability between the two disciplines. Extraneous variables affecting the results included spontaneous resolution of stroke or TIA symptoms or the patient's decline in neurological status. For more insights from the authors, see Supplemental Digital Content 1, at http://links.lww.com/JNN/A9.

Risk Prediction of Subsequent Early Stroke in Patients with Transient Ischemic Attacks

Background: Prognostic clinical scores (ABCD2 and ABCD3-I), as well as specific clinical signs and symptoms (e.g. fluctuations) have been used to predict early stroke risk in patients admitted to hospital after transient ischemic attacks (TIAs). We compared the utility of these scores and signs for prognosis and outcome. Methods: 235 patients with TIAs admitted to our Comprehensive Stroke Center entered the study. Patients were monitored over 3 days with detailed brain imaging [diffusion-weighted imaging (DWI) was performed either directly on admission or within 24 h from admission and was repeated in cases of stroke recurrence], vascular ultrasound imaging, repeated neurological scoring and continuous ECG monitoring. Duration, fluctuation of symptoms, clinical patterns of initial signs and/or symptoms as well as general patient characteristics and stroke risk factors, including atrial fibrillation (AF), were analyzed and recorded in our stroke databank. Fluctuation of symptoms was defined as the complete remitting and relapsing of TIA symptoms for ≥2 times in the acute phase within the first 24 h. This differs from the ‘dual TIA' definition of the ABCD3-I score, which is defined as ‘an earlier TIA within 7 days of the index event'. ABCD2 and ABCD3-I scores were calculated and the patients were placed into three categories: ‘low', ‘moderate' and ‘high' risk for every score. Risk associations were assessed by the χ² test and the φ-coefficient. Results: Out of 235 patients, 17 patients (7.2%) experienced an early stroke during hospitalization (mean duration 7.4 ± 2.7 days). ABCD2 scores failed to predict early stroke (p = 0.544). ABCD3-I scores correlated better with early stroke recurrences (p = 0.021). Positive DWI findings (6/17; 35.3%), presence of carotid stenosis (3/17; 17.6%) or AF (1/17; 5.9%) alone failed to predict early stroke. Fluctuations of symptoms, however, showed a significant prediction for early stroke after TIA: 13/17 (76.5%) patients (p < 0.001). The combination of symptom fluctuation and MR-DWI-positive findings (4/17; 23.5%) also turned out to be statistically significant in this regard (p = 0.003), while the combination of symptom fluctuations with carotid stenosis ≥50% did not (p = 0.151). Combining fluctuations with carotid stenosis and DWI-positive findings did not improve the result (p = 0.029). Conclusions: While the ABCD3-I score is indeed very useful, symptom fluctuations seem to be the best available and an easily accessible and applicable parameter for individual prediction of a high early stroke risk after TIAs.

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.

Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial: Rationale and design

Ischemic stroke and other vascular outcomes occur in 10-20% of patients in the three-months following a transient ischemic attack or minor ischemic stroke, and many are disabling. The highest risk period for these outcomes is the early hours and days immediately following the ischemic event. Aspirin is the most common antithrombotic treatment used for these patients. The aim of POINT is to determine whether clopidogrel plus aspirin taken <12 h after transient ischemic attack or minor ischemic stroke symptom onset is more effective in preventing major ischemic vascular events at 90 days in the high-risk, and acceptably safe, compared with aspirin alone. POINT is a prospective, randomized, double-blind, multicenter trial in patients with transient ischemic attack or minor ischemic stroke. Subjects are randomized to clopidogrel (600 mg loading dose followed by 75 mg/day) or matching placebo, and all will receive open-label aspirin 50-325 mg/day, with a dose of 162 mg daily for five-days followed by 81 mg daily strongly recommended. The primary efficacy outcome is the composite of new ischemic vascular events - ischemic stroke, myocardial infarction, or ischemic vascular death - by 90 days. The primary safety outcome is major hemorrhage, which includes symptomatic intracranial hemorrhage. Aspirin is the most common antithrombotic given to patients with a stroke or transient ischemic attack, as it reduces the risk of subsequent stroke. This trial expects to determine whether more aggressive antithrombotic therapy with clopidogrel plus aspirin, initiated acutely, is more effective than aspirin alone.

Factors associated with delayed presentation in patients with TIA and minor stroke in China: analysis of data from the China National Stroke Registry (CNSR)

Objective: We aimed to evaluate the management of patients with transient ischemic attack (TIA) and minor stroke in China.Methods: Data from the China National Stroke Registry (CNSR) were used to identify patients who were admitted to 132 urban hospitals across China with TIA or minor stroke. Factors associated with delayed presentation to hospital were evaluated. Univariate and multivariate analyses were performed to analyze relationships between patient characteristics and time of presentation.Results: Of the 7467 patients entered into the CNSR (1204 with TIA, 6263 with minor stroke), 780 patients (64·78%) with TIA and 3467 patients (55·36%) with minor stroke had delayed presentation to hospital (>24 hours). In both groups, factors associated with early presentation (≤24 hours) included transportation by ambulance and direct presentation to the emergency room. In patients with minor stroke, early presentation was associated with older age (65–80 years), motor and sensory symptoms, speech impairment, atrial fibrillation, previous TIA, and living in central or eastern China; and delayed presentation was associated with female sex, cognitive dysfunction, and diabetes. In patients with TIA, early presentation was associated with motor symptoms, and delayed presentation was associated with headache or vertigo.Discussion: In China, many patients with TIA and minor stroke do not seek medical treatment immediately. Further education is needed to teach members of the public about the warning signs and symptoms of TIA and minor stroke, and encourage the use of ambulance transportation after TIA or stroke.

Abstract TMP98: Transient Ischemic Attack in Children and Its Relationship to Cerebral Infarction Identified by MRI

Objectives: Recent definition of transient ischemic attack (TIA) in adults includes negative neuroimaging for ischemic injury. Among children, TIA has not been well characterized. Further, the extent to which TIA symptoms are associated with MRI evidence of new cerebral injury has not been investigated. We present a cohort of 68 children with TIA symptoms and associated neuroimaging (MRI). Methods: We searched the patient medical record database at Boston Children’s Hospital using the search terms “transient ischemic attack” or “TIA” in the year 2010. We examined cases of TIAs in children 18 years of age or younger whose TIA occurred between 2009 to 2011. TIA was defined as a focal neurologic deficit that resolved completely. We only included children who had an MRI done close to the time of the event. A blinded neuroradiologist evaluated all MRIs. Results: Diffusion weighted imaging was done in 82% of cases in the cohort. Time from TIA to MRI varied from the day of TIA to 122 days after TIA with 68% scanned within 10 days of TIA presentation. Following TIA, nine of the 68 patients (13%) sustained a stroke verified by evidence of new ischemic injury in a vascular territory on neuroimaging. Time from initial TIA to stroke occurrence varied from hours to 3 years. Acute stroke was documented within one week of TIA in 56% of children who developed stroke following TIA. Further, 67% of the children who had a stroke after TIA demonstrated neuroimaging evidence of arteriopathy as compared to only 10% of children who did not have a stroke. Recurrent TIA was more common in children who eventually had a stroke (78%) than in children who did not have a stroke (59%). Conclusion: In our cohort of 68 children who presented with TIA symptoms, 13% subsequently demonstrated evidence of acute cerebral infarction by neuroimaging, some as early as the first week following TIA. Like adults, TIA symptoms may herald stroke in children. Clinical evidence of cerebral arteriopathy and multiple TIAs may identify children at high risk for stroke after presentation with TIA symptoms. Additional inquiry to identify features of TIAs in children that impart high risk for stroke and their treatment is warranted.

Abstract NS8: Colorado’s First Nurse Facilitated Transient Ischemic Attack Clinic: The New Paradigm for Transient Ischemic Attack Treatment

The risk of a disabling stroke after a Transient Ischemic Attack (TIA) is suggested to be highest within the first 48 hours after the TIA event and nearly half of recurrent stroke events ensue within the first 7 days. The TIA Clinic at Porter Adventist Hospital was developed to promote timely, efficient, and comprehensive treatment services for patients, allowing for targeted long term follow-up. Patients presenting with a TIA have limited options for receiving efficient evaluation and follow-up care. They can be admitted to hospitals for further diagnostic testing, seek care at their PCP or attempt to find a neurologist. Unfortunately these options are often expensive and can be the cause of treatment delays. Patients admitted to the hospital often incur higher out of pocket expenses, lost work time and exposure to hospital acquired conditions. The interdisciplinary service provides evaluation of TIA etiology and enables secondary stroke-prevention interventions to be initiated the day of patient’s evaluation. Once diagnostic procedures are completed, the neurologist finalizes the TIA etiology, risk-factor profile, and recommended secondary prevention strategies. Measurement strategies are obtained through patient satisfaction survey at the end of clinic, ninety day phone call follow-up and physician e-mail follow-up. The clinical nurse coordinator collects post-clinic data on this group of patients. After evaluation of 54 patients since the clinics inception there was no recurrence of TIA or stroke symptoms with 90 day follow-up in any patient. In addition, the clinic has proven to provide (1) expedited consultations and diagnosis as available to hospitalized patients; (2) identification and treatment of patients who have actually had a stroke rather than TIA; (3) identification and treatment of “stroke-mimicking” diagnoses such as migraine with aura, seizure, hypoglycemia, arrhythmias, intracerebral hemorrhage and intracranial tumor; and (4) identification of stroke risk factors and rapid implementation of specific interventions in the most vulnerable period for disabling stroke (i.e., the first 2-7 days).

Abstract TP133: Previous Stroke and Carotid Stenting Predict Periprocedural Risk of Symptomatic Carotid Intervention in a Large Community Hospital Vascular Registry

Introduction: Published analysis of the NASCET and ECST studies revealed a significant impact of the timing of surgery from symptomatic event, type of symptomatic event, gender, and age on patient outcomes. Hypothesis: Identified periprocedural risks of age, gender, timing of procedure, and type of symptomatic event will predict carotid endarterectomy complications in a large community hospital vascular registry and be similar for patients undergoing carotid stenting. Methods: Patients were prospectively enrolled in a community hospital carotid vascular registry. The study included patients diagnosed with stroke or transient ischemic attack (TIA) who subsequently underwent carotid endarterectomy or stenting. Procedural risk was defined by occurrence of stroke, myocardial infarction (MI) post-operatively or death within 30 days of the procedure. Multiple logistic regression was conducted to predict procedural risk using age (&lt;65, 65-74, ≥75), gender, time to intervention (&lt;2 weeks, 2-4 weeks, &gt;4 weeks), type of symptom event (TIA, stroke, ocular only) and procedure (stent versus endarterectomy) as predictors. Results: Seven hundred and one patients with symptomatic carotid disease were included in the analysis. Over 60% were male and the mean age was 71.2 years. Time of symptom onset to intervention was as follows: 29.7% at &lt;2 weeks, 32.9% at 2-4 weeks and 31.2% at &gt;4 weeks. Twenty-eight patients (4.0%) had post-operative stroke or death within 30 days. No patients experienced an MI. Multiple logistic regression results indicate that the symptomatic event of stroke (n=194) compared to ocular only symptoms (n=257) (Odds Ratio (OR)=2.82, p=.032) and carotid stenting (n=93) versus carotid endarterectomy (n=608) (OR=2.45, p=.046) were significant predictors of periprocedural risk. Timing, gender, age, and TIA symptom event were not significant predictors. Conclusions: Our study of symptomatic carotid disease showed that patients with a stroke and those undergoing carotid stenting were at higher risk of periprocedural complications. Timing of surgery, age, gender and TIA symptom events did not have an effect. Future analyses will focus on the risk or benefit of these procedures on long-term functional outcomes.

Synchronized Babinski and Chaddock Signs Preceded the MRI Findings in a Case of Repetitive Transient Ischemic Attack

We herein report a 53-year-old female with repeated transient ischemic attack (TIA) symptoms including 13 instances of right hemiparesis that decreased in duration over 4 days. Two separate examinations using diffusion weighted image (DWI) in magnetic resonance imaging (MRI) revealed normal findings, but we observed that both Babinski and Chaddock signs were completely synchronized with her right hemiparesis. We were only able to diagnose this case of early stage TIA using clinical signs. This diagnosis was confirmed 4 days after the onset by the presence of abnormalities on the MRI. DWI-MRI is generally useful when diagnosing TIA, but a neurological examination may be more sensitive, especially in the early stages.

A Case Of Transient Ischemic Attack Presenting As Hemichroea

Chorea is defined as; involuntary movements of the distal parts of limbs which have arrhythmic, rapid, bouncing or smooth, simple or complex properties. Choreiform movements occur when putamen, globus pallidus and subthalamic nucleus are affected. Chorea can be observed during the course of metabolic and vascular diseases, neurodegenerative or hereditary diseases. Chorea may be a rare symptom of cerebral hypoperfusion. Transient ischemic attack is an event that occurs in short term characterized by a temporary ischemia of brain. A wide variety of symptoms can be seen depending on the localization of cerebral hypoperfusion. Hemichorea is a very rare finding observed during transient ischemic attacks. In this article hemichorea in a case of symptomatic transient ischemic attack is discussed with relevant literature.

A Cross-Sectional Study of Individuals Seeking Information on Transient Ischemic Attack and Stroke Symptoms Online: A Target for Intervention?

BackgroundIndividuals with TIA/stroke symptoms often do not seek urgent medical attention. We assessed the feasibility of identifying individuals searching for information on TIA/stroke symptoms online as a target for future interventions to encourage urgent evaluation and we evaluated the performance of a self-reported risk score to identify subjects with true TIA or stroke.Methodology/Principal FindingsWe placed online advertisements to target English-speaking adults in the United States searching for TIA/stroke-related keywords. After completing an online questionnaire, participants were telephoned by a vascular neurologist to assess the likelihood of TIA/stroke. We used logistic regression and the c-statistic to assess associations and model discrimination respectively. Over 122 days, 251 (1%) of 25,292 website visitors completed the online questionnaire and 175 were reached by telephone (mean age 58.5 years; 63% women) for follow-up. Of these participants, 37 (21%) had symptoms within 24 hours, 60 (34%) had not had a medical evaluation yet, and 68 (39%) had TIA/stroke. Applying a modified ABCD2 score yielded a c-statistic of 0.66, but 2 of 12 with a zero score had a TIA/stroke. Those with new symptoms were more likely to have TIA/stroke (OR 4.90, 95% CI 2.56−9.09).Conclusions/SignificanceIndividuals with TIA/stroke that are seeking real-time information on symptoms online can be readily identified, in some cases before they have sought formal medical evaluation. Although a simple self-reported risk score was unable to identify a low-risk population in this selected group, this population may still present an attractive target for future interventions designed to encourage urgent medical evaluation.

Prospective neurocognitive evaluation of patients undergoing carotid interventions

Distal cerebral embolization is a known complication of carotid interventions. We prospectively investigated whether subclinical microembolization seen on postoperative magnetic resonance imaging (MRI) leads to cognitive deficits in patients undergoing carotid revascularization procedures. Patients undergoing carotid interventions and eligible for MRI scanning were recruited. Among 247 patients who received preoperative and postoperative MRI evaluations, 51 also completed neuropsychologic testing before and at 1 month after their procedure. Cognitive evaluation included the Rey Auditory Verbal Learning Test (RAVLT) for memory evaluation and the Mini-Mental State Examination (MMSE) for general cognitive impairment screening. The 51 patients (all men), comprising 16 with carotid artery stenting (CAS) and 35 with carotid endarterectomy (CEA), were a mean age of 71 years (range, 54-89 years). Among them, 27 patients (53%) were symptomatic preoperatively, including 11 who had prior stroke and 16 who had prior preoperative transient ischemic attack symptoms. Most patients had significant medical comorbidities, including hypertension (96%), diabetes (31.3%), coronary artery disease (47%), and chronic obstructive pulmonary disease (15.7%). Two patients (4%) had prior ipsilateral CEA and eight had contralateral carotid occlusion (15.7%). Memory decline evident on RAVLT was identified in eight CAS patients and 13 CEA patients. Eleven patients had evidence of procedure-related microemboli. Although there was no significant difference in baseline cognitive function or memory change between the CEA and CAS cohorts, the CAS cohort had a significantly higher incidence of microembolic lesions. Multivariate regression analysis showed that procedure-related microembolization was associated with memory decline (P = .016) as evident by change in RAVLT. A history of neurologic symptoms was significantly associated with poor baseline cognitive function (MMSE; P = .03) and overall cognitive deterioration (change in MMSE; P = .026), as determined by Wilcoxon rank sum test and linear regression analysis, respectively. Although CEA and CAS are effective in stroke prevention, with minimal neurologic complication, neurocognitive effects remain uncertain. Procedure-associated microembolization and pre-existing neurologic symptoms are associated with poor baseline cognitive function and memory decline after the procedures. Further comprehensive cognitive evaluation to determine the benefit of carotid interventions is warranted.