Treatment Of Transient Ischemic Attacks Research Articles

Systematic Review of Tongxinluo Capsule on the Therapeutic Effect and Hemorheology of Patients with Transient Ischemic Attack.

Objectives This study aims to systematically evaluate the clinical efficacy of Tongxinluo capsule in the treatment of transient ischemic attack (TIA) and its effect on hemorheology, thereby providing scientific basis for clinical decision making. Methods A comprehensive and systematic literature retrieval was conducted in the CNKI, Wanfang database, SinoMed, EMbase, and PubMed to screen the randomized controlled trials (RCTs) of Tongxinluo capsule in the treatment of TIA. The retrieval time was from the inception of each database to September 10, 2020. Endnote X9 was used to screen the literature. Cochrane Collaboration tool for assessing risk of bias was used to evaluate the quality of the included studies. Stata16.0 statistical software was used for meta-analysis. Results A total of 12 RCTs were included, involving 946 subjects. (1) The clinical efficacy of the Tongxinluo group was better than that of the control group (RR = 1.19, 95% CI (1.09, 1.30), P ≤ 0.001). (2) The hemorheological characteristics of the Tongxinluo group were significantly improved compared with those of the control group (whole blood high shear viscosity: SMD = −1.61, 95% CI (−1.89, −1.34); P ≤ 0.001, whole blood low shear viscosity: SMD = −1.06, 95% CI (−1.31, −0.80), P ≤ 0.001, fibrinogen: SMD = −1.12, 95% CI (−1.94, −0.29), P = 0.008, plasma specific viscosity: SMD = −1.00, 95% CI (−1.69, −0.31), P = 0.004, and hematocrit: SMD = −1.47, 95% CI (−2.16, −0.77), P ≤ 0.001). (3) There was no significant difference in the incidence of adverse reactions between the Tongxinluo group and control group (RR = 7.76, 95% CI (0.98, 61.28), P = 0.052). Conclusion Tongxinluo capsule is superior to conventional treatment in improving clinical overall response rate and hemorheological indexes and is relatively safe. Due to the deficiencies of the existing studies, more high-quality studies with rigorous design are required for further verification.

Effect Of Butylphthalide Combined with Ozagrel Sodium on Cerebral Perfusion and Oxidative Stress Indexes in Patients with Transient Ischemic Attack

Background The pathogenesis of transient ischemic attack is not clear. Microthrombosis theory is a theory with high clinical recognition. Microthrombosis of carotid artery and vertebral basilar artery wall occurs shedding and vasospasm, resulting in transient cerebral insufficiency. Microembolic decomposition or distal movement, cerebrovascular dilatation, local collateral circulation after the establishment of symptoms relieved or disappeared. Most patients can be relieved in a short time, but recurrent attacks can gradually damage the structure and function of brain tissue, and increase the risk of acute cerebral infarction. The clinical treatment of this disease is mainly based on the comprehensive control of risk factors, anti thrombosis, and anti-platelet aggregation. Objective To observe the effect of butylphthalide combined with ozagrel sodium on cerebral perfusion and oxidative stress indexes in patients with transient ischemic attack. Methods A total of 116 patients diagnosed as transient ischemic attack in our hospital (February 2018 - February 2020) were selected and divided into two groups according to the treatment methods. 58 cases in the control group were treated with ozagrel sodium, 58 cases in the observation group were treated with butylphthalide combined with ozagrel sodium. The CT perfusion imaging parameters, oxidative stress indexes, plaque area, and the levels of platelet activating factor ( PAF ), α-granule membrane protein-140 ( GMP-140 ), fibrinogen ( FIB ), platelet aggregation rate (PAgT), neuron-specific enolase (NSE), oxygend-inducible factor-1α (HIF-1α), and matrix metalloproteinases 9 (MMP-9) in the two groups were recorded, and the total effective rate and adverse reaction rate were counted. Results The total effective rate of the observation group was higher than that of the control group, and the difference was statistically significant (χ2=4.640, P = 0.031). Compared with before treatment, the average time (MTT) required for the two groups of contrast agents to pass through the local brain tissue and the time (TTP) required to start the injection of contrast agents to reach the peak concentration decreased compared with before treatment. After treatment, the MTT and TTP of the observation group were shorter than those of the control group (P < 0.05). Compared with before treatment, superoxide dismutase ( SOD ) in the two groups was higher than that in the control group, PAF, GMP-140, FIB, PAgT, NSE, HIF-la, MMP-9, malondialdehyde (MDA) and plaque area decreased. After treatment, the levels of related factors in the observation group were better than those in the control group, and the plaque area was less than that in the control group (P < 0.05). There was no significant difference in the adverse reaction rate between the observation group and the control group (χ2 = 0.438, P=0.508). Conclusion Butylphthalide combined with ozagrel sodium in the treatment of transient ischemic attack can improve cerebral perfusion, reduce oxidative stress injury, reduce plaque and improve curative effect.

Modern algorithms for the diagnosis and treatment of transient ischaemic attacks

The article analyzes the current tendencies in the diagnosis and treatment of transient ischaemic attacks (TIA). The prevalence of TIA in the population has not been established due to the uncertainty of the diagnostic criteria. The authors discuss the problem of a qualitative diagnosis of TIA in detail. Based on the current clinical recommendations, modern and promising methods of treatment are discussed. The authors pay special attention to the assessment of the risk of bleeding during aggressive antithrombotic therapy.

Discussion on the Effect of Early Cerebrovascular Perfusion Therapy in the Treatment of Transient Ischemic Attack

Discussion on the Effect of Early Cerebrovascular Perfusion Therapy in the Treatment of Transient Ischemic Attack

Effects of butylphthalide injection on treatment of transient ischemic attack as shown by diffusion-weighted magnetic resonance imaging abnormality

Background and Objective: Transient ischemic attack (TIA) is a serious condition that is often called a warning stroke. The risk of cerebral infarction in patients with TIA and positive DWI findings is greater than that in patients with TIA and normal DWI findings. Butylphthalide injection is a new type of brain protective drug. The study aimed to determine the efficacy and safety of butylphthalide injection for treating TIA as shown by DWI abnormality progressing to infarction.Methods: We studied 98 patients with positive DWI findings among 260 patients with TIA, and randomly divided into the experimental (treatment with butylphthalide injection) and control (treatment with aspirin) groups. The number of cerebral infarctions in the two groups was recorded on 7th, 14th, 30th and 90th day, and adverse reactions were observed. The number of cerebral infarctions was compared among the different ABCD2 scores of patients with TIA and positive DWI findings.Results: The incidence of cerebral infarction in the experimental group was significantly lower than that in the control group (p < .05). The incidence of cerebral infarction with an ABCD2 score less than 3 points was significantly lower than that with an ABCD2 score of more than 3 points (p < .05), with less adverse reactions.Conclusion: Butylphthalide injection is helpful and safe for preventing stroke following TIA, and treating TIA with positive DWI and progression to infarction.

Early Management of Transient Ischemic Attack in Emergency Departments in France

IntroductionEmergency departments play a key role in the diagnosis and treatment of transient ischemic attacks, but limited data are available about the early management of such patients in emergency wards. Therefore, we aimed to evaluate emergency physicians’ management of transient ischemic attack and analyze variations factors. MethodsA multicenter survey among emergency physicians of the Grand Est region network (Est-RESCUE) was conducted from January 28th to March 28th, 2019. Medical and administrative data were collected by the same network and the national directory of medical resources. ResultsAmong 542 emergency physicians recipients, 78 answered (14%) and 71 were finally included, practicing in 25 public hospitals homogeneously distributed across the territory, including 3 university hospitals. A cerebral magnetic resonance imaging was obtained for 75%-100% of patients by 4.3% of responders, 36.4% of which were performed within more than 24 hours. A cardiac monitoring was prescribed in 75%-100% of cases by 32.4% of responders. A neurologic consultation was routinely requested by 84.6% of responders practicing in a university hospital and 36.8% of responders practicing in a community hospital (P = .02). Patients were hospitalized in a neurovascular unit in 75%-100% of cases by 17.4% of responders, which happened more likely in university hospitals (P < .001). ConclusionsTransient ischemic attack suffers from management disparities across territories, due to limited access to technical facilities and neurologic consultations. Therefore, international recommendations are too often not followed. Implementation of territorial neurovascular tracks may help to standardize the management of these patients.

A Comparison of the Evaluation and Treatment of Transient Ischemic Attack in a Comprehensive Stroke Center and Four Acute Stroke Ready Hospitals (P3.3-055)

A Comparison of the Evaluation and Treatment of Transient Ischemic Attack in a Comprehensive Stroke Center and Four Acute Stroke Ready Hospitals (P3.3-055)

Study of Serum CD147 Level in Patients with Transient Ischemic Attack and CD147 Expression in Atherosclerotic Plaque.

There is growing evidence that highlighted the potential effects of CD147 in atherosclerosis, but the potential implication of CD147 in diagnosis and treatment of transient ischemic attack (TIA) and acute cerebral infarction (ACI) is still unclear. In this work, we investigated the serum level of CD147 in patients with TIA and ACI, and CD147 expression in atherosclerotic plaque. The result showed significantly increasing serum level of CD147 in patients with TIA and ACI, and increasing amount of CD147 in vulnerable plaque compared with that in migrating plaque. The serum level of CD147 was correlation with risk of stroke after an episode of TIA. These results together suggest a potential involvement of CD147 in the development and progression of TIA and ACI and CD147 as a potential biomarker for stroke prediction.

Effect of aspirin combined with clopidogrel in the treatment of transient ischemic attack and its influence on coagulation function

Objective To investigate the effect of aspirin combined with clopidogrel in the treatment of transient ischemic attack(TIA), and its influence on blood coagulation. Methods Ninety-six patients with TIA were selected and divided into observation group and control group by random number table method, with 48 cases in each group.The control group was treated with aspirin, and the observation group was treated with aspirin and clopidogrel.The treatment effect, coagulation index changes and adverse reactions were compared between the two groups. Results The effective rate of the observation group was 91.67%(44/48), which was higher than 68.75%(33/48) of the control group (χ2=7.941, P 0.05). Conclusion The curative effect of aspirin combined with clopidogrel is superior to aspirin alone in the treatment of TIA, and it can improve the coagulation function of patients, which has high security. Key words: Aspirin; Clopidogrel; Ischemic attack, transient; Fibrinogen; Prothrombin time; Activated partial thromboplastin time

Efficacy and mechanism of clopidogrel combined with aspirin in the treatment of transient ischemic attack

Objective To study the efficacy and mechanism of sequential therapy of clopidogrel combined with aspirin in the treatment of transient ischemic attack. Methods 150 cases with transient ischemic attack were set as the research subjects. According to the random number table method, they were divided into aspirin group, clopidogrel group and combination group. The clopidogrel group was treated with 75mg clopidogrel, once daily. The aspirin group was treated with 50mg aspirin, twice a day. The combined group was treated with 300mg clopidogrel + 300mg aspirin at the first day, 75mg clopidogrel + 100mg aspirin at the second day. Three groups were treated for a period of 15 days. After 15d treatment, the raw fiber protein (FIB), two D dimer (D-D), activated partial thromboplastin time (APTT) and prothrombin time (PT) of three groups and adverse reactions, curative effect and recurrence rate were analyzed. Results After treatment, the FIB, D-D, APTT and PT of the combined group were (3.14±0.24)g/L, (0.61±0.26)mg/L, (33.58±2.77)s, (15.67±0.72)s, which of the clopidogrel group were (3.32±0.25)g/L, (0.91±0.32)mg/L, (30.19±2.19)s, (15.64±0.78)s, which of the aspirin group were (3.40±0.22)g/L, (1.02±0.39)mg/L, (29.71±2.21)s, (13.21±0.80)s, which were significantly improved than before treatment[the combination group (3.59±0.26)g/L, (2.50±0.35)mg/L, (27.53±2.41)s, (11.23±0.69)s; the clopidogrel group (3.58±0.28)g/L, (2.51±0.40)mg/L, (27.19±2.53)s, (11.73±0.82)s; the aspirin group (3.61±0.27)g/L, (2.46±0.32)mg/L, (27.61±2.13)s, (11.68±0.77)s], the effect of the combined group was better than that of the clopidogrel group and aspirin group (F=8.12, P<0.05). The total effective rate of the combination group (96.00%) was significantly higher than that of clopidogrel group (84.00%) and aspirin group (76.00%), the differences were statistically significant (χ2combination group vs. clopidogrel group=4.00, χ2combination group vs. aspirin group=8.31, all P<0.05). The adverse reactions in the three groups had no difference, but the recurrence rate of the combination group (8.00%) was significantly lower than that of the clopidogrel group (24.00%) and the aspirin group (28.00%), the differences were statistically significant (χ2combination group vs. clopidogrel group=4.76, χ2combination group vs. aspirin group=6.78, all P<0.05). Conclusion The combination of clopidogrel and aspirin in the treatment of transient ischemic attack has significant effect and low recurrence rate, which is worthy of popularizing widely. Key words: Ischemic attack, transient; Clopidogrel; Aspirin

Self-Determination Theory Application In The Discharge Of Patients With Transient Ischemic Attack

Background: The principle of transient ischemic attack treatment is lifestyle modification and pharmacological treatment that would reduce recurrence and incidence of stroke. Lifestyle changes require follow-up care and continuity of nurse and patient relationships, but the current training does not meet this need. The trainings based on motivating theory such as self-determination, besides continuity of the relationship with patient, improve his/her incentive, specially of it is carried out at the discharge time. Therefore, this study has been done by the purpose of defining the impact of discharge plan based on self-determination theory on the lifestyle patients with transient ischemic attack.Methodology: The analysis has been done on 57, 18-90 years old clinical random patients in Tehran hospitals (29 cases and 28 controls) in 2015. Data were collected by demographic questionnaire at the beginning and health-promoting lifestyle questionnaire(second edition) were collected at the end of the study. Discharge plan based on self-determination theory, including patients and families meeting in hospital and telephone counseling during the 12 weeks after discharge was accomplished in cases group. The control group received only routine hospital care. Data were analyzed by t-test and chi- squre test.Results: The score of lifestyle was similar in both groups (p&gt; .05) at beginning of the study, but at the end of the study, the average score of cases group (17.1 ± 164.2) significantly higher than the control group (17.6 ± 118.3) (p &lt; 0.001). Furthermore, At the end of study, the mean scores of nutrition, physical activity, stress management, interpersonal relationships, spiritual growth and responsibility in the lifestyle cases group was significantly higher than the control group (p &lt;.001). The frequency of transient ischemic attacks after discharge in the cases group (13.8%), significantly lower than the control group (46.4%), respectively (p = .016).Conclusion: By executing discharge plan based on self-determination theory, transient ischemic attack patients lifestyle score increased to 26.7% and the frequency of transient ischemic attacks32.6% reduces. So use this simple and accessible program in the care of patients with ischemic attack is recommended.

Prevention is paramount if we are to overcome stroke

British Journal of Neuroscience NursingVol. 12, No. Sup2 CommentPrevention is paramount if we are to overcome strokePeter RothwellPeter RothwellSearch for more papers by this authorPeter RothwellPublished Online:27 Apr 2016https://doi.org/10.12968/bjnn.2016.12.Sup2.S4AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Adamson J, Beswick A, Ebrahim S (2004) Is stroke the most common cause of disability? J Stroke Cerebrovasc Dis 13(4): 171–7 Crossref, Google ScholarAlbers GW, Caplan LR, Easton JD et al. (2002) Transient attack—proposal for a new definition. N Engl J Med 347(21): 1713–6 Crossref, Google ScholarDepartment of Health (2013) Cardiovascular Disease Outcomes Strategy. Improving outcomes for people with or at risk of cardiovascular disease. http://bit.ly/1aN51FO (accessed 11 April 2016) Google ScholarFeigin VL, Forouzanfar MH, Krishnamurthi R et al. (2014) Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 383(9913): 245–54 Crossref, Google ScholarHackett ML, Yang M, Anderson CS et al. (2010) Pharmaceutical interventions for emotionalism after stroke. Cochrane Database Syst Rev 2: CD003690. doi: https://doi.org/10.1002/14651858.CD003690.pub3 Google ScholarHealth and Social Care Information Centre (2015) Quality and Outcomes Framework (QOF)—2014–15. http://bit.ly/1PhPYmL (accessed 11 April 2016) Google ScholarNational cardiovascular intelligence network (2016) Cardiovascular (CVD) intelligence packs. http://tinyurl.com/gub54ut (accessed 11 April 2016) Google ScholarNational Institute for Health and Care Excellence (2016) Mechanical clot retrieval for treating acute ischaemic stroke. http://tinyurl.com/hq8ho3u (accessed 11 April 2016) Google ScholarRothwell PM, Giles MF, Chandratheva A et al. (2007) Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 370(9596): 1432–42 Crossref, Google ScholarScarborough P, Peto V, Bhatnagar P et al. (2009) Stroke Statistics. British Heart Foundation and Stroke Association. http://tinyurl.com/hhr5rfh (accessed 11 April 2016) Google ScholarTownsend N, Wickramasinghe K, Bhatnagar P et al. (2012) Coronary Heart Disease Statistics. A Compendum of Health Statistics 2012 edition. British Heart Foundation, London. http://tinyurl.com/h6e643b (accessed 11 April 2016) Google Scholar FiguresReferencesRelatedDetails 1 April 2016Volume 12Issue Sup2ISSN (print): 1747-0307ISSN (online): 2052-2800 Metrics History Published online 27 April 2016 Published in print 1 April 2016 Information© MA Healthcare LimitedPDF download

Spotlight on the June 9 Issue

#### Notable in Neurology This issue features articles discussing the time from pediatric convulsive status epilepticus onset to antiepileptic drug administration and the feasibility of EEG-guided resections to achieve outcomes comparable to those achieved by standard temporal lobectomy for mesial temporal lobe epilepsy. Another featured article focuses on the prevalence, knowledge, and treatment of transient ischemic attacks in China. ### Neuropsychological effects of levetiracetam and carbamazepine in children with focal epilepsy![Graphic][1] Levetiracetam exerted no adverse effects on cognitive function, but this study failed to demonstrate that levetiracetam causes fewer neurocognitive side effects than carbamazepine. Carbamazepine and levetiracetam are equally … [1]: /embed/inline-graphic-1.gif

Prevalence, knowledge, and treatment of transient ischemic attacks in China.

To investigate the prevalence, knowledge, and treatment of TIA in a Chinese adult population. We conducted a complex, multistage, probability sampling-designed, cross-sectional, nationwide survey of 98,658 Chinese adults in 2010. Possible TIA cases were first identified by symptoms recall or self-reported history of TIA through face-to-face interviews, and the final diagnosis was then made by expert neurologists through phone interviews or record review. The age-standardized prevalence of TIA was 2.27%. Clinically, only 16.0% of the participants were diagnosed before the study. The prevalence of TIA was higher in women and in patients who were older, had less education, were current smokers, lived in rural or undeveloped areas, and had a history of stroke, hypertension, myocardial infarction, dyslipidemia, or diabetes. Based on the survey responses, approximately 3.08% of Chinese adults had knowledge of TIA. Among patients with TIA, only 5.02% received treatment and 4.07% received guideline-recommended therapy. TIA is prevalent and an estimated 23.9 million people in China may have experienced a TIA. Public knowledge on TIA is very limited. TIA appears to be largely undiagnosed and untreated in China. There is an urgent need to develop strategies to improve the identification and appropriate management of TIA.

Research of Shuxuetong injection in the treatment of transient ischemic attack

Objective To investigate the therapeutic effects and safety of Shuxuetong injection in the treatment of transient ischemic attack.Methods 102 cases of transient ischemic attack were randomly divided into treatment group and control group,51 cases in each group.Treatment group received intravenous drip of Shuxuetong injection 6 ml in 0.9％ sodium chloride injection 250 ml,1 time/day,for 7 days; while control group received intravenous drip of 0.9％ sodium chloride injection 250 ml,1 time/day,for 7 days; both two groups were treated with anti platelet,blood lipids and other conventional treatment.Observed blood viscosity,plasma viscosity and erythrocyte aggregation index in two groups before and after treatment.Results The total effective rate was 98.04％ in treatment group,and 88.24％ in control group,with statistically significant difference between two groups (P ＜ 0.05).Whole blood viscosity,plasma viscosity and erythrocyte aggregation index after treatment in treatment group were significantly lower than those before treatment,which were significantly different from those after treatment in control group (P ＜ 0.05).Conclusion Treatment group got a better and quicker effect without adverse reactions. Key words: Shuxuetong injection; Transient ischemic attack; Therapeutic effect

Применение Милдроната® при лечении острых и хронических нарушений мозгового кровообращения

Милдронат® является антиишемическим, метаболическим, антиоксидантным средством и используется для лечения ишемических повреждений органов. Установлено, что его лечебный эффект при острых и хронических расстройствах мозгового кровообращения связан главным образом с повышением содержания в организме NO, сосудорасширяющие свойства которого способствуют увеличению церебрального кровотока и оксигенации мозга. При ишемическом инсульте Милдронат® уменьшает выраженность неврологического дефицита, улучшает когнитивные функции, уменьшает астению и дисфорию, повышает качество жизни. При дисциркуляторной энцефалопатии в дополнение к этому препарат уменьшает выраженность цефалгии, вестибулоатаксии и диссомнии. Пилотные исследования подтверждают ценность препарата при лечении транзиторных ишемических атак. Накопленные к сегодняшнему дню данные требуют дальнейшего подтверждения в более крупных плацебо-контролируемых международных исследованиях.

The results of the second year of carotid stenting

Introduction-objectives: Carotid artery stenting (CAS) process, especially in highrisk patients, is carotid endarterectomy (CEA) alternative. Our aim in this study, the reliability of CAS process, to evaluate the clinical and radiological results of the second year. Method: 120 patients [mean age 68 (48-86)] who have admitted to our hospital between December 2010 and March 2013 and CAS decision taken, were included in the study. Patients with symptomatic carotid artery and 50% of those with stenosis, patients with asymptomatic carotid artery stenosis greater than 70% were included. 80% of asymptomatic patients, coronary bypass surgery in patients who had precreated screen-detected. 75% of symptomatic patients, 81% of coronary artery disease, 64% of hypertensive, was 44% of the diabetic. 81% of male patients in our study group, the rate of smoking was 40%. Patients were on average 21 months (2-28 months), were followed. All the patients before the procedure, carotid doppler ultrasound and patients who require computed tomography (CT) angiography, was performed. Ultrasound, instent peak flow velocity 224 cm/sec and CT angiography in the detection of stenosis 50% was considered as restenosis. CAS operation, 62% of patients, proximal-lock braking system (Mo.Ma ), 38% in the distal embolic protection device (Anjioguard ) was used. 23% of patients (28 patients) had bilateral carotid artery stenosis. Of these patients, 19 of them lock braking system proximal, distal embolic protection device was used in 9 of them. 9 patients (7%) 100% against the carotid artery was occluded. Distal embolic protection devices were used in these patients. Results: One patient (0.8%) 24 hours after treatment, cerebrovascular ischemic events with sequelae, developed. Patients were followed up for neurology and medical recommendation. 2 patients (1.7%), 6 and 11 months after treatment of transient ischemic attack (TIA) is observed. TIA patients undergoing open carotid stents was observed, in one of these patients with paroxysmal atrial fibrillation was detected and warfarin medication was started, other patients cranial angiography, intracerebral lesions in the arteries viewed and neurology clinic with the proposal of a serious medical follow-up was continued. 3 (2.5%) patients were asymptomatic, 12th month restenosis were detected with doppler ultrasound scans and confirmed by CT angiography. Two of the patients with restenosis, one of them %60 stent restenosis in carotid artery, while the other was at the level of 80%. For patient who has 80% stenosis lesion, CEA procedures were performed. Symptomatic restenosis was not observed. Conclusion: CAS-treated patients in our clinic, the success and complication rates are similar to other studies.The largest share of low complication and high success rates, getting experience in our clinic, patient selection and follow-up with neurology and radiology clinics provide an important contribution are made in the opinion.

Review, Historical Context, and Clarifications of the NINDS rt-PA Stroke Trials Exclusion Criteria

Background and Purpose— Since Food and Drug Administration approval of intravenous tissue-type plasminogen activator (tPA) for treatment of acute ischemic stroke in 1996, it has become clear that several criteria used for exclusion from therapy were not based on actual data or operationally defined for use in clinical practice. All eligibility criteria from the National Institute of Neurological Disorders and Stroke (NINDS) recombinant tPA Stroke Study were adopted within the alteplase package insert as contraindications/warnings. Many clinicians have expressed the need for clarification and better definition of these treatment criteria. Methods— A group of investigators who also practice as stroke physicians convened a collaborative endeavor to work toward developing more clinically meaningful and consensus-driven exclusion criteria for intravenous tPA. The first of these exclusion criteria chosen was rapidly improving stroke symptoms (RISS). We reviewed and clarified the historical context and intention with the original investigators, held e-mail discussions, convened an in-person RISS Summit, and obtained the understanding of experienced stroke physicians broadly. Results— Historically, the intent of this exclusion criterion within the NINDS recombinant tPA Stroke Trial was to avoid treatment of transient ischemic attacks—who would have recovered completely without treatment. There was unanimous consensus that, in the absence of other contraindications, patients who experience improvement of any degree, but have a persisting neurological deficit that is potentially disabling, should be treated with intravenous tPA. This statement is supported from the methods established for the original NINDS trial, on the basis of detailed discussions and interviews with the former NINDS trialists. It was agreed that improvement should only be monitored for the extent of time needed to prepare and administer the intravenous tPA bolus/infusion. An explicit operational definition of RISS was developed by consensus to guide future decision making in acute stroke. There was unanimous agreement that all neurological deficits present at the time of the treatment decision should be considered in the context of individual risk and benefit, as well as the patient’s baseline functional status. Conclusions— A structured framework and quantitative approach toward defining RISS emerged through expert opinion and consensus. The term, RISS, should be reserved for those who improve to a mild deficit, specifically one which is perceived to be nondisabling. This is recommended to guide decision making on intravenous tPA eligibility going forward, including the design of future studies. An additional study of patients with rapid improvement to nonmild deficits is not justified because these patients should be treated.

The Epidemiology of Delirium: Challenges and Opportunities for Population Studies

Delirium is a serious and common acute neuropsychiatric syndrome that is associated with short- and long-term adverse health outcomes. However, relatively little delirium research has been conducted in unselected populations. Epidemiologic research in such populations has the potential to resolve several questions of clinical significance in delirium. Part 1 of this article explores the importance of population selection, case-ascertainment, attrition, and confounding. Part 2 examines a specific question in delirium epidemiology: What is the relationship between delirium and trajectories of cognitive decline? This section assesses previous work through two systematic reviews and proposes a design for investigating delirium in the context of longitudinal cohort studies. Such a design requires robust links between community and hospital settings. Practical considerations for case-ascertainment in the hospital, as well as the necessary quality control of these programs, are outlined. We argue that attention to these factors is important if delirium research is to benefit fully from a population perspective.

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.