Transient Neurological Attacks Research Articles

The crosstalk between Stroke and Cancer: Incidence of cancer after a first-ever cerebrovascular event in a population-based study.

To determine the cancer incidence after the first-ever cerebrovascular event (CVE) and compare it to the cancer incidence in the population from the same region. We evaluated 1069 patients with a first-ever CVE (Ischaemic or haemorrhagic stroke and Transient Ischaemic Attack) from a prospective population registry of stroke and transient focal neurological attacks, diagnosed between 2009 and 2011. We conducted a structured search to identify cancer-related variables and case-fatality for a period of 8 years following CVE. Cancer incidence in CVE patients was compared to the North Region Cancer Registry (RORENO). We found that 90/1069 (8.4%) CVE patients developed cancer after a first-ever CVE. Overall cancer annual incidence rate was higher after a CVE (820/100,000, 95%CI: 619-1020) than in general population (513/100,000, 95%CI: 508-518). In the 45-54 age group cancer incidence post-CVE was 3.2-fold (RR, 95%CI: 1.6-6.4) higher compared to the general population, decreasing gradually in older age-groups. Median time between CVE and cancer was 3.2 years (IQR = 1.4-5.2). Lower respiratory tract and colorectal were the most frequent cancer types. In univariable models, male sex (sHR = 1.78, 95%CI: 1.17-2.72, p = 0.007), tobacco use (sHR = 2.04, 95%CI: 1.31-3.18, p = 0.002) and peripheral artery disease (sHR = 2.37, 95%CI: 1.10-5.13, p = 0.028) were associated to higher cancer risk after CVE. After adjustment, tobacco use (sHR = 1.84, 95%CI: 1.08-3.14, p = 0.026) remained associated to a higher risk of cancer. At the population level, patients presenting a first-ever CVE have higher cancer incidence, that is particularly prominent in younger age-groups. Higher cancer incidence, delayed cancer diagnosis and increased mortality post-CVE warrants further research on long-term cancer surveillance in first-ever CVE survivors.

Neuroimaging for differential diagnosis of transient neurological attacks.

Rapid yet comprehensive neuroimaging protocols are required for patients with suspected acute stroke. However, stroke mimics can account for approximately one in five clinically diagnosed acute ischemic strokes and the rate of thrombolyzed mimics can be as high as 17%. Therefore, to accurately determine the diagnosis and differentiate mimics from true transient ischemic attacks, acute ischemic stroke is a challenge to every clinician. Medical history and neurological examination, noncontract head computed tomography, and routine magnetic resonance imaging play important roles in the assessment and management of patients with transient neurological attacks in the emergency department. This review attempts to summarize how neuroimaging can be utilized to help differentiate the most common mimics from transient ischemic attack and acute ischemic stroke. Although imaging can help direct critical triage decisions for intravenous thrombolysis or endovascular therapy, more detailed medical history and neurological examination are crucial for making a prompt and accurate diagnosis for transient neurological attack patients.

Abstract TP289: Diagnostic Evaluation of Patients Admitted to Emergency Department Observation Unit for Suspected TIA

Introduction: Emergency department observation units (ED-OU) allow patients with a suspected transient ischemic attack (TIA) an expedited workup without the need for a prolonged inpatient admission. Despite risk stratification scores and physician evaluation, however, the reliability in diagnosis of TIA remains poor, which may lead to unnecessary testing. This study aimed to identify and compare the diagnostic workup between patients with final diagnosis of true vascular events (TIA or minor stroke, TIAMS) versus nonischemic transient neurological attacks (NI-TNA) in suspected TIA patients admitted to an ED observation unit. Methods: A retrospective analysis was performed on consecutive patients who were admitted to an ED-OU at a single center for suspected TIA. All diagnostic testing obtained during observation stay was abstracted from chart review. Final discharge diagnosis was dichotomized to either TIAMS or NI-TNA. Standard statistical tests were used for comparison testing between the two groups with significance defined as p<0.05. Results: Of 186 suspected TIA patients admitted to an ED-OU, median ABCD2 score was 4 [IQR 3-4]. Final diagnosis was TIAMS in 85 (46%) patients and NI-TNA in 101 (54%) patients. A total of 182 (98%) patients had non-contrast head CT (NCHCT); 160 (86%) brain MRI; 117 (63%) extracranial vessel imaging; 116 (62%) transthoracic echocardiogram (TTE); and 108 (58%) intracranial vessel imaging. Assessing diagnostic work-up by final diagnosis, TTE (78% vs 40%, p<0.01), and extracranial imaging (75% vs 55%, p<0.01) were more common in patients with TIAMS. Restricted diffusion on MRI (27% vs. 2%, p<0.01) and abnormality on TTE (50% vs. 28% p=0.02) were more common in TIAMS patients. The overall rate of symptomatic stenosis was low: 1 patient had a symptomatic carotid and 4 patients had symptomatic intracranial stenosis. Conclusion: Extensive diagnostic testing is done on patients with suspected TIA admitted to ED-OU, with more studies acquired on patients with true ischemic events as compared to NI-TNA. As the use of ED-OUs increases, refinement of current diagnostic testing algorithms to reduce workup for cerebrovascular disease among patients with NI-TIA and among different ischemic stroke subtypes is warranted.

Abstract TP174: Identifying Predictors for Final Diagnosis of Ischemic Events in an Emergency Department Observation Unit

Introduction: Transient neurologic events have high rates of diagnostic uncertainty. Emergency department observation units (ED-OU) allow an accelerated diagnostic work up for suspected transient ischemic attacks (TIAs). However, clinical decision support regarding which patients to admit to these units is lacking. This study aimed to identify clinical features that differentiate true ischemic events from nonischemic transient neurological attacks (NI-TNA) among patients admitted to an ED-OU for suspected TIA. Methods: A retrospective analysis was performed on consecutive patients admitted to the ED-OU at a single academic center for suspected TIA. Demographics, vascular risk factors, presenting symptoms, and details of the clinical presentation were abstracted from chart review. Final discharge diagnosis was dichotomized to either ischemic event (TIA or minor stroke, TIAMS) or NI-TNA based on the treating vascular neurologist’s final diagnosis. Standard statistical tests were used for comparison testing between the two groups. Significantly different factors with p<0.2 on univariate analysis were carried forward in a multivariable logistic regression model. Results: Of 186 consecutive patients, 101 (54%) had a final diagnosis of NI-TNA and 85 (46%) of TIAMS. The median population ABCD2 score was 4 [IQR 3-4]. On univariate analysis, older age (63 vs. 70, p<0.01), history of atrial fibrillation (AF) (12% vs. 26%, p=0.01), and facial weakness (5% vs. 14% p=0.03) were associated with TIAMS. Headache (24% vs. 12%, p=0.04) and symptom duration>60min (57% vs. 40%, p=0.02) were associated with NI-TNA. On multivariable analysis, only symptom duration>60 minutes predicted NI-TNA (OR 0.39, p=0.04) and only history of AF (OR 2.53, p=0.03) predicted TIAMS. Facial weakness was strongly predictive of TIAMS (OR 3.22, p=0.05), but not significant. Conclusion: We identified two clinical features that distinguished TIAMS from NI-TNA among patients admitted to an ED-OU for suspected TIA.These may be helpful in emergency room triage of TIAMS. Data from ED-OU can be used to identify factors associated with cerebral ischemia and improve current care pathways for patients with suspected TIA, so diagnostic evaluation is received in the most appropriate setting.

Nonfocal Transient Neurological Attacks Are Associated With Cerebral Small Vessel Disease

Background and Purpose- Nonfocal transient neurological attacks (TNAs), such as unsteadiness, bilateral weakness, or confusion, are associated with an increased risk of stroke and dementia. Cerebral ischemia plays a role in their pathogenesis, but the precise mechanisms are unknown. We hypothesized that cerebral small vessel disease is involved in the pathogenesis of TNAs and assessed the relation between TNAs and manifestations of cerebral small vessel disease on magnetic resonance imaging. Methods- We included participants from the HBC (Heart-Brain Connection) study. In this study, hemodynamic and cardiovascular contributions to cognitive impairment have been studied in patients with heart failure, carotid artery occlusion, or possible vascular cognitive impairment, as well as in a reference group. We excluded participants with a history of stroke or transient ischemic attacks. The occurrence of the following 8 TNAs was assessed with a standardized interview: unconsciousness, confusion, amnesia, unsteadiness, bilateral leg weakness, blurred vision, nonrotatory dizziness, and paresthesias. The occurrence of TNAs was related to the presence of lacunes or white matter hyperintensities (Fazekas score, ≥2; early confluent or confluent lesions) in logistic regression analysis, adjusted for age, sex, and hypertension. Results- Of 304 participants (60% men; mean age, 67±9 years), 63 participants (21%) experienced ≥1 TNAs. Lacunes and early confluent or confluent white matter hyperintensities were more common in participants with TNAs than in participants without TNAs (35% versus 20%; adjusted odds ratio, 2.32 [95% CI, 1.22-4.40] and 48% versus 27%; adjusted odds ratio, 2.65 [95% CI, 1.44-4.90], respectively). Conclusions- In our study, TNAs are associated with the presence of lacunes and early confluent or confluent white matter hyperintensities of presumed vascular origin, which indicates that cerebral small vessel disease might play a role in the pathogenesis of TNAs.

Cerebral Perfusion and the Occurrence of Nonfocal Transient Neurological Attacks

Introduction: Nonfocal transient neurological attacks (TNAs) are associated with an increased risk of cardiac events, stroke and dementia. Their etiology is still unknown. Global cerebral hypoperfusion has been suggested to play a role in their etiology, but this has not been investigated. We assessed whether lower total brain perfusion is associated with a higher occurrence of TNAs. Methods: Between 2015 and 2018, patients with heart failure were included in the Heart Brain Connection study. Patients underwent brain magnetic resonance imaging, including quantitative magnetic resonance angiography (QMRA) to measure cerebral blood flow (CBF). We calculated total brain perfusion of each participant by dividing total CBF by brain volume. Patients were interviewed with a standardized questionnaire on the occurrence of TNAs by physicians who were blinded to QMRA flow status. We assessed the relation between total brain perfusion and the occurrence of TNAs with Poisson regression analysis. Results: Of 136 patients (mean age 70 years, 68% men), 29 (21%) experienced ≥1 TNAs. Nonrotatory dizziness was the most common subtype of TNA. Patients with TNAs were more often female and more often had angina pectoris than patients without TNAs, but total CBF and total brain perfusion were not different between both groups. Total brain perfusion was not associated with the occurrence of TNAs (adjusted risk ratio 1.12, 95% CI 0.88–1.42). Conclusion: We found no association between total brain perfusion and the occurrence of TNAs in patients with heart failure.

Nonfocal transient neurological attacks are related to cognitive impairment in patients with heart failure

IntroductionNonfocal transient neurological attacks (TNAs) are associated with an increased risk of future dementia, but it is unclear whether TNAs are also associated with concurrent cognitive impairment. We hypothesized that recent TNAs are related to worse cognitive functioning. We tested our hypothesis in patients with heart failure, as these patients are at risk of cerebral hypoperfusion, which might play a role in the etiology of TNAs.MethodsWe performed neuropsychological testing in all patients with heart failure enrolled in the Heart Brain Connection study. We assessed global cognition, attention-psychomotor speed, executive functioning, memory and language. All patients were interviewed with a standardized questionnaire on the occurrence of TNAs in the preceding 6 months. We studied associations between TNAs and cognitive functioning with linear and logistic regression analyses, adjusted for age, sex and education. We performed additional analyses in patients without previous stroke or TIA and in patients without brain infarction on MRI.ResultsThirty-seven (23%) of 158 patients (mean age 70 years, 67% men) experienced one or more TNAs. Patients with a recent TNA were more likely to be impaired on ≥ 1 cognitive domains than patients without TNAs [41% vs. 18%, adjusted odds ratio 4.6, 95% confidence interval (CI) 1.8–11.8]. Patients with TNAs performed worse than patients without TNAs on global cognition (mean difference in z scores − 0.36, 95% CI − 0.54 to − 0.18), and on the cognitive domains attention-psychomotor speed (mean difference − 0.40, 95% CI − 0.66 to − 0.14), memory (mean difference − 0.57, 95% CI − 0.98 to − 0.15) and language (mean difference − 0.47, 95% CI − 0.79 to − 0.16). These associations were independent of cardiac output and volume of white matter hyperintensities. Subgroup analyses in patients without previous stroke or TIA or brain infarction on MRI (n = 78) yielded comparable results, with the exception of the cognitive domain language, which was no longer different between patients with and without TNAs.ConclusionAmong patients with heart failure, TNAs are associated with cognitive impairment, which warrants the need for more clinical awareness of this problem.

Recrudescence of Old Stroke Deficits Among Transient Neurological Attacks.

Recrudescence of old stroke deficits (ROSD) is a reported cause of transient neurological symptoms, but it is not well characterized. We sought to determine the prevalence, potential triggers, and clinical outcome of ROSD in a cohort of patients presenting with acute transient neurological attack (TNA) and absent acute pathology on brain imaging. We retrospectively analyzed 340 consecutive patients who presented with TNA and no acute pathology on brain imaging that were included in an institutional stroke registry between February 2013 and April 2015. The presumed TNA cause was categorized as transient ischemic attack (TIA), ROSD, and other cause. Baseline characteristics, triggers, cardiovascular complications within 90 days, and death were recorded. The prevalence of ROSD in the studied cohort was 10% (34/340). Infectious stressors and acute metabolite derangements were more common in ROSD compared to TIA (P < .05, each). Compared to TIA and the other TNA, ROSD was more likely to have more than 1 acute stressor (P < .001). Patients with ROSD had similar vascular risk factors compared to TIA (P > .05), including hypertension, diabetes mellitus, peripheral vascular disease, hyperlipidemia, and similarly used HMG-CoA reductase inhibitor, antihypertensive, and antiplatelet medications. Among the patients with an available 90-day follow-up (n = 233), cardiovascular events were more frequent in the TIA group as compared to other TNA (P < .05). ROSD is common and distinct from TIA and is associated with a triggering physiologic reaction leading to transient reemergence of prior neurologic deficits. Further study of the mechanism of this phenomenon is needed to help better identify these patients.

Trans-Iliac Aortic Valve Replacement: Feasibility, Safety, and Medium-Term Follow-up.

Background:Transcatheter aortic valve replacement (TAVR) is nowadays generally accepted as the treatment of choice for high- to intermediate-risk patients with severe aortic stenosis not suitable for the standard surgical replacement. Many vascular accesses have been described for the valve delivery, comprising the common iliac artery as the arterial site of access.Methods:From September 2008 to June 2014, 440 patients underwent TAVR at our institution. We report a series of 12 patients that have undergone TAVR via a trans-iliac (TI) retroperitoneal surgical approach and also discuss its feasibility, security, and medium-term follow-up.Results:The 30-day survival rate was 92%. Only 1 local vascular access major complication occurred requiring an iliac-femoral bypass grafting with a vascular graft. Two patients experienced transient neurological ischemic attack. At 3-year follow-up, all the 11 patients were alive and well and the echocardiographic evaluation revealed good function of the prosthesis.Conclusions:The TI route seems to be feasible with a low profile of local complications. It may be a reasonable access alternative to the femoral artery and to the trans-apical approach. A broader, prospective study is advisable to gain general consensus on this approach.

Nonfocal transient neurological attacks in patients with carotid artery occlusion.

IntroductionNonfocal transient neurological attacks (TNAs) are episodes with atypical, nonlocalizing cerebral symptoms. We examined the prevalence of nonfocal TNAs, in patients with and without carotid artery occlusion (CAO).MethodsWe included 67 patients with CAO and 62 patients without CAO. In both groups, patients had a history of transient ischemic attack (TIA) or nondisabling ischemic stroke in the anterior circulation that had occurred >6 months before inclusion. Patients without CAO did not have ipsilateral or contralateral carotid artery stenosis of ≥50%. All patients were interviewed with a standardized questionnaire on the occurrence of nonfocal TNA symptoms during the preceding six months. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for the occurrence of ≥1 and ≥2 different nonfocal TNAs after adjustments for age, sex, systolic blood pressure and time interval between most recent TIA or ischemic stroke and administration of the questionnaire.ResultsForty-three of all patients (33%) had had one or more nonfocal TNAs in the preceding six months. Nonrotatory dizziness (24%) was reported most often. The prevalence of ≥1 nonfocal TNAs was not significantly different between patients with and without CAO (39% vs. 27%; adjusted RR 1.47, 95% CI 0.83–2.61), but the prevalence of ≥2 or more different nonfocal TNAs was higher in patients with CAO (16% vs. 3%; adjusted RR 4.77, 95% CI 1.20–18.98). In patients with CAO who also had a contralateral carotid or vertebral artery steno-occlusion, nonfocal TNAs occurred more often than in patients without any carotid or vertebral artery steno-occlusion (46% vs. 27%; adjusted RR 2.22, 95% CI 1.08–4.60 for ≥1 and 21% vs. 3%; adjusted RR 8.27, 95% CI 1.83–37.32 for ≥2 nonfocal TNAs).ConclusionsPatients with CAO more often experienced multiple nonfocal TNAs than patients without CAO.

Ischemic Stroke After Emergency Department Discharge for Symptoms of Transient Neurological Attack.

The significance of transient neurological attack (TNA) symptoms is unclear. We sought to determine the risk of ischemic stroke after discharge from the emergency department (ED) with a diagnosis consistent with symptoms of TNA. Using administrative claims data, we identified patients discharged from EDs in New York between 2006 and 2012 with a primary discharge diagnosis of a TNA symptom, defined as altered mental status, generalized weakness, and sensory changes. The primary outcome was ischemic stroke. We used Kaplan-Meier survival statistics to calculate cumulative rates, and Cox regression to compare stroke risk after TNA versus after transient ischemic attack (TIA; positive control) or renal colic (negative control) while adjusting for demographics and vascular risk factors. Of 499 369 patients diagnosed with a TNA symptom and discharged from the ED, 7756 were hospitalized for ischemic stroke over a period of 4.7 (±1.9) years. At 90 days, the cumulative stroke rate was 0.29% (95% confidence interval [CI]: 0.28%-0.31%) after TNA symptoms versus 2.08% (95% CI: 1.89%-2.28%) after TIA and 0.03% (95% CI: 0.02%-0.04%) after renal colic. The hazard ratio (HR) of stroke was higher after TNA than after renal colic (HR: 2.13; 95% CI: 1.90-2.40) but significantly lower than after TIA (HR: 0.47; 95% CI: 0.44-0.50). Compared to TIA, TNA was less strongly associated with stroke among patients under 60 years of age compared to those over 60. Patients discharged from the ED with TNA symptoms faced a higher risk of ischemic stroke than patients with renal colic, but the magnitude of stroke risk was low, particularly compared to TIA.

Executive Function Declines in the First 6 Months After a Transient Ischemic Attack or Transient Neurological Attack

Although by definition transient, both transient ischemic attack (TIA) and transient neurological attack (TNA) are associated with cognitive impairment. Determinants and course of cognitive function afterward are, however, unclear. We prospectively determined cognitive performance after TIA and TNA in relation to clinical diagnosis and diffusion-weighted imaging (DWI) results. TIA and TNA patients aged ≥45 years without prior stroke or dementia underwent comprehensive cognitive assessment and magnetic resonance imaging within 7 days after the qualifying event. Cognitive tests were repeated after 6 months. Domain-specific compound z scores based on the baseline mean and SD were calculated. Repeated-measures analysis was used to test for differences in domain-specific cognitive performance over time between DWI-positive and DWI-negative patients, as well as between TIA and TNA patients. One hundred twenty-one patients were included (mean age (SD), 64.6 years (9.2 years), 60% TIA and 40% TNA) of whom 32 (26%) had a DWI lesion. Executive function performance decreased over time (mean change in compound score -0.23; P=0.01 adjusted for age, sex, education), whereas attention improved (0.11; P=0.02), and information processing speed and episodic memory remained unchanged. Patients with a DWI lesion had worse executive function at baseline than those without a DWI lesion (compound scores -0.26 versus 0.08; P=0.048), which persisted throughout the study period (P=0.04). Clinical diagnosis (TIA or TNA) was not related to cognitive function over time. Executive function declines during the first 6 months after TIA or TNA. Patients with an initial DWI lesion have persisting worse executive function than those without.

Occipital transcranial magnetic stimulation discriminates transient neurological symptoms of vascular origin from migraine aura without headache

The diagnosis of transient neurological attacks (TNA) relies on medical history. Transient ischemic attack is often considered until proven otherwise, because of lack of objective paraclinical tools that can help discriminate TIA from differential diagnoses such as migraine aura. This may lead to needless and potentially harmful stroke secondary prevention in many cases. This study aimed at determining the yield of occipital transcranial magnetic stimulation (oTMS) in discriminating TNA of vascular origin from migraine aura without headache (MAWH). Ten patients with acute TNA of vascular origin and ten patients with migraine aura without headache (MAWH), without prior history of migrainous headache, were prospectively included. TNA of vascular origin were considered for individuals presenting unilateral focal symptoms with full resolution within 24hours and positive diffusion weighted imaging (DWI+). For individuals with MAWH, diagnostic criteria were either ICHD-III beta or Fischer criteria for a first episode of MAWH. All participants underwent one session of oTMS. Induction and threshold of phosphene induction were recorded. In TNA of vascular origin, MRI disclosed cortical lesions in nine and one sub-cortical lesion. Phosphenes were induced in 9/10 subjects with MAWH with a mean threshold of 66% of the maximal intensity, whereas oTMS induced phosphenes in only one subject with TNA of vascular origin at a threshold of 85%. In this pilot study, oTMS was found to be an effective tool to discriminate between MAWH and transient neurological symptoms of vascular origin.

Association between Demographic Characteristics and Hospital Admission in Patients Presenting to the Emergency Department for Transient Neurological Attack (P6.277)

Association between Demographic Characteristics and Hospital Admission in Patients Presenting to the Emergency Department for Transient Neurological Attack (P6.277)

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

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

Abstract WP323: Association between Demographic Characteristics and Hospital Admission in Patients Presenting to the Emergency Department for Transient Neurological Attack

Introduction: Significant demographic differences in the management of ischemic stroke and transient ischemic attack exist in the United States. Transient neurological attack (TNA) is a common neurological diagnosis that can result from cerebral ischemia, and is associated with recurrent stroke. Demographic factors may be associated with differences in admission rates for patients that present to the emergency department (ED) with a diagnosis of TNA. Methods: In a population-based, retrospective, administrative claims-based cohort study, we identified patients who presented to a non-federal ED in Florida from 2005 through 2013 with a complaint consistent with TNA, which was defined as a poorly-localized, non-specific neurological symptom. Our predictor variables were race (white vs. non-white) and sex. Our outcome variable was admission to the hospital. We used multiple logistic regressions to characterize the relationship between the predictor variables and our chosen outcome while adjusting for age, insurance status, income, and vascular risk factors. Results: We identified 1,231,046 patients presenting to the ED with TNA. Female patients in this cohort were less often white, and had fewer vascular comorbidities than men, including alcohol abuse. Non-white patients were younger, more often had Medicaid or no insurance, less often had atrial fibrillation, coronary heart disease or alcohol abuse, and more commonly had diabetes. Among all patients, 22,300 (1.8%) were admitted. After adjustment for age, insurance status, income, and vascular comorbidities, we found lower odds of hospital admission in female patients (odds ratio [OR], 0.69; 95% confidence interval [CI]; 0.67-0.70) and non-white patients (OR, 0.65; 95% CI, 0.63-0.67). Conclusions: Among patients presenting to the ED with TNA, female sex and race are associated with decreased odds of admission, even after adjusting for age, income, insurance status, and vascular risk factors. Further studies are warranted to reproduce these findings in other states, and to determine the public health impact of our results.

Subjective Cognitive Impairment, Depressive Symptoms, and Fatigue after a TIA or Transient Neurological Attack: A Prospective Study.

Introduction Subjective cognitive impairment (SCI), depressive symptoms, and fatigue are common after stroke and are associated with reduced quality of life. We prospectively investigated their prevalence and course after a transient ischemic attack (TIA) or nonfocal transient neurological attack (TNA) and the association with diffusion-weighted imaging (DWI) lesions. Methods The Cognitive Failures Questionnaire, Hospital Anxiety and Depression Scale, and Subjective Fatigue subscale from the Checklist Individual Strength were used to assess subjective complaints shortly after TIA or TNA and six months later. With repeated measure analysis, the associations between DWI lesion presence or clinical diagnosis (TIA or TNA) and subjective complaints over time were determined. Results We included 103 patients (28 DWI positive). At baseline, SCI and fatigue were less severe in DWI positive than in DWI negative patients, whereas at follow-up, there were no differences. SCI (p = 0.02) and fatigue (p = 0.01) increased in severity only in DWI positive patients. There were no differences between TIA and TNA. Conclusions Subjective complaints are highly prevalent in TIA and TNA patients. The short-term prognosis is not different between DWI-positive and DWI negative patients, but SCI and fatigue increase in severity within six months after the event when an initial DWI lesion is present.

Electrographic Correlates of Plateau Waves in Patients With Leptomeningeal Metastases

We describe video electroencephalography (video-EEG) correlates of transient neurological attacks due to plateau waves-paroxysmal elevations in intracranial pressure-in patients with leptomeningeal metastases. We identified 3 patients with leptomeningeal metastases, intracranial hypertension, and transient neurological attacks captured on video-EEG without evidence of seizures or epileptiform activity. We identified all clinical events on video and reviewed the corresponding EEG data for evidence of abnormalities. All 3 patients had mild to moderate slowing and 2 had frontal intermittent rhythmic delta activity during background EEG recording. There were 33 clinical events recorded and stereotyped for each patient. All 33 events were associated with an increase in delta range slowing of ≥30% compared to the background. This abnormality started ≤2 minutes before the onset of clinical symptoms and persisted for minutes after clinical resolution. This study is the first to carefully describe the electrographic correlates of transient neurological attacks due to plateau waves in patients with leptomeningeal metastasis. Clinical attacks were consistently associated with a possible EEG signature of diffuse delta range slowing. Future studies can validate the sensitivity and specificity of these EEG changes as a prognostic and/or response biomarker in patients with leptomeningeal metastases with or without intracranial hypertension.

Long-term follow-up after percutaneous closure of patent foramen ovale with Amplatzer PFO Occluder: a single center experience.

IntroductionPatent foramen ovale (PFO) is associated with the occurrence of cryptogenic strokes, transient neurological ischemic attacks (TIA) and migraine. Therefore despite the recent ambiguous results of prospective controlled trials, percutaneous closure of PFO is still performed in many centers.AimTo evaluate the safety and effectiveness of percutaneous PFO closure in the prevention of recurrence of neurologic events and migraine symptoms in long-term observation.Material and methodsIn 70 patients (31 male, age: 38 ±18 years) percutaneous PFO closure was successfully performed with the Amplatzer PFO Occluder. An interview in conjunction with neurological follow-up was performed in all patients to reveal recurrence of embolism such as TIA or stroke and the presence of migraine symptoms before and after the procedure.ResultsThe mean follow-up period was 857 ±363 days (median: 571 days). No serious complications of the procedure and no death were observed. Neurological events recurred in 5 (7.1%) patients – stroke in 1 patient, TIA in 3 patients, ocular embolism in 1 patient. All of these patients were over 40 years old or had other cardiovascular risk factors. Migraine was observed in 21 (30%) patients before the procedure and in 11 (15.7%) after the procedure (p = 0.04).ConclusionsThe complication rate and recurrence of neurological events in young patients after PFO closure are low. However, careful qualification and postprocedural monitoring of the patients are necessary. Patent foramen ovale closure seems to result in attenuation of migraine symptoms.

Diffusion-weighted imaging in transient neurological attacks.

Transient ischemic attack (TIA) can be difficult to diagnose. Episodes of acute atypical or nonfocal neurological symptoms, referred to as transient neurological attack (TNA), are as prevalent as TIAs. Diffusion-weighted imaging (DWI) provides evidence of acute cerebral ischemia in a third of TIA patients. We now report that DWI shows acute ischemia in 23% of patients clinically diagnosed as TNA by experienced stroke neurologists. This questions the accuracy of clinically diagnosing TIA and suggests added value for early magnetic resonance imaging after an episode of acute onset atypical or nonfocal neurological symptoms.