Treatment Of Transient Ischemic Attacks Research Articles

Abstract WP252: Reduction in Stroke Readmission Rates After Implementing an Emergency Department-based Transient Ischemic Attack Observation Unit

Background and Purpose —Diagnosis and treatment of transient ischemic attacks (TIAs) is often delayed by lack of access to immediate comprehensive evaluation of the underlying etiology. Early initiation of treatment can reduce the risk of early recurrent stroke by up to 80%. Up to 40% of people who have experienced a TIA will go on to have a stroke. The purpose of this review was to determine the efficacy of an Emergency Department (ED)-based TIA observation unit using a standardized TIA protocol designed to provide rapid evaluation and treatment of patients presenting with TIA in reducing the rates of readmission with stroke to a community-based hospital. Methods —We did a retrospective chart review of all patients discharged from Bellin Hospital with a diagnosis of stroke before implementing a standardized TIA protocol in our ED-based TIA observation unit (July to December 2010) and after implementation of the TIA observation unit (November 2011 to April 2012). We identified the patients in these cohorts who had previously been evaluated in the ED with signs or symptoms of stroke in the 6 months prior to admission and compared their stroke readmission rates. Patients who received evaluation through the TIA observation unit from November 2011 to April 2012 were monitored for readmission for stroke in the 6 months after evaluation. Results —Prior to use of the TIA observation unit, 7 of 51 (13.7%) patients discharged with a diagnosis of stroke had been seen in the ED in the previous 6 months with stroke-like symptoms. After implementation of the TIA observation unit, 7 of 119 (5.9%) patients discharged with a diagnosis of stroke had been seen in the ED, a 57.1% reduction in stroke readmission at 6 months. Of these, 4 (57.1%) had not completed the work-up during their previous ED visit. 122 patients underwent evaluation using the TIA observation unit. Of these, only 3 (2.5%) patients were readmitted for stroke in the next 6 months. 16 of these 122 (13.1%) patients were diagnosed with stroke during their TIA work-up. Conclusions —Rapid evaluation and treatment of TIA through an ED-based TIA observation unit substantially reduces the risk of readmission for stroke.

Hospital Admission After Transient Ischemic Attack

Patients with TIA are at high risk of short-term stroke, myocardial infarction, and vascular death. Because stroke risk is reduced by immediate medical or surgical intervention, emergent evaluation and treatment is warranted. The Effect of urgent treatment of transient ischemic attack and minor stroke on early recurrent stroke (EXPRESS) and effectiveness of round-the-clock access (SOS-TIA) studies1 showed that urgent evaluation and initiation of preventive treatments such as antiplatelets, statins, anticoagulation, and carotid revascularization markedly reduce the risk of early stroke after a TIA or minor stroke. The ABCD2 score, based on clinical features and demographic data, has been shown to predict the short-term stroke risk after TIA and is being increasingly used to triage patients with TIA. However, its low interrater reliability, poor correlation with imaging findings, and its inability to identify patients who require in-hospital intervention preclude the use of the ABCD2 scores as a sole decision-making tool. In other words, the ABCD2 score represents field glasses that help shepherds to visualize a flock at a long distance in an attempt …

Low risk of vascular events following urgent treatment of transient ischaemic attack: the Aarhus TIA study

Patients with TIA have a high short-time risk of stroke and an increased long-term risk of ischaemic vascular events compared with the general population. Urgent intervention may reduce short-time stroke risk, but little is known about the effect beyond 3 months. We examined 1-year outcome and risk factor management in patients with TIA after urgent intervention. All patients with TIA referred to Aarhus University Hospital 1 March 2007-28 February 2008 were seen by an acute TIA team (ATT), integrating outpatient care and stroke unit facilities. Preventive treatment was initiated immediately, including fast-track surgery for carotid stenosis. Follow-up including nurse-conducted health counseling was carried out after 7, 90, and 365 days. A total of 306 patients were included. Stroke, myocardial infarction, or vascular death occurred in 5.2% during 1 year of follow-up. The cumulated stroke rate was 1.6%, 2.0%, and 4.4% after 7, 90, and 365 days, respectively, compared to expected 4.5% [relative risk (RR) 0.36, 95% CI 0.13-0.98] and 7.5% (RR 0.26, 95% CI 0.11-0.63) after 7 and 90 days using ABCD(2) criteria. Recurrent TIA occurred in 10.2% (n = 32). Secondary prevention targets were attained in 47.6% after 1 year. Carotid surgery was performed in 8.1%; median time to operation was 11 days after contact with the ATT. Urgent intervention after TIA by an ATT covering outpatient and stroke unit facilities combined with nurse-conducted health counseling is associated with a low 1-year risk of new vascular events and may improve risk factor control.

Yield of systematic transcranial doppler in patients with transient ischemic attack

Urgent evaluation and treatment of transient ischemic attack (TIA) patients in a dedicated TIA clinic may reduce the 90-day stroke risk by 80%. ABCD2 (Age, Blood pressure, Clinical features, Duration, Diabetes) score and magnetic resonance imaging abnormalities help to identify patients at high risk of stroke. Our aim was to determine whether the use of transcranial Doppler (TCD) examination on arrival at the TIA clinic yields additional information that facilitates the identification of patients at high risk of stroke recurrence. Between January 2003 and December 2007, 1,881 patients were admitted to SOS-TIA clinic (a TIA clinic with around-the-clock access). Clinical and vascular assessment included TCD performed by a neurologist immediately after admission. Stroke prevention measures were initiated on arrival, in accordance with guidelines. All patients were followed for 1 year after presentation to the SOS-TIA clinic. A total of 1,823 TCD examinations were performed within 4 hours of admission. Intracranial narrowing or occlusion was found in 8.8% of patients, and was independently associated with age, hypertension, and diabetes. After 1-year follow-up on best preventive therapy, the incidence of recurrent vascular events (intracranial revascularization for TIA recurrence, stroke, myocardial infarction, and vascular death combined) was 7.0% in patients with intracranial narrowing or occlusion and 2.4% in those without (log-rank, p = 0.007). The hazard ratio of combined outcome for the presence of intracranial narrowing or occlusion was 2.29 (95% confidence interval [CI], 1.15-4.56; p = 0.02) in multivariate analysis including age, gender, hypertension, and diabetes, and was 2.50 (95%CI, 1.24-5.05; p = 0.01) in multivariate analysis including ABCD2 score > or =4. Immediate TCD examination on arrival at the TIA clinic is feasible and could help to identify patients at high risk of vascular events recurrence. This study supports a systematic intracranial vascular examination in the initial management of TIA.

Effects of health education on improving compliance of patients with transient ischemic attack treatment

Objective To study the effects of health education concerning transient ischemic attack (TIA) knowledge on improving compliance of patients and how it affect therapy. Methods Ninety patients with transient ischemic attack were divided into the experiment group (n = 45) and the control group (n =45) at random. The experiment group performed health education intervention including providing health education manual, carrying out the individual education, group education and random education while the control group wag given ordinary medical advice only. Results The knowledge about transient ischemic attack mastered by patients in two groups was different. T 和 experiment group was higher than the control group (P < 0. 05). TIA seizure frequency in the experiment group was lower than that in the control group (P <0. 05). Conclusions Health education can enhance disease-related knowledge and improve the compliance for patients with TIA, so as to prevent the recrudesce of TIA. Key words: Transient Ischemic Attack; Health Education; Compliance

Transient Ischemic Attacks (TIAs) Treated With Electroacupuncture and Chinese Herbal Medicine

ABSTRACT Background: Little data exist about the treatment of transient ischemic attacks (TIAs) with acupuncture and/or Chinese herbal medicine. Objective: To describe a single-case experience with acupuncture and herbal medicine for TIA. Design and Patient: A 36-year-old Australian woman with a recent history of headaches and numbness presented for treatment. Of note, she had been receiving chiropractic treatment for neck and upper back pain once a week for the last 2 months. Intervention: Scalp acupoint was MS 7 line (the scalp sense response line). Two needles were inserted toward GB 7 (Qu Bin). An electroacupuncture stimulator was used at about 20 Hz with intermittent waves. Treatment was 20 minutes per session, 2 sessions per week. In addition, Notoginseng Plus (panax notoginseng plus salvia miltiorrhiza) was prescribed at a standard dosage (two 500-mg tablets, 3 times daily) from the second week onward, invigorating Qi and Blood circulation. Main Outcome Measure: Change in numbness and dermal sense....

GABA is not elevated during neuroprotective neuronal depression in the hypoxic epaulette shark ( Hemiscyllium ocellatum)

Prolonged hypoxic exposure results in cell failure, glutamate excitotoxicity and apoptosis in the brain. The epaulette shark can withstand prolonged hypoxic exposure without brain injury, while maintaining normal function and activity at tropical temperatures. We examined whether the inhibitory neurotransmitter GABA was involved in hypoxia tolerance and neuroprotection during hypoxic preconditioning. Sharks were exposed to either cyclic hypoxic preconditioning or normoxic conditions. Whole brain GABA concentration was determined using high performance liquid chromatography; GABA distribution in neuronal structures was localised with immunohistochemistry and quantified. While the overall brain level of GABA was not significantly different, there was a significant heterogeneous change in GABA distribution. GABA immunoreactivity was elevated in key motor and sensory nuclei from preconditioned animals, including the nucleus motorius nervi vagi and the cerebellar crest ( p < 0.001), corresponding to areas of previously reported neuronal hypometabolism. Since the neuroprotection in all other hypoxia and anoxia tolerant species examined so far relies in part on significant elevations in GABA and the phylogenetically older epaulette shark does not, it is reasonable to assume that further research in this unique animal model may yield clues to new key modulators of neuroprotection. Understanding such mechanisms may facilitate the development of therapeutic interventions in the treatment of transient ischaemic attacks, strokes and traumatic brain injury.

Review: Risk for stroke is high at 2, 30, and 90 days after transient ischemic attack

ACP Journal Club17 June 2008Review: Risk for stroke is high at 2, 30, and 90 days after transient ischemic attackDavid Tong, MDDavid Tong, MDCalifornia Pacific Medical Center, San Francisco, California, USA (D.T.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-148-12-200806170-02012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationWu CM, McLaughlin K, Lorenzetti DL, et al. Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med. 2007;167:2417-22. https://pubmed.ncbi.nlm.nih.gov/18071162Clinical Impact RatingsGIM/FP/GP: Emergency Med: Hospitalists: Neurology: References1 Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007;370:1432-42. [PMID: 17928046] Google Scholar2 Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6:953-60. [PMID: 17928270] Google Scholar3 Bos MJ, van Rijn MJ, Witteman JC, et al. Incidence and prognosis of transient neurological attacks. JAMA. 2007;298:2877-85. [PMID: 18159057] Google Scholar Author, Article, and Disclosure InformationAffiliations: California Pacific Medical Center, San Francisco, California, USA (D.T.)This article was published at Annals.org on 3 June 2008. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 17 June 2008Volume 148, Issue 12Page: JC4-12KeywordsAntiplatelet therapyCohort studiesIschemic strokeNeurologyStatinsStenosisStrokeSurgerySystematic reviewsTransient ischemic attacks ePublished: 17 June 2008 Issue Published: 17 June 2008 Copyright & PermissionsCopyright © 2008 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Urgent Need for Secondary Stroke Prevention After Transient Ischemic Attack

To review symptom awareness, diagnostic techniques, and therapeutic interventions for the recognition and treatment of transient ischemic attack (TIA) and to discuss secondary stroke prevention after TIA. Published information related to recognition and treatment of TIA and the prevention of a secondary cerebrovascular event after TIA. Literature review reveals high risk for an early, secondary cerebrovascular event after TIA. Historically, TIA was not treated urgently; today, it is understood that TIA is a sign of a serious condition and may be an indication of impending disability and death. Prompt initiation of treatment may significantly reduce morbidity and mortality. However, many factors, such as low public awareness of symptoms, lack of urgency, or unavailability of brain imaging devices, are responsible for treatment delay. Delay between symptom onset and symptom diagnosis may preclude the use of tissue-plasminogen activator, which must be administered within a three-hour window from time of onset. Other therapeutic interventions for secondary stroke prevention after a TIA include the early use of antiplatelet agents (aspirin, clopidogrel, dipyridamole), and may involve procedures such as carotid endarterectomy and stenting. Risk reduction may also be achieved by treating hypertension and hypercholesterolemia. TIA and stroke must be recognized and treated urgently. Through public education, readily available information, access to diagnostic imaging devices, and aggressive preventive strategies and treatments, the frequency and severity of secondary cerebrovascular events, as well as the economic burden of secondary stroke, could be substantially reduced.

Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison

Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison

Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison

The risk of recurrent stroke is up to 10% in the week after a transient ischaemic attack (TIA) or minor stroke. Modelling studies suggest that urgent use of existing preventive treatments could reduce the risk by 80-90%, but in the absence of evidence many health-care systems make little provision. Our aim was to determine the effect of more rapid treatment after TIA and minor stroke in patients who are not admitted direct to hospital. We did a prospective before (phase 1: April 1, 2002, to Sept 30, 2004) versus after (phase 2: Oct 1, 2004, to March 31, 2007) study of the effect on process of care and outcome of more urgent assessment and immediate treatment in clinic, rather than subsequent initiation in primary care, in all patients with TIA or minor stroke not admitted direct to hospital. The study was nested within a rigorous population-based incidence study of all TIA and stroke (Oxford Vascular Study; OXVASC), such that case ascertainment, investigation, and follow-up were complete and identical in both periods. The primary outcome was the risk of stroke within 90 days of first seeking medical attention, with independent blinded (to study period) audit of all events. Of the 1278 patients in OXVASC who presented with TIA or stroke (634 in phase 1 and 644 in phase 2), 607 were referred or presented direct to hospital, 620 were referred for outpatient assessment, and 51 were not referred to secondary care. 95% (n=591) of all outpatient referrals were to the study clinic. Baseline characteristics and delays in seeking medical attention were similar in both periods, but median delay to assessment in the study clinic fell from 3 (IQR 2-5) days in phase 1 to less than 1 (0-3) day in phase 2 (p<0.0001), and median delay to first prescription of treatment fell from 20 (8-53) days to 1 (0-3) day (p<0.0001). The 90-day risk of recurrent stroke in the patients referred to the study clinic was 10.3% (32/310 patients) in phase 1 and 2.1% (6/281 patients) in phase 2 (adjusted hazard ratio 0.20, 95% CI 0.08-0.49; p=0.0001); there was no significant change in risk in patients treated elsewhere. The reduction in risk was independent of age and sex, and early treatment did not increase the risk of intracerebral haemorrhage or other bleeding. Early initiation of existing treatments after TIA or minor stroke was associated with an 80% reduction in the risk of early recurrent stroke. Further follow-up is required to determine long-term outcome, but these results have immediate implications for service provision and public education about TIA and minor stroke.

Aplicación de una vía clínica para el tratamiento del accidente isquémico transitorio: estrategias de implantación y evaluación a los dos años

Management of cerebral vascular pathologies by means of clinical pathways allows us to make cost effective use of resources, to enhance health care quality and to obtain a greater degree of satisfaction in patients. To assess the efficiency of applying a clinical pathway designed for the treatment of transient ischemic attacks (TIA) by monitoring a series of indicators that enable us to detect existing problems, to introduce any corrections that are needed and to draw conclusions that can be useful in the future. To this end, a clinical pathway was drawn up with the general agreement of the members of our service and the different professionals involved in caring for these patients. Analyses were performed to study the data from 1998 to 2001, prior to implementation of the pathway, and from 2002 and 2003, which were the first years in which it was being applied. Altogether 1,433 patients with a diagnosis of TIA were hospitalised during this period, 554 of whom were admitted during the years 2002 and 2003. Of this group, the pathway was initially applied in 123 cases and 62 completed it. The mean stay in hospital was reduced from 9.2 days in 2000 to 5.7 days in 2003. The mean stay of patients who fulfilled all the requirements of the pathway was only 2.9 days. As far as the survey on satisfaction is concerned, 97% of patients said they were satisfied or very satisfied with the care they had received. The application of a clinical pathway in the treatment of TIA resulted in a high degree of satisfaction among the patients who were treated and a notable reduction in the mean stay in hospital.

A suggested training programme for carotid artery stenting (CAS)

Carotid artery stenting as an alternative to traditional carotid endartrectomy is becoming increasingly important in the treatment of transient ischemic attack and stroke. Physicians from several different medical disciplines are interested in treating appropriate patients by this method. Patients are entitled to know what training and experience the surgeon or clinician has before giving consent. This should involve endovascular experience in all systems and experience and knowledge of cerebral angiography and intervention. A multidisciplinary approach and reporting of adverse events is vital for patient safety.

Gestión y mejora del proceso de tratamiento ambulatorio del accidente isquémico transitorio en consultas de Neurología

To describe our experience in the ambulatory treatment of transient ischemic attacks (TIA) in a second-level hospital with the implementation of an example of process management within the different services involved in attending such conditions. The following aspects of the process--mission, limits, flowchart, eligibility criteria and performance indicators (process, sentinel and effectiveness)--were defined by multidisciplinary consensus (Emergency, Vascular Surgery, Cardiology, Neurology and Radiology departments). This process was implemented from April 2002 to May 2004, and monthly assessments were carried out to check for problems and to introduce corrective measures. After ending the process, patients with TIA were admitted as inpatients for a hospital study. Definition of the process: medical care (diagnosis and treatment) of TIA patients who are eligible for a complete outpatient study within seven days. Patients evaluated: 254. Indicator 1 (percentage of suitable referrals): 2002: 53%, 2003: 75%, 2004: 73%. Indicator 2 (percentage of complete studies in less than one week): 2002: 35%, 2003: 57%, 2004: 50%; hospitalised: 90%. Indicator 3 (infarcts during the study): 2002: 4.3%, 2003: 0%, 2004: 0%; hospitalised: 0%. Indicator 4 (percentage of adjustments made to treatment): 2002: 39%, 2003: 31%, 2004: 62%; hospitalised: 72%. Mean delay before visit: in February 2002: 90 days, in April 2002: 7.67 days and in April 2003: 5.37. Problems detected: delays in referrals, failure to fit hospitalisation criteria, delays in carrying out examinations not included in the protocol, unsuitable indicator design. Steps taken: redefinition of indicators, modification of the referral system, adjustments made to the circuits involved in carrying out tests, review of hospitalisation criteria. Process management is an ideal tool for achieving ongoing improvements in clinical praxis. Early monitoring makes it possible to detect problems and to implement corrective measures. In our area, the study of TIA must be performed in a hospital inpatient regimen in order to comply with the guidelines for clinical practice.

The need for emergency treatment of transient ischemic attack and minor stroke

The risk of recurrent stroke following transient ischemic attack or minor stroke has recently been shown to be 5–10% at 1 week and 10–20% at 3 months, depending on study population and methods. This is considerably higher than previously estimated and current clinical guidelines reflect the need for rapid assessment although a wide variation in practice exists. Effective management of patients with transient ischemic attack or minor stroke, therefore, requires identification of individuals at the highest (and lowest) risk and initiation of appropriate secondary prevention. Risk can be stratified at initial presentation by the presence or absence of simple clinical features and following subsequent investigation. For transient ischemic attack patients, older age, diabetes, longer duration of symptoms and weakness or speech disturbance identify patients at highest risk, as does the presence of large artery atherosclerosis (mainly internal carotid artery stenosis) and lesions on diffusion-weighted magnetic resonance imaging. Strong evidence exists for the benefit of some early interventions (carotid endarterectomy and antiplatelet agents), but is circumstantial or awaited for others (statins and antihypertensives). In order for the public health challenge posed by transient ischemic attack and minor stroke to be met, considerable change is required in both public education (to ensure correct recognition of symptoms and swift presentation to medical attention) and the provision of clinical services to ensure the timely initiation of effective treatment.

Effective Prophylaxis for Deep Vein Thrombosis After Stroke

Approximately 5% of hospitalized stroke patients have a clinically apparent deep vein thrombosis (DVT) and ≈2% will have a pulmonary embolus (PE) confirmed.1 However, prospective studies that systematically screen for DVT with, for example compression Doppler ultrasound or magnetic resonance imaging, identified DVT in up to 50% of patients.2 Some patients who are breathless because of aspiration pneumonia, chest infection, or heart failure may actually have had an undiagnosed pulmonary embolus. Autopsies often identify clinically unrecognized PEs that probably contributed to the patient’s death. Therefore, it seems sensible to offer patients prophylaxis against venous thromboembolism. However, a brief discussion with colleagues is likely to reveal wide variation in the approaches taken to prophylaxis. In our unit, we aim to treat all patients with ischemic stroke with aspirin within 48 hours, because this has been shown to improve long-term outcomes and probably also reduces the risk of venous thromboembolism to some extent.3 In addition, we …

Phenytoin Toxicity Associated With Ticlopidine Administration

A case of phenytoin sodium toxicity that appeared to be related to the administration of ticlopidine hydrochloride was recently observed at the Prescott Veterans Affairs Medical Center in Arizona. Report of a Case. A 71-year-old man had been taking ticlopidine for treatment of transient ischemic attacks. Concurrent medications included phenytoin sodium (350 mg/d), phenobarbital (90 mg/d), and cholestyramine resin (4 g at bedtime). The dosage of the phenytoin therapy had not been changed over the last 6 years (serum phenytoin concentrations, 60 to 80 μmol/L [15 to 20 mg/L]). A serum phenytoin concentration of 60 μmol/L (15 mg/L) was noted 2 weeks before ticlopidine therapy was initiated. The dosage of the phenobarbital therapy had not been changed for more than 2 years. After 1 month of ticlopidine hydrochloride therapy (250 mg twice daily), the patient began complaining of difficulty in walking and bilateral leg weakness. Serum concentrations of phenytoin and

Anticoagulants for the treatment of transient ischemic attacks.

Anticoagulants as a treatment for Transient Ischemic Attacks were originally suggested over 30 years ago. After 30 years of study and many clinical reports covering their use plus several specifically conducted studies to evaluate their effectiveness, there is no unanimity of opinion now whether or not they are a useful treatment for the prevention of recurrent transient ischemic attacks and whether they reduce the possibility of stroke in the future (6, 11, 23, 47).

Transient Ischemic Attacks

The editors of this timely volume of The Science and Practice of Surgery have managed to organize a complex and controversial medical and surgical topic (cerebrovascular insufficiency) into a scholarly, readable book. The basic science aspects (epidemiology and pathogenesis) are carefully detailed and completely referenced. The differential diagnosis of transient cerebral ischemia is covered well and the chapter on cardiac causes of transient neurologic disturbances is excellent. The clinical treatment of patients with transient ischemic attacks is well presented. The authors are careful to adhere to the strict definition of transient ischemic attacks. The chapters on neuroradiologic and noninvasive investigations are excellent and state of the art. The book describes both medical and surgical management for carotid territory as well as vertebrobasilar transient ischemic attacks. This book summarizes current knowledge regarding etiology, diagnosis, and treatment of transient ischemic attacks. It is superbly referenced and appropriately illustrated and is a must

Treatment of transient ischemic attacks.

Treatment of transient ischemic attacks.