Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies

BACKGROUND

It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians.

METHODS

We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (rs) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference.

RESULTS

We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (rs=0.70 [95% CI, 0.68-0.72]). Concerning individual items, prehospital assessment of arm (rs=0.68) and leg (rs=0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (rs=0.31), abnormal speech (rs=0.50), and gaze deviation (rs=0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%).

CONCLUSIONS

The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.

Dual Antiplatelet Therapies and Causes in Minor Stroke or Transient Ischemic Attack: A Prespecified Analysis in the CHANCE-2 Trial

BACKGROUND

It is unclear whether patients with different stroke/transient ischemic attack etiologies benefit differently from gene-directed dual antiplatelet therapy. This study explored the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in transient ischemic attack or minor stroke with different causes in the CHANCE-2 trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II).

METHODS

This was a prespecified analysis of the CHANCE-2 trial, which enrolled 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles. Patients with centralized evaluation of TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification of large-artery atherosclerosis, small-vessel occlusion, and stroke of undetermined cause were included. The primary efficacy outcome was new stroke, and the primary safety outcome was severe or moderate bleeding, both within 90 days. Cox proportional hazards models were used to assess the interaction of TOAST classification with the effects of dual antiplatelet therapy with ticagrelor-aspirin versus clopidogrel-aspirin.

RESULTS

A total of 6336 patients were included in this study. In patients administered ticagrelor-aspirin and clopidogrel-aspirin, respectively, stroke recurred in 85 (9.8%) and 88 (10.7%) patients with large-artery atherosclerosis (hazard ratio, 0.86 [95% CI, 0.63-1.18]; P=0.34); 32 (3.6%) and 61 (7.0%) patients with small-vessel occlusion (hazard ratio, 0.51 [95% CI, 0.33-0.79]; P=0.002); and 68 (4.8%) and 87 (5.9%) patients with stroke of undetermined cause (hazard ratio, 0.80 [95% CI, 0.58-1.10]; P=0.17), with P=0.08 for the treatment×cause subtype interaction effect. There were no significant differences in severe or moderate bleeding events in patients with different cause and different treatment.

CONCLUSIONS

In this prespecified analysis of the CHANCE-2 trial, the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in preventing new stroke were consistent in patients with different causes. The influence of stroke cause on benefit of gene-guided antiplatelet therapy should be explored by further trials.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04078737.

Prevalence and Factors Associated with Atrial Fibrillation in Patients with Transient Ischemic Attack or Ischemic Stroke in Northern Vietnam

BACKGROUND

The prevalence and risk factors of atrial fibrillation (AF) in patients with transient ischemic attack (TIA) or ischemic stroke in Northern Vietnam are not well understood. This study aimed to estimate the prevalence and identify factors associated with AF in this population.

METHODS

A cross-sectional study was conducted on 2038 consecutive patients with TIA or ischemic stroke admitted to Bach Mai Hospital. AF was diagnosed using an electrocardiogram or Holter monitor. Logistic regression analyses were performed to determine the association between AF and risk factors.

RESULTS

Among the patients, 18.1% (95% CI: 16.46 to 19.85) had AF. Older age, renal dysfunction, valvular heart disease (VHD), and low ejection fraction were significantly associated with AF. Advanced age (per 10 years) (adjusted OR, aOR 1.39; 95% CI, 1.23 to 1.57), estimated glomerular filtration ratio decrease (per 10 mL/min/1.73 m2) (aOR 1.12; 95% CI, 1.06 to 1.17), VHD (aOR 9.59; 95% CI, 7.10 to 12.95), and low ejection fraction (<50%) (aOR 2.61; 95% CI, 1.62 to 4.21) had notable odds ratios for AF.

CONCLUSIONS

Atrial fibrillation is prevalent among patients with TIA or ischemic stroke in Northern Vietnam, surpassing rates in other Southeast Asian countries. Age, renal dysfunction, VHD, and low ejection fraction were significant risk factors for AF in this population.

Transient ischemic attack and coronary artery disease: a two-sample Mendelian randomization analysis

Background

Although observational studies have shown that patients who experienced transient ischemic attacks (TIAs) had a higher risk of coronary artery disease (CAD), the causal relationship is ambiguous.

Methods

We conducted a two-sample Mendelian randomization (MR) study to analyze the causal relationship between TIA and CAD using data from the FinnGen genome-wide association study. Analysis was performed using the inverse-variance weighted (IVW) method. The robustness of the results was evaluated using MR-Egger regression, the weighted median, MR pleiotropy residual sum, and outlier (MR-PRESSO) and multivariable MR analysis.

Results

Results from IVW random-effect model showed that TIA was associated with an increased risk of coronary artery atherosclerosis (OR 1.17, 95% CI 1.06-1.28, P = 0.002), ischemic heart disease (OR 1.15, 95% CI 1.04-1.27, P = 0.007), and myocardial infarction (OR1.15, 95% CI 1.02-1.29, P = 0.025). In addition, heterogeneity and horizontal pleiotropy were observed in the ischemic heart disease results, while the sensitivity analysis revealed no evidence of horizontal pleiotropy in other outcomes.

Conclusions

This MR study demonstrated a potential causal relationship between TIA and CAD. Further research should be conducted to investigate the mechanism underlying the association.

Limb-shaking transient ischemic attack misdiagnosed as focal seizure: A video case report

Content available: Video

Assessment Precision of CT Perfusion Imaging in the Detection of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Stroke, a prevalent medical emergency, comprises ischemic and hemorrhagic subtypes, with acute ischemic stroke (AIS) being a predominant type. The application of computed tomography perfusion (CTP) imaging has gained prominence due to its rapidity and accessibility in stroke evaluation. This study systematically reviews and conducts a meta-analysis of existing literature to assess the diagnostic accuracy of CTP in detecting AIS and predicting hemorrhagic transformation (HT). Employing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, an extensive search was conducted across electronic databases and relevant radiology journals. Studies conducted between 2007 and 2023 that fulfilled predetermined inclusion criteria underwent quality assessment using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS 2) tool. Cochrane diagnostic accuracy tools were used for data extraction. Thirteen studies involving a total of 1014 patients were included in the analysis. The diagnostic performance of CTP in predicting HT demonstrated high sensitivity (86.7%) and moderate specificity (77.8%), resulting in an overall accuracy of 79.1%. The negative predictive value (NPV) was notably high (92.9%), signifying its efficacy in excluding patients at risk of HT. The positive predictive value (PPV) was comparatively lower (60.3%), highlighting the need for clinical context when making thrombolysis decisions. The false positive rate was 16.2%, while the false negative rate was minimal (9.8%). Subgroup analysis underscored consistent sensitivity and specificity across diverse imaging metrics. The findings of this study emphasize the promising diagnostic accuracy of CTP imaging in predicting HT subsequent to AIS. This non-invasive technique can aid treatment decisions and patient management strategies. By effectively assessing perfusion status and offering predictive insights, CTP imaging improves stroke intervention choices, especially in identifying patients with a lower risk of HT.

A Neuro-Informatics Pipeline for Cerebrovascular Disease: Research Registry Development

BACKGROUND

Although stroke is well recognized as a critical disease, treatment options are often limited. Inpatient stroke encounters carry critical information regarding the mechanisms of stroke and patient outcomes; however, these data are typically formatted to support administrative functions instead of research. To support improvements in the care of patients with stroke, a substantive research data platform is needed.

OBJECTIVE

To advance a stroke-oriented learning health care system, we sought to establish a comprehensive research repository of stroke data using the Houston Methodist electronic health record (EHR) system.

METHODS

Dedicated processes were developed to import EHR data of patients with primary acute ischemic stroke, intracerebral hemorrhage (ICH), transient ischemic attack, and subarachnoid hemorrhage under a review board-approved protocol. Relevant patients were identified from discharge diagnosis codes and assigned registry patient identification numbers. For identified patients, extract, transform, and load processes imported EHR data of primary cerebrovascular disease admissions and available data from any previous or subsequent admissions. Data were loaded into patient-focused SQL objects to enable cross-sectional and longitudinal analyses. Primary data domains (admission details, comorbidities, laboratory data, medications, imaging data, and discharge characteristics) were loaded into separate relational tables unified by patient and encounter identification numbers. Computed tomography, magnetic resonance, and angiography images were retrieved. Imaging data from patients with ICH were assessed for hemorrhage characteristics and cerebral small vessel disease markers. Patient information needed to interface with other local and national databases was retained. Prospective patient outreach was established, with patients contacted via telephone to assess functional outcomes 30, 90, 180, and 365 days after discharge. Dashboards were constructed to provide investigators with data summaries to support access.

RESULTS

The Registry of Neurological Endpoint Assessments among Patients with Ischemic and Hemorrhagic Stroke (REINAH) database was constructed as a series of relational category-specific SQL objects. Encounter summaries and dashboards were constructed to draw from these objects, providing visual data summaries for investigators seeking to build studies based on REINAH data. As of June 2022, the database contains 18,061 total patients, including 1809 (10.02%) with ICH, 13,444 (74.43%) with acute ischemic stroke, 1221 (6.76%) with subarachnoid hemorrhage, and 3165 (17.52%) with transient ischemic attack. Depending on the cohort, imaging data from computed tomography are available for 85.83% (1048/1221) to 98.4% (1780/1809) of patients, with magnetic resonance imaging available for 27.85% (340/1221) to 85.54% (11,500/13,444) of patients. Outcome assessment has successfully contacted 56.1% (240/428) of patients after ICH, with 71.3% (171/240) of responders providing consent for assessment. Responders reported a median modified Rankin Scale score of 3 at 90 days after discharge.

CONCLUSIONS

A highly curated and clinically focused research platform for stroke data will establish a foundation for future research that may fundamentally improve poststroke patient care and outcomes.

Homoarginine Associates with Carotid Intima-Media Thickness and Atrial Fibrillation and Predicts Adverse Events after Stroke

Homoarginine is associated with cardio- and cerebrovascular morbidity and mortality. However, the underlying pathomechanisms remain elusive. Here, we evaluated the association of homoarginine with adverse events (i.e., death, stroke, and myocardial infarction) and carotid intima-media thickness (cIMT) in stroke patients. In the prospective bioMARKers in STROKE (MARK-STROKE) cohort, patients with acute ischemic stroke or transient ischemic attack (TIA) were enrolled. Plasma homoarginine concentrations were analyzed and associated with clinical phenotypes in cross-sectional (374 patients) and prospective (273 patients) analyses. Adjustments for possible confounders were evaluated. A two-fold increase in homoarginine was inversely associated with the National Institutes of Health Stroke Scale (NIHSS) score at admission, cIMT, and prevalent atrial fibrillation (mean factor -0.68 [95% confidence interval (CI): -1.30, -0.07], -0.14 [95% CI: -0.22, -0.05]; and odds ratio 0.57 [95% CI: 0.33, 0.96], respectively). During the follow-up (median 284 [25th, 75th percentile: 198, 431] days), individuals with homoarginine levels in the highest tertile had fewer incident events compared with patients in the lowest homoarginine tertile independent of traditional risk factors (hazard ratio 0.22 [95% CI: 0.08, 0.63]). A lower prevalence of atrial fibrillation and a reduced cIMT pinpointed potential underlying pathomechanisms.

Malpractice Lawsuits Relating to Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review

Background and Purpose

Medical-legal claims for malpractice relating to the use of alteplase for acute ischemic stroke (AIS) are usually for failure to treat rather than for complications. The advent of mechanical thrombectomy (MT) as a standard of AIS treatment has added a new dimension to the medical-legal landscape as there is a need for the delivery of a higher level of care creating the potential for delays and errors associated with such treatment. Information on causes of malpractice related to mechanical thrombectomy (MT) is currently lacking.

Methods

We conducted a systematic review of legal databases (Westlaw, LexisNexis, Google Scholar Case Law, and VerdictSearch) to identify medical malpractice cases with and without verdicts filed in the United States up to March 31, 2021 which pertained to performance or non-performance of MT for AIS. We collected various case characteristics, case outcomes, and root causes for malpractice claims.

Results

We found 25 cases, 16 of which alleged failure to treat with MT, 8 for harm due to delay in treatment and 1 case that alleged complications. Root causes included delay in vascular imaging, communication breakdowns, and transportation delays. Eight cases had an outcome in favor of the defendant, 9 in favor of the plaintiff, and 8 remained to be determined.

Conclusions

As with alteplase, malpractice allegations regarding MT for AIS are largely for failure to treat or delay in treatment as opposed to complications. Addressing root causes of diagnostic delay, communication breakdowns, and transportation delays may reduce subsequent malpractice risk.

Differences in Stroke Recurrence Risk Between Atrial Fibrillation Detected on ECG and 14-Day Cardiac Monitoring

BACKGROUND

Ischemic stroke and transient ischemic attack (TIA) standard-of-care etiological investigations include an ECG and prolonged cardiac monitoring (PCM). Atrial fibrillation (AF) detected after stroke has been generally considered a single entity, regardless of how it is diagnosed. We hypothesized that ECG-detected AF is associated with a higher risk of stroke recurrence than AF detected on 14-day Holter (PCM-detected AF).

METHODS

We conducted a retrospective, registry-based, cohort study of consecutive patients with ischemic stroke and TIA included in the London Ontario Stroke Registry between 2018 and 2020, with ECG-detected and PCM-detected AF lasting ≥30 seconds. We quantified PCM-detected AF burden. The primary outcome was recurrent ischemic stroke, ascertained by systematically reviewing all medical records until November 2022. We applied marginal cause-specific Cox proportional hazards models adjusted for qualifying event type (ischemic stroke versus TIA), CHA₂DS₂-VASc score, anticoagulation, left ventricular ejection fraction, left atrial size, and high-sensitivity troponin T to estimate adjusted hazard ratios for recurrent ischemic stroke.

RESULTS

We included 366 patients with ischemic stroke and TIA with AF, 218 ECG-detected, and 148 PCM-detected. Median PCM duration was 12 (interquartile range, 8.8-14.0) days. Median PCM-detected AF duration was 5.2 (interquartile range, 0.3-33.0) hours, with a burden (total AF duration/total net monitoring duration) of 2.23% (interquartile range, 0.13%-12.25%). Anticoagulation rate at the end of follow-up or at the first event was 83.1%. After a median follow-up of 17 (interquartile range, 5-34) months, recurrent ischemic strokes occurred in 16 patients with ECG-detected AF (13 on anticoagulants) and 2 with PCM-detected AF (both on anticoagulants). Recurrent ischemic stroke rates for ECG-detected and PCM-detected AF groups were 4.05 and 0.72 per 100 patient-years (adjusted hazard ratio, 5.06 [95% CI, 1.13-22.7]; P=0.034).

CONCLUSIONS

ECG-detected AF was associated with 5-fold higher adjusted recurrent ischemic stroke risk than PCM-detected AF in a cohort of ischemic stroke and TIA with >80% anticoagulation rate.

External Validation of the Nelson Equation for Kidney Function Decline in Patients with Acute Ischemic Stroke or Transient Ischemic Attack

Background

There is a close brain-kidney interaction following ischemic cerebrovascular disease. The new-onset kidney injury after stroke leads to severe neurological deficits and poor functional outcomes. We aimed to validate the Nelson equation for predicting the new-onset and long-term kidney function decline in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA).

Methods

A total of 3169 patients were enrolled in the Third China National Stroke Registry, whose baseline estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m². The outcome of interest was the incident eGFR< 60 mL/min/1.73 m² at 3 months. The prediction equation of participants with or without diabetes was validated respectively. The receiver operating characteristic curve (AUC) evaluated prediction performance. The Delong test compared the Nelson equation performance with the O'Seaghdha equation and the Chien equation. Continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were determined to evaluate the incremental effect.

Results

During the 3-mo follow-up period, among 1151 patients with diabetes, there were 31 cases (2.7%) of reduced eGFR. Meanwhile, among 2018 non-diabetic patients, there were 23 cases (1.1%) of reduced eGFR. The Nelson equation showed good discrimination and was well-calibrated in patients with diabetes (AUC 0.82, Hosmer-Lemeshow test p = 0.67) or without diabetes (AUC 0.82, Hosmer-Lemeshow test p = 0.09). The performance of the Nelson equation was superior to other equation, as increased continuous NRI (diabetic, 0.64; non-diabetic, 1.13) and IDI (diabetic, 0.10; non-diabetic, 0.13) to the Chien equation.

Conclusion

The Nelson equation reliably predicted the risks of the new-onset and long-term kidney function decline in patients with AIS or TIA, which could help clinicians screen high-risk patients and improve clinical care.

A Rare Case of Moyamoya Disease in a Patient With Sickle Cell Disease

Moyamoya disease (MMD) is an infrequent progressive cerebral pathology that primarily affects the branches of the internal carotid artery, resulting in stenosis of the internal carotid artery and subsequent development of multiple collateral vessels. As the disease advances, it manifests through various clinical presentations, including stroke and seizures. Prevalence rates indicate a higher incidence among individuals of Eastern Asian descent, while it is notably less common among African Americans. This case report describes the clinical presentation of a 32-year-old African-American female with a past medical history of sickle cell disease and stroke, who sought medical attention at our institution due to a deterioration in left-sided weakness and left wrist drop. Although the patient had been diagnosed with MMD at an early age, no previous medical records were available. Diagnostic evaluation utilizing brain imaging techniques confirmed the presence of MMD, exhibiting minute collaterals that had replaced the middle cerebral artery.

Lambl's Excrescence as an Etiology of Thromboembolism: Case Report and Literature Review

Lambl's excrescence (LE), a rare thin linear fibrous thread of collagen and elastic fibrous tissue originating at closure margins of heart valve leaflets is considered a rare cause of thromboembolism, causing ischemic stroke, transient ischemic attack (TIA), acute coronary syndrome, or peripheral thromboembolism. The gold standard for diagnosing LE is transesophageal echocardiography (TEE). Due to the rarity of the disease and lack of significant research, no guidelines exist about the management of LE. Twenty-two papers about LE were reviewed, focusing on the management aspect aiming to assist in guideline publication. Articles were retrieved using PubMed database using "Lambl's excrescences" as a keyword. All free full text papers up to 2023 were retrieved. In this report, we present the first publication of a case of a TIA secondary to LE in the United Arab Emirates. A 53-year-old male presented with transient attacks of left monocular blindness with complete recovery 2 days later. Extensive stroke work-up was negative, except for TEE, which showed an echo-dense linear mobile structure attached to the aortic surface of the aortic valve closure margin, suggesting LE. As no guidelines exist on the management of LE, the patient was started on Clopidogrel 75 mg daily and remained asymptomatic for 2 years. After reviewing the literature, we suggest the use of Aspirin for patients with ⩾1 embolic event attributed to LE while not on antiplatelets or anticoagulants, as it is the most used and recommended treatment option and is effective in preventing recurrent thromboembolic events.

Chronic Low Back Pain and Incident Transient Ischemic Attack and Stroke in General Practices in Germany

The aim was to investigate the association between chronic low back pain (CLBP) and incident transient ischemic attack (TIA) and stroke in Germany. The present retrospective cohort study included adults aged ≥18 years who were diagnosed for the first time with CLBP in one of 1198 general practices in Germany in 2005-2019 (index date). Patients without CLBP were matched to those with CLBP (1:1) using a propensity score based on age, sex, the index year, the number of medical consultations per year during the follow-up, and the number of years of follow-up. In patients without CLBP, the index date was a randomly selected visit date. Both groups were followed for up to 10 years. There were 159,440 patients included in the study (mean (SD) age: 52.1 (16.5) years; 51.5% women). Within 10 years of the index date, 6.5% and 5.9% of patients with and without CLBP were diagnosed with TIA or stroke, respectively (log-rank p-value < 0.001). The Cox regression analysis corroborated these results, as there was a significant association between CLBP and incident TIA or stroke (HR = 1.28, 95% CI = 1.22-1.35). CLBP was positively and significantly associated with incident TIA and stroke in Germany. More research is warranted to better understand this relationship.

Lasting impairments following transient ischemic attack and minor stroke: a systematic review protocol

Introduction

The focus on medical management and secondary prevention following Transient Ischemic Attack (TIA) and minor stroke is well-established. Evidence is emerging that people with TIA and minor stroke can experience lasting impairments as fatigue, depression, anxiety, cognitive impairment, and communication difficulties. These impairments are often underrecognized and inconsistently treated. Research in this area is developing rapidly and an updated systematic review is required to evaluate new evidence as it emerges. This living systematic review aims to describe the prevalence of lasting impairments and how they affect the lives of people with TIA and minor stroke. Furthermore, we will explore whether there are differences in impairments experienced by people with TIA compared to minor stroke.

Methods

Systematic searches of PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Libraries will be undertaken. The protocol will follow the Cochrane living systematic review guideline with an update annually. A team of interdisciplinary reviewers will independently screen search results, identify relevant studies based on the defined criteria, conduct quality assessments, and extract data. This systematic review will include quantitative studies on people with TIA and/or minor stroke that report on outcomes in relation to fatigue, cognitive and communication impairments, depression, anxiety, quality of life, return to work/education, or social participation. Where possible, findings will be grouped for TIA and minor stroke and collated according to the time that follow-up occurred (short-term < 3 months, medium-term 3-12 months, and long-term > 12 months). Sub-group analysis on TIA and minor stroke will be performed based on results from the included studies. Data from individual studies will be pooled to perform meta-analysis where possible. Reporting will follow the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) guideline.

Perspectives

This living systematic review will collate the latest knowledge on lasting impairments and how these affect the lives of people with TIA and minor stroke. It will seek to guide and support future research on impairments emphasizing distinctions between TIA and minor stroke. Finally, this evidence will allow healthcare professionals to improve follow-up care for people with TIA and minor stroke by supporting them to identify and address lasting impairments.

Ninety-Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke

Background For patients with atrial fibrillation seen in the emergency department (ED) following a transient ischemic attack (TIA) or minor stroke, the impact of initiating oral anticoagulation immediately rather than deferring the decision to outpatient follow-up is unknown. Methods and Results We conducted a planned secondary data analysis of a prospective cohort of 11 507 adults in 13 Canadian EDs between 2006 and 2018. Patients were eligible if they were aged 18 years or older, with a final diagnosis of TIA or minor stroke with previously documented or newly diagnosed atrial fibrillation. The primary outcome was subsequent stroke, recurrent TIA, or all-cause mortality within 90 days of the index TIA diagnosis. Secondary outcomes included stroke, recurrent TIA, or death and rates of major bleeding. Of 11 507 subjects with TIA/minor stroke, atrial fibrillation was identified in 11.2% (1286, mean age, 77.3 [SD 11.1] years, 52.4% male). Over half (699; 54.4%) were already taking anticoagulation, 89 (6.9%) were newly prescribed anticoagulation in the ED. By 90 days, 4.0% of the atrial fibrillation cohort had experienced a subsequent stroke, 6.5% subsequent TIA, and 2.6% died. Results of a multivariable logistic regression indicate no association between prescribed anticoagulation in the ED and these 90-day outcomes (composite odds ratio, 1.37 [95% CI, 0.74-2.52]). Major bleeding was found in 5 patients, none of whom were in the ED-initiated anticoagulation group. Conclusions Initiating oral anticoagulation in the ED following new TIA was not associated with lower recurrence rates of neurovascular events or all-cause mortality in patients with atrial fibrillation.

The Coronavirus Double Threat: A Rare Presentation of Chest Pain in a Young Female

Severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) led to global coronavirus disease 2019 (COVID-19) pandemic. The virus affects the respiratory system predominantly and has resulted in multiorgan complications. Myocarditis, acute coronary syndrome (ACS), cardiogenic shock, and sudden cardiac death were common cardiac manifestations of COVID-19. Spontaneous coronary artery dissection (SCAD) is a rare form of coronary artery disease that is previously reported in patients with COVID-19. SCAD usually occurs in a middle-aged woman with few or without any cardiovascular risk factors. The gold standard for its diagnosis is coronary angiography. The SCAD treatment recommendations depend on the hemodynamic status: conservative therapy in hemodynamically stable SCAD patients and urgent revascularization in hemodynamically unstable SCAD patients. The exact pathophysiology of COVID-19 associated with SCAD is unknown. It is considered a combination of systemic inflammatory response and localized vascular inflammation. The case reported is of COVID-19-associated SCAD in a patient with no history of cardiovascular disease later complicated by the transient ischemic attack (TIA) and left ventricular (LV) thrombus.

Cost-effectiveness of testing for CYP2C19 loss-of-function carriers following transient ischemic attack/minor stroke: A Canadian perspective

BACKGROUND

The CHANCE-2 study compared 3 weeks of aspirin-ticagrelor to aspirin-clopidogrel in CYP2C19 loss-of-function (LOF) allele carriers following a transient ischemic attack (TIA)/minor stroke and demonstrated a modestly lower risk of stroke recurrence with aspirin-ticagrelor. This stroke protection was largely for minor stroke and came at an increased risk of bleeding. The cost-effectiveness of implementing testing for LOF allele status to personalize antiplatelet regimen for secondary stroke prevention after a TIA/minor stroke in the Canadian health care context is unknown.

METHODS

Cost-effectiveness analysis using a decision-analytic Markov cohort model with a lifetime horizon was performed to determine the costs and health benefits of testing for LOF allele status compared with no testing (current standard of care). The population of interest was patients living in Canada who suffered a TIA/minor stroke. Outcomes of interest were life-years gained (LYG), quality-adjusted life years (QALY) gained, costs (reported in 2022 Canadian dollars), and the incremental cost-effectiveness ratio (ICER). We adopted the perspective of the Federal, Provincial, and Territorial Ministries of Health and used a 1.5% annual discount rate. Sensitivity analyses were performed to assess uncertainty.

RESULTS

Compared to standard of care, LOF allele testing leads to 0.14 LYG (undiscounted), 0.12 QALYs gained (undiscounted), and additional lifetime costs of CAD$432 (discounted) per patient. The ICER of the LOF allele testing strategy is CAD$4310 per QALY gained compared with standard of care. The probabilistic sensitivity analyses demonstrated that LOF allele testing was cost-effective in more than 99.99% of simulations using a willingness-to-pay threshold of CAD$50,000 per QALY.

CONCLUSION

Based on available evidence, testing for LOF allele followed by short duration 3 weeks of aspirin-ticagrelor compared to standard-of-care aspirin-clopidogrel can lead to prolonged life and improved quality of life and can be considered very cost-effective when compared with other well-accepted technologies in health and medicine.

Transient Ischemic Attack in a Patient With Poland Syndrome With Dextrocardia

This report discusses the case of a patient with a past medical history of Poland syndrome and dextrocardia who was admitted for a transient ischemic attack. Poland syndrome is a rare genetic condition characterized by underdevelopment of chest wall musculature that presents with a variety of associations that may or may not be present in each case. This case report intends to discuss a unique presentation of Poland syndrome with dextrocardia, one of the rare conditions associated with Poland syndrome, as well as the treatment of Poland syndrome as a whole and possible associated complications.

Retrospective Study of Normal Variations in Vertebral Artery on Computed Tomography Angiography With Special Emphasis on Relevant Embryology

Background The vertebral arteries (VA) nourish the posterior cerebral circulation. Planning neck and cervical interventions like drilling and instrumentation, which involves VA manipulation, require an in-depth acquaintance with the normal and variant patterns encountered in the origin and course of the VA. Embryological events involved in forming these variant patterns can be correlated to their prior disposition in the lower vertebrate's understanding which becomes crucial while planning cervical interventions.  Study design This is a single-center, retrospective study.  Materials and methods The study involved 70 patients of both sexes and was done from September 2021 to February 2022 in the Department of Radiodiagnosis and Imaging at North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Meghalaya, India. The CT angiographies were studied for variations of VA under V1 - from origin to entrance into the foramen transversarium (FT), V2 - part inside FT, V3 - from its exit from FT till it pierces the cranial dura mater, and V4 - intracranial part. Further, VA was observed for its origin, dominance, level of entry in FT, and any associated anomalies.  Results The VA was found mostly to be codominant. There was an opposite directional relationship between the basilar artery curvature and the dominance of VA. The association of ischemic events with hypoplastic VA was more on the left side (66.67%). Left VA originated from the aorta in 4.3% of subjects. One case presented a dual origin of VA. The abnormal origin of the LVA from the aorta showed a higher rate of abnormal entry into FT which was also found to be statistically significant.  Conclusion Our study identifies and documents the anatomical variations present in VA specific to the population of northeast India by CT angiography and thus provides a much-needed reference for the healthcare professionals working in the field of Head and Neck interventions by providing opportunities further to understand these patterns for better diagnostic and therapeutic outcomes.

Recurrent Transient Ischemic Attacks in a Patient with Multiple Pacemaker Leads

Venous complications-specifically, stenosis and thrombosis-are both well-known complications of transvenous implantation of pacemakers and defibrillators. Although they are a well-recognized phenomenon, these complications are rarely of clinical significance. One of the most concerning complications is the development of superior vena cava (SVC) syndrome. Studies have found that the incidence of SVC syndrome varies from 1 in 3,100 to 1 in 650 patients. The azygos-hemiazygos venous system is the most commonly observed collateral. We report a case of a 71-year-old female patient who presented with stroke-like symptoms during the injection of agitated saline bubbles while performing an echo and was found to have an unusual venous collateral circulation formed as a result of brachiocephalic and SVC obstruction from multiple pacemaker leads. Our patient's clinical presentation was extremely unique, and we did not find any cases during our literature search reporting a similar presentation. Multiple collaterals formed between the brachiocephalic and subclavian veins, and bilateral pulmonary veins in our patient allowed the injected air bubbles from the venous system to reach the left side of the heart and eventually the cerebrovascular system, resulting in these transient ischemic attacks. These attacks eventually resolved as the air bubbles were dissolved and washed away by the continuous blood flow. It is advisable to monitor the patient for possible venous stenosis and SVC syndrome after any device insertion during regular device follow-up appointments.

7T MRI in transient ischemic attacks: Have we only seen the tip of the iceberg?

Transient ischemic attack (TIA) has gained significant attention recently due to the increased incidence of subsequent stroke. However, there are many nonvascular clinical mimics of TIA, creating a need for improved biomarkers to identify a vascular origin. Following the recent approval of ultra-high field (UHF) 7T MRI in clinical practice, several clinical studies have highlighted its added utility in neuroimaging compared to lower-field 1.5T and 3T MRI, particularly in epilepsy and multiple sclerosis. Our case series of three patients with TIA illustrates that 7T MRI can depict small areas of intracortical microhemorrhages and microinfarctions, which could not be resolved with 3T or 1.5T MRI. There are currently no reports of intracortical localization of microhemorrhages in patients with TIA. This discovery may enhance our understanding and characterization of cerebrovascular abnormalities in TIAs. In addition, UHF imaging could potentially be utilized to distinguish transient neurological episodes secondary to cerebrovascular events from other differential considerations. Our cases highlight the underestimation of imaging abnormalities in cases of TIA and support the potential expanded application of clinical 7T to assess patients with TIA. Future studies are necessary at 7T redundant to determine the true incidence of such lesions in TIA and to examine the correlation between cortical microhemorrhages and subsequent ischemic stroke, hemorrhagic events, and neurocognitive impairment.

Multiple sleep-wake disturbances after stroke predict an increased risk of cardio-cerebrovascular events or death - a prospective cohort study

BACKGROUND

In the general population, sleep-wake disturbances (SWD) have been shown to increase the risk of cardio- and cerebrovascular events (CCE) including death. Systematic studies on the effect of SWD on the risk of CCE in patients with stroke are lacking.

METHODS

Patients with acute ischemic stroke or transient ischemic attack (TIA) were prospectively recruited. Four SWD were analyzed: 1) sleep-disordered breathing (SDB) with respirography, 2) insomnia (by insomnia severity index, ISI), 3) restless legs syndrome (RLS, by International RLS Study Group rating scale) and 4) self-estimated sleep duration at 1 and 3 months. A "sleep burden index" as the mean of z-transformed values from assessments of these four SWD was created. The occurrence of CCE was recorded over a follow-up of 3.2±0.3 years (mean±standard deviation).

RESULTS

We assessed 437 patients (87% ischemic stroke, 13% TIA, 64% males) with a mean age of 65.1±13.0 years. SDB (respiratory event index, REI≥5) was present in 66.2% thereof. Insomnia (ISI≥10), RLS and extreme sleep duration affected 26.2%, 6.4% and 13.7% of the patients 3-month post-stroke. Seventy out of the 437 (16%) had at least one CCE during the follow-up. The sleep burden index was associated with a higher risk for subsequent CCE including death (Odds Ratio = 1.80 per index unit, 95% CI: 1.19-2.72, p=0.0056).

CONCLUSION

The presence of multiple SWDs constitutes a risk for subsequent CCE (including death) within the first three years following stroke. Larger systematic studies should assess the sleep burden index' utility for patients' risk stratification in clinical practice.