Headache in transient ischemic attacks (TIA).

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Transient Ischemic Attacks—Populations and Prognosis

Stenting Versus Aggressive Medical Management for Symptomatic Vertebral Artery Stenosis

Objectives: Patients with transient ischemic attack (TIA) are at high risk of early stroke, indicating a need for urgent diagnostic workup and treatment. Atrial fibrillation (AF) is one of important causes for TIA. The purpose of this study was to investigate characteristics of TIA patients with AF, using data of a multicenter retrospective study. Methods: The subjects of this study were TIA patients admitted to 13 stroke centers within 7 days after onset between 2008 and 2009. The definition of TIA used in this study was that of clinical symptoms lasting less than 24 hours, regardless of imaging findings. We compared baseline characteristics and diffusion weighted-MRI (DWI) findings between patients with AF and those without AF. Results: A total of 464 patients (69 ± 13 years in age, 172 women) were enrolled. We diagnosed 79 patients (17%) as having AF. TIA patients with AF were older (74 ± 9 vs. 67 ± 14 years old, P = 0.0001) and more likely to have a longer length of hospital stay (15 ± 9 vs. 14 ± 20 days, P = 0.046) than those without AF. Of 464 TIA patients, 458 patients (99%) underwent head MRI. DWI lesion was detected in 96 (21%) patients. There was no difference of DWI positivity rate between patients with or without AF (28% vs. 20%, P = 0.10). Compared to patients without AF, patients with AF were more likely to have a single lesion on DWI (86% vs. 51%, P = 0.005). DWI lesion of ≥15 mm was found more frequently in TIA patients with AF than in those without AF (45% vs. 22%, P = 0.04). Conclusions: This study demonstrated that TIA patients with AF were older and had a longer length of hospital stay than those without AF. In addition, characteristics of DWI findings differed between TIA patient with AF and those without AF; TIA patients with AF were more likely to have a single lesion with a size of ≥15 mm.

In 205 patients with carotid transient ischemic attacks (TIAs) who underwent full angiographic and cardiac investigations, we found that ipsilateral carotid bruit and triggering of TIA by exertion or standing up suggested a carotid lesion. Angina pectoris or palpitations at onset of TIA suggested a cardiac source of emboli. Patients with only one TIA, multiple identical attacks, progression of symptoms over minutes, and appropriate infarct on computed tomograms (28%) were likely to show a potential arterial or cardiac cause for the TIAs in subsequent investigations. Transient monocular blindness correlated with carotid occlusion, but the severity of the carotid lesion did not influence the duration and repetition of attacks. Transient ischemic attacks in multiple territories, identical attacks, and multiple or silent infarcts on computed tomograms occurred equally in the patients with arterial lesions and those with cardiac lesions. These findings suggest that only a few, albeit important, conclusions regarding etiology can be drawn from the clinical characteristics of TIAs.

The significance of cerebral infarction and atrophy in patients with amaurosis fugax and transient ischemic attacks in relations to internal carotid artery stenosis: A preliminary report

To determine the prevalence of radiologically evident carotid stenosis in patients with transient cerebral ischemic attacks, we analyzed 95 consecutive hospitalized patients who during a two-year period had appropriate symptoms and also underwent angiography. Pure transient hemisphere symptoms affected 52 patients, pure monocular blindness occurred in 33, and 10 experienced each type of attack separately. Tight stenosis (less than or equal to 2 mm) or occlusion was present in 49 patients (52 per cent). Thirteen patients showed intracranial-branch occlusion, nine of whom had no notable stenosis. Only two clinical transient ischemic attack features correlated with angiographic findings: in transient hemisphere attacks lasting for one hour or longer, the carotid arteries revealed no notable stenosis (0.05 less than P less than 0.1); and separate hemisphere and ocular attacks in the same patient correlated with tight carotid stenosis. On the basis of the angiographic findings, the study indicates there are several distinct groups of patients with carotid transient ischemic attacks.

The American Stroke Association has recommended changing the criteria for defining transient ischemic attack (TIA) from time-based to tissue-based (infarction identified on diffusion-weighted magnetic resonance imaging [DWI]). In an international observational study, researchers compared the prognostic accuracy of the two definitions of TIA for predicting recurrent stroke at 7 and 90 …

Introducción:El manejo del ictus isquémico minor presenta desafíos significativos, debido a la variabilidad en la aplicación de protocolos de neuroimagen y tratamiento endovascular (TEV). La ausencia de consenso sobre la indicación de la angiografía por tomografía computarizada (angioTC) en estos casos subraya la importancia de investigar la prevalencia y las implicaciones clínicas de la oclusión de gran vaso en esta población.Metodología:Análisis del registro multicéntrico CODICT en pacientes con ictus isquémico minor (National Institutes of Health Stroke Scale (NIHSS) ≤5) atendidos en centros terciarios de atención al código ictus (CI) de la Comunidad Valenciana en el periodo 01/07/2020–30/11/2023. Se evaluó la frecuencia de oclusión de gran vaso (OGV), definida como oclusiones en carótida interna, arteria vertebral, basilar, y segmentos críticos de la arteria cerebral media (M1, M2), anterior (A1, A2) y posterior (P1, P2), mediante angioTC.Resultados:Se identificaron un total de 5473 activaciones de CI en el periodo de estudio. Un total de 833 pacientes sufrieron un ictus isquémico minor. El 17,5% (n = 146) de los ictus minor mostraron una OGV en el angioTC. El 48,6% (n = 71) de los pacientes con ictus minor y OGV fueron sometidos a TEV. Los vasos más frecuentemente ocluidos fueron la arteria cerebral media (ACM) en sus segmentos M1 y M2 ambos en el 35,6% (n = 52) de los casos. Sin embargo, el vaso más frecuentemente tratado mediante TEV fue M1 en el 29,5% (n = 43), seguido por M2 en el 10,9% (n = 16) de los casos.Conclusiones:Este estudio pone de manifiesto la importancia de la realización de angioTC en todo paciente que cumpla criterios de activación de Código Ictus, independientemente de la gravedad clínica. La presencia de OGV cambió el manejo clínico en casi la mitad de los pacientes con ictus minor y OGV.

Gender difference in prognosis after transient cerebral ischemia or minor stroke

Using Doppler ultrasonography, we evaluated the frequency and severity of carotid artery stenosis in 261 patients with carotid ischemic strokes, 813 patients with carotid transient ischemic attacks, 500 patients with asymptomatic neck bruits, and 500 controls. Most patients with strokes and transient ischemic attacks had no associated carotid artery disease (55% and 64%, respectively), and such patients without neck bruits were even more likely to be without carotid artery disease (69% and 77%, respectively). Carotid stenosis was more frequent and more likely to be severe in symptomatic than in asymptomatic patients (p less than 0.0002), even after adjusting for age and sex. Carotid stenosis is present in only a minority of patients with strokes and transient ischemic attacks, especially if neck bruits are absent, and the cause of the ischemic cerebral events in most of these patients remains unexplained.

Transient ischemic attack (TIA) is a neurologic deficit resulting from focal ischemia in the brain, spinal cord, or retina. Historically, the definition included symptom resolution within 24 hours. However, recent studies investigating cognition after TIA suggest that deficits in executive function persist at 7 days post-TIA, although few studies have examined these effects long term. Recent advances in neuroimaging techniques provide emerging evidence of permanent microvascular tissue damage in the brain, suggesting that the effects of TIA may persist beyond resolution of focal symptoms. A further challenge is that there is debate concerning the clinical definition of TIA and the use of diagnostic neuroimaging studies and standardization of neuropsychological tests used to evaluate cognitive deficits in this population. Subtle changes in memory, attention, and problem-solving abilities may negatively influence an individual's ability to adopt positive health behaviors. Despite advances in the field, more research is needed; hence, the purpose of this article is to provide an overview of clinical factors for clinicians and researchers to consider when investigating cognitive deficits among post-TIA populations. Definitions of TIA are reviewed, and the importance of neuropsychological evaluation and neuroimaging correlates of TIA in establishing a positive diagnosis will be discussed. Nurses especially in advanced practice roles are uniquely positioned to assess and implement treatments in at-risk groups and therefore should be knowledgeable about these possible cognitive effects.

We read with interest the review by Huang et al. [1] regarding intravenous thrombolysis for minor stroke and rapidly improving symptoms (MRIS). Although this review attempts to address an important clinical dilemma faced by stroke physicians on a daily basis, we strongly feel that one should be cautious in accepting the conclusion regarding futility of intravenous thrombolysis in MRIS. Intravenously administered tissue plasminogen activator (IV-tPA) remains the only approved drug therapy for achieving arterial recanalization in acute ischemic stroke (AIS) and improves the chances of favorable outcome. However, numerous contraindications need to be carefully excluded before initiating thrombolysis. Minor stroke is one such important contraindication for withholding IV thrombolysis due to uncertain benefits. Although, it was not an explicit contraindication, the pivotal NINDs thrombolysis trial included only 58 patients with minor stroke. Interestingly, 2,971 patients with minor or rapidly improving strokes were excluded from thrombolysis [2]. Similarly, about one-third of the 93,517 patients arriving to the hospital within 2 h were not treated with IV-tPA solely because of the milder or rapidly improving stroke. In a recent meta-analysis, we have shown that patients with mild strokes derive benefit from intravenous thrombolysis (pooled odds ratio 1.319; 95 % confidence interval, 1.004–1.733; z = 1.987; p = 0.047) without any significant increase in mortality [3]. It is important to look into the possible reasons for contradictory reports regarding the benefits of IV-tPA in MRIS. Huang et al. [1] considered minor stroke and rapidly improving symptoms as representing one entity, largely owing to the similar etiopathogenic mechanism. Perhaps, this approach influenced the overall results. Rapidly improving stroke and mild stroke may not always represent the same clinical entity. Accordingly, rapidly improving symptoms are expected in patients with large artery occlusion that recanalises spontaneously while the neurological deficits in a lacunar stoke are often mild and may persist. An important reason for contradictory results among various studies on patients with MRIS is the heterogeneity of data that introduce bias due to the approach taken when choosing studies to include. For example, Huang included the case series by Strbian et al. [4] which did not have control group outcome and the study byMittal et al. [5] which did not report functional outcomes at 3 months. We feel that the current IV thrombolysis guidelines for mild or minor acute stroke are in need of revision to support the clinician who may feel that IV-tPA may benefit his patient, but are limited as the situation falls outside the published guidelines. Nonetheless, we congratulate Huang et al. on shedding light on this practically relevant aspect of acute stroke care. We look forward to the results of thrombolysis for minor ischemic stroke with proven acute symptomatic occlusion using Tenecteplase-tPA (TEMPO-1) trial, which is expected to put to rest the ambiguity faced by the front-line stroke neurologists. L. L. L. Yeo (&) R. Rathakrishnan P. R. Paliwal V. K. Sharma Division of Neurology, Department of Medicine, National University Hospital, 5 Lower Kent Ridge Road, 119074 Singapore, Singapore e-mail: leonardyeoll@gmail.com

Background: ICD-9-CM codes recorded in administrative databases are often used to identify patients with specific clinical conditions. We determined if there are variations in the accuracy of stroke and transient ischemic attack (TIA) ICD-9-CM codes based on hospital characteristics and stroke severity. Methods: We used the records of patients discharged from hospitals in the Paul Coverdell National Acute Stroke Program in 2013. Diagnosis categories included ischemic stroke, TIA, subarachnoid hemorrhage, and intracerebral hemorrhage. We compared the agreement between the principal ICD-9-CM code and attending physician’s clinical diagnosis. The effects of hospital characteristics and stroke severity (National Institutes of Health Stroke Scale score, NIHSS) on percent agreement were assessed. Results: Among 67,442 patient records with hospital characteristic data, agreement between ICD-9-CM codes and the clinical diagnosis for ischemic stroke was higher for hospitals with stroke units, stroke teams, larger numbers of beds, and locations in metropolitan areas (P<0.05) (Table). For 55,373 records with a documented NIHSS at admission, agreement was lower for mild ischemic strokes (NIHSS 0-7) compared with more severe strokes (P<0.001); disagreements were commonly due to the patient having a carotid endarterectomy (potentially reflecting continuity of care for a stroke event) or TIA rather than a stroke. Conclusion: Systematic variations in the accuracy of ICD-9-CM codes by hospital characteristics and stroke severity may affect case identification in epidemiologic studies and have implications for hospital-level quality metrics.

Continuous-wave (CW) Doppler sonography has proved to be a reliable tool both to detect subclavian stenosis or occlusion and to detect reversal of blood flow in the vertebral artery. This method is entirely atraumatic and in contrast to angiography allows investigation of asymptomatic patients and provides more representative data for epidemiological studies. The incidence of subclavian stenosis or occlusion was 1.15% among the 23,500 patients examined in our department between 1978 and 1985. Of the 272 patients with unilateral or bilateral subclavian stenosis or occlusion, 54% were asymptomatic with no subjective complaints and were normal upon neurological examination; 29% reported vertebrobasilar transient ischaemic attacks (TIAs), with or without concomitant TIAs or infarction in the vascular territory of the carotid arteries; and 17% complained of symptoms exclusively referring to the region of carotid blood supply. Reversal of blood flow in the ipsilateral vertebral artery was detected in 152 patients (56%). The incidence of neurological symptoms within this group was double that found in patients without steal. None of the patients suffered from permanent vertebrobasilar damage. In most cases, subclavian artery disease was due to atherosclerosis. For 13 patients an inflammatory, iatrogenic, traumatic, or congenital aetiology could be assumed. The marked preponderance of left-sided subclavian stenosis or occlusion, reported by others, could be confirmed among our patients, but was less pronounced for tight stenoses than for occlusions. Mild-to-moderate subclavian stenoses were about equally distributed on each side.