National Stroke Association guidelines for the management of transient ischemic attacks

Risk of New-Diagnosed Atrial Fibrillation After Transient Ischemic Attack

Background

Transient ischemic attack (TIA) provides a unique opportunity to optimize secondary preventive treatments to avoid subsequent ischemic stroke (SIS). Although atrial fibrillation (AF) is the leading cause of cardioembolism in IS and anticoagulation prevents stroke recurrence (SR), limited data exists about the risk of new-diagnosed AF (NDAF) after TIA and the consequences of the diagnostic delay. The aim of our study was to determine this risk in a cohort of TIA patients with long-term follow-up.

Methods

We carried out a prospective cohort study of 723 consecutive TIA patients from January 2006 to June 2010. Median follow-up was 6.5 (5.0–9.6) years. In a subgroup of 204 (28.2%) consecutive patients, a panel of biomarkers was assessed during the first 24 h of the onset of symptoms. Multivariate analyses were performed to find out the associated factors of NDAF. Kaplan-Meier analysis was also performed to analyzed risk of SIS.

Results

NDAF was indentified in 116 (16.0%) patients: 42 (36.2%) during admission, 18 (15.5%) within first year, 29 (25%) between one and five years and 27 (23.3%) beyond 5 years. NDAF was associated with sex (female) [hazard ratio (HR) 1.61 (95% CI, 1.07- 2.41)], age [[HR 1.05 (95% CI, 1.03–1.07)], previous ischemic heart disease (IHD) [HR 1.84, (95% CI 1.15–2.97)] and cortical DWI pattern [HR 2.81 (95% CI, 1.87–4.21)]. In the Kaplan-Meier analysis, NT-proBNP ≥ 218.2 pg/ml (log-rank test P < 0.001) was associated with significant risk of NDAF during the first 5 years of follow-up. Patients with NDAF after admission and before 5 years of follow-up had the highest risk of SIS (P = 0.002).

Conclusion

The risk of NDAF after TIA is clinically relevant. We identified clinical and neuroimaging factors of NDAF. In addition, NT-proBNP was related to NDAF. Our results can be used to evaluate the benefit of long-term cardiac monitoring in selected patients.

Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

BACKGROUND

Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably.

OBJECTIVES

We sought to identify factors associated with the decision to admit patents with TIA.

DESIGN

We conducted a secondary analysis of a prior study's data including semi-structured interviews, administrative data, and chart review.

PARTICIPANTS

We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011.

APPROACH

For the qualitative data, we focused on interviewees' responses to the prompt: "Tell me what influences you in the decision to or not to admit TIA patients." We used administrative data to identify admission rates and chart review data to identify ABCD² scores (a tool to classify stroke risk after TIA).

KEY RESULTS

Providers' decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD² score, and concerns about facilities' ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD² scores and related guidelines in admission decision-making.

CONCLUSIONS

Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians' uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.

Japanese Versus Non-Japanese Patients with Transient Ischemic Attack or Minor Stroke: Subanalysis of TIA registry.org

BACKGROUND

TIAregistry.org is an international cohort of patients with transient ischemic attack (TIA) or minor stroke within 7 days before enrollment in the registry. Main analyses of 1-year follow-up data have been reported.⁵ We conducted subanalysis on the baseline and 1-year follow-up data of Japanese patients.

METHODS

The patients were classified into 2 groups based on Japanese ethnicity, Japanese (345) and non-Japanese (3238), and their baseline data and 1-year event rates were compared. We also determined risk factors and predictors of 1-year stroke.

RESULTS

Current smoking, regular alcohol drinking, intracranial arterial stenosis, and small vessel occlusion; and hypertension, dyslipidemia, coronary artery disease, and extracranial arterial stenosis were more and less common among Japanese patients, respectively. Stroke risk was higher and TIA risk was lower at 1-year follow-up among Japanese patients. The baseline risk factors for recurrent stroke were diabetes, alcohol drinking, and large artery atherosclerosis. Independent predictors of 1-year stroke risk were prior congestive heart failure and alcohol consumption.

CONCLUSIONS

The two populations of patients featured differences in risk factors, stroke subtypes, and outcome events. Predictors of recurrent stroke among Japanese patients included congestive heart failure and regular alcohol drinking. Strategies to attenuate residual risk of stroke aside from adherence to current guidelines should take our Japanese-patient specific findings into account.

A challenge for psychocardiology: Addressing the causes and consequences of patients' perceptions of enduring somatic threat

The enduring somatic threat (EST) model of posttraumatic stress disorder (PTSD) due to life-threatening medical events suggests that PTSD-like symptoms represent patients' sensitization to cues of ongoing threat in the body. In this article, we review research on the prevalence and consequences of such reactions in cardiovascular disease patients, discuss early tests of the EST model, and then report a new test of the EST model in 143 patients enrolled during their first acute coronary syndrome (ACS; i.e., non-ST elevation myocardial infarction or unstable angina-colloquially, "heart attack"). Invasive coronary revascularization procedures are commonly used to reduce secondary ACS risk and may reduce patients' EST, as revascularized patients often report being "cured." We assessed ACS patients' initial threat perceptions during emergency department (ED) evaluation and followed them for 1 month for PTSD symptoms (specific for ACS, by telephone). We compared PTSD symptoms in participants who were revascularized (n = 65), catheterized but not revascularized (n = 35), and medically managed (n = 43). PTSD symptoms were lower for revascularized versus medically managed participants (B = -5.32, 95% confidence interval [-9.77, -0.87]), t(98.19) = -2.37, p = .020. In a multiple regression model adjusted for clinical and psychosocial covariates, the interaction of threat perception in the ED and ACS management group was significant (greater ED threat predicted greater 1-month PTSD symptoms only in medically managed participants). These findings offer further support for the EST model and suggest that psychological interventions to preempt patients' development of EST should be considered in the hospital. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Use of Antiplatelet Agents in the Neurosurgical Patient

Antiplatelet agents used to treat neurovascular disease include aspirin; P2Y12 receptor antagonists clopidogrel, prasugrel, and ticagrelor; ADP antagonist ticlopidine; phosphodiesterase inhibitor dipyridamole; and glycoprotein IIb/IIIa inhibitors abciximab, eptifibatide, and tirofiban. Numerous studies have been performed evaluating their efficacy in stroke, extracranial carotid artery disease and dissection, intracranial atherosclerotic disease, and moyamoya disease. The rapid technological advancements in endovascular neurosurgical devices have also made antiplatelet therapy a necessary part of treating intracranial aneurysms. This article presents the relevant data supporting the use of antiplatelet agents in vascular neurosurgery and recommendations based on the described studies.

Is Parenteral Levothyroxine Therapy Safe in Intractable Hypothyroidism?

CASE

A 32-year old woman was admitted to the hospital due to intractable hypothyroidism refractory to high dose of oral l-thyroxine therapy. She underwent total thyroidectomy and radioactive iodine therapy due to papillary thyroid cancer. After excluding poor adherence to therapy and malabsorption, levothyroxine absorption test was performed. No response was detected. Transient neurologic symptoms developed during the test. She developed 3 attacks consisting of neurologic symptoms during high dose administration. The patient was considered a case of isolated l-thyroxine malabsorption. She became euthyroid after intramuscular twice weekly l-thyroxine therapy.

DISCUSSION

There are a few case reports regarding isolated l-thyroxine. We report successful long term results of twice weekly administered intramuscular l-thyroxine therapy. We also draw attention to neurologic side effects of high dose l-thyroxine therapy.

A shorter system delay for haemorrhagic stroke than ischaemic stroke among patients who use emergency medical service

OBJECTIVES

We compare various aspects in the early chain of care among patients with haemorrhagic stroke and ischaemic stroke.

MATERIALS & METHODS

The Emergency Medical Services (EMS) and nine emergency hospitals, each with a stroke unit, were included. All patients hospitalised with a first and a final diagnosis of stroke between 15 December 2010 and 15 April 2011 were included. The primary endpoint was the system delay (from call to the EMS until diagnosis). Secondary endpoints were: (i) use of the EMS, (ii) delay from symptom onset until call to the EMS; (iii) priority at the dispatch centre; (iv) priority by the EMS; and (v) suspicion of stroke by the EMS nurse and physician on admission to hospital.

RESULTS

Of 1336 patients, 172 (13%) had a haemorrhagic stroke. The delay from call to the EMS until diagnosis was significantly shorter in haemorrhagic stroke. The patient's decision time was significantly shorter in haemorrhagic stroke. The priority level at the dispatch centre did not differ between the two groups, whereas the EMS nurse gave a significantly higher priority to patients with haemorrhage. There was no significant difference between groups with regard to the suspicion of stroke either by the EMS nurse or by the physician on admission to hospital.

CONCLUSIONS

Patients with a haemorrhagic stroke differed from other stroke patients with a more frequent and rapid activation of EMS.

Can I Send This Patient with Stroke Home? Strategies Managing Transient Ischemic Attack and Minor Stroke in the Emergency Department

BACKGROUND

While transient ischemic attack and minor stroke (TIAMS) are common conditions evaluated in the emergency department (ED), there is controversy regarding the most effective and efficient strategies for managing them in the ED. Some patients are discharged after evaluation in the ED and cared for in the outpatient setting, while others remain in an observation unit without being admitted or discharged, and others experience prolonged and potentially costly inpatient admissions.

OBJECTIVE OF THE REVIEW

The goal of this clinical review was to summarize and present recommendations regarding the disposition of TIAMS patients in the ED (e.g., admission vs. discharge).

DISCUSSION

An estimated 250,000 to 300,000 TIA events occur each year in the United States, with an estimated near-term risk of subsequent stroke ranging from 3.5% to 10% at 2 days, rising to 17% by 90 days. While popular and easy to use, reliance solely on risk-stratification tools, such as the ABCD2, should not be used to determine whether TIAMS patients can be discharged safely. Additional vascular imaging and advanced brain imaging may improve prediction of short-term neurologic risk. We also review various disposition strategies (e.g., inpatient vs. outpatient/ED observation units) with regard to their association with neurologic outcomes, such as 30-day or 90-day stroke recurrence or new stroke, in addition to other outcomes, such as hospital length of stay and health care costs.

CONCLUSIONS

Discharge from the ED for rapid outpatient follow-up may be a safe and effective strategy for some forms of minor stroke without disabling deficit and TIA patients after careful evaluation and initial ED workup. Future research on such strategies has the potential to improve neurologic and overall patient outcomes and reduce hospital costs and ED length of stay.

Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department

OBJECTIVE

Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting.

METHODS

A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors.

RESULTS

Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals.

CONCLUSION

Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.

Severity of White Matter Lesions Correlates with Subcortical Diffusion-Weighted Imaging Abnormalities and Predicts Stroke Risk

BACKGROUND AND PURPOSE

The severity of white matter lesions (WMLs) has been strongly linked to small-vessel diseases or lacunar infarction. The present study aimed to investigate the correlation between severity of WMLs and distribution of diffusion-weighted imaging (DWI) hyperintensities, and to explore whether the severity of WMLs is an independent neuroimaging predictor of stroke risk after transient symptoms with infarction (TSI).

METHODS

We evaluated the presence and severity of WMLs on fluid-attenuated inversion recovery sequences using the age-related white matter changes scale and the location and size of hyperintensities on DWI sequences, respectively, in a prospective cohort study of TSI patients. The primary end point was recurrent stroke within 90 days.

RESULTS

A total of 191 consecutive TSI patients were eligible for inclusion in the present analysis. The average age of the patients was 57.3 ± 12.8 years. DWI abnormalities occurred more often in the deep white matter with increasing severity of WMLs (P < .001). During 90-day follow-up, Kaplan-Meier analysis showed that recurrent stroke was correlated to the severity of WMLs (P = .01). The Cox proportional hazards model revealed that WMLs were predictive of recurrent stroke (hazard ratio, 1.748; 95% confidence interval, 1.16-2.634; P = .008).

CONCLUSIONS

Severe WMLs were correlated with DWI hyperintensities in the deep white matter in TSI patients and contributed to an increased risk of recurrent stroke.

Neurologic Emergencies in the Elderly

Neurologic diseases are a major cause of death and disability in elderly patients. Due to the physiologic changes and increased comorbidities that occur as people age, neurologic diseases are more common in geriatric patients and a major cause of death and disability in this population. This article discusses the elderly patient presenting to the emergency department with acute ischemic stroke, transient ischemic attack, intracerebral hemorrhage, subarachnoid hemorrhage, chronic subdural hematoma, traumatic brain injury, seizures, and central nervous system infections. This article reviews the subtle presentations, difficult workups, and complicated treatment decisions as they pertain to our older patients."

Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke

In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010–2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006–08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States.

Update on the evaluation of transient vision loss

Transient vision loss may indicate underlying vascular disease, including carotid occlusion and thromboembolism, or it may have a more benign etiology, such as migraine or vasospasm. This review focuses on the differential diagnosis and workup of patients presenting with transient vision loss, focusing on several key areas: the relationship to thromboembolic vascular disease, hypercoagulable testing, retinal migraine, and bilateral vision loss. The objective is to provide the ophthalmologist with information on how to best manage these patients. Thromboembolic etiologies for transient vision loss are sometimes managed with medications, but when carotid surgery is indicated, earlier intervention may prevent future stroke. This need for early treatment places the ophthalmologist in the important role of expediting the management process. Hospital admission is recommended in patients presenting with transient symptoms within 72 hours who meet certain high-risk criteria. When the cause is giant cell arteritis, ocular ischemic syndrome, or a cardioembolic source, early management of the underlying condition is equally important. For nonthromboembolic causes of transient vision loss such as retinal migraine or retinal vasospasm, the ophthalmologist can provide reassurance as well as potentially give medications to decrease the frequency of vision loss episodes.

TIA Management: Should TIA Patients be Admitted? Should TIA Patients Get Combination Antiplatelet Therapy?

Transient ischemic attack (TIA) has gained increasing attention over the last 2 decades with the realization that the condition is common, portends potentially serious consequences, and, when identified early, can be evaluated and treated to modify future risk. In this review, we examine the issues of whether all TIA patients need admission and whether such patients should receive short-term dual antiplatelet therapy. Not all patients require admission if evaluation and treatment are done promptly. There may be a role for dual antiplatelet therapy, but the results of further clinical trials will help provide better clarity on which patients are the best candidates for this treatment.

Predictors of anxiety after stroke: a systematic review of observational studies

BACKGROUND

Anxiety disorders or symptoms are relatively common after stroke. A better understanding of the predictors of anxiety in stroke patients may improve the management of these disorders. The current review was conducted to determine the predictors of anxiety after stroke.

METHODS

Relevant articles concerning population, hospital, or rehabilitation-based studies were identified by searching 10 electronic databases up to May 2014. Methodological quality appraisal, including the validity of prognostic models and data extraction were conducted by 3 reviewers.

RESULTS

A total of 18 studies were identified. Data from 3 population-based studies including 8130 patients, 8 hospital-based studies including 1199 patients, and 7 rehabilitation-based studies including 1103 patients were evaluated. Prestroke depression, stroke severity, early anxiety, and dementia or cognitive impairment after stroke were the main predictors of poststroke anxiety. Older age, physical disability or impairment, and use of antidepressant drugs were not associated with the presence of anxiety. Limitations of studies included wide variation in screening tools and cutoff scores, variability in the time frame of screening for anxiety, use of extensive exclusion criteria, and questionable statistical internal and external validity of the models.

CONCLUSIONS

Lack of methodological and statistical rigor affects the validity of proposed models to predict anxiety after stroke. Future research should focus on testing proposed models on both internal and external samples to ultimately inform future clinical practice.

Yizhi Xingnao prescription improves the cognitive function of patients after a transient ischemic attack

Patients with mild cognitive impairment after a transient ischemic attack were included in this study. They were treated with Yizhi Xingnao prescription, ergoloid mesylates or aspirin for 60 days. Evaluation using the Montreal Cognitive Assessment Scale showed that cognitive function was significantly improved in all patients, especially after the combined treatment of Yizhi Xingnao and aspirin. The scores from the Montreal Cognitive Assessment Scale were improved overall and the effective treatment rate was as high as 79%, which was higher than patients treated with a combination of ergoloid mesylates and aspirin, or aspirin alone. Our experimental findings indicate that Yizhi Xingnao prescription can improve mild cognitive impairment after a transient ischemic attack, and that it is more effective than ergoloid mesylates.

Recommendations for the evaluation and management of observation services: a consensus white paper: the Society of Cardiovascular Patient Care

Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. A well-structured observation program will help hospitals reduce the number of inappropriate, costly inpatient admissions while avoiding the potential of inappropriate discharges. Observation medicine is a complicated multidimensional issue that has generated much confusion. This service is designed to provide the best possible patient care in a value-based purchasing environment where quality, cost, and patient satisfaction must continually be addressed. Observation medicine is a service not a status. Therefore, patients are admitted to the service as outpatients no matter whether they are placed in a virtual or dedicated observation unit. The key to a successful observation program is to determine how to maximize efficiencies. This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.

Transient ischaemic attack: a qualitative study of the long term consequences for patients

BACKGROUND

Transient ischaemic attack (TIA) is characterised by its transient nature with symptoms of neurological dysfunction resolving within 24 hours. The occurrence of TIA is a major risk factor for stroke with 10-15% of TIA patients going on to have ischaemic stroke. Internationally, recommendations for the management of TIA focus on the need for early diagnosis and medical management of the acute increased risk of ischaemic stroke. However there is a limited amount of evidence that some patients suffer enduring consequences as a result of this 'transient' event. This paper focusses on patients' long term lived experience following a TIA.

METHODS

Semi structured interviews were carried out with patients who had a TIA between two and 24 months previously. Participants were asked about their TIA, the advice and management received and any changes made as a result of the TIA. Interviews were recorded and transcribed verbatim. Thematic content analysis involved scrutinising transcripts to look for links and associations within and between accounts in a process similar to the grounded theory approach of open coding. The category of transience emerged and was explored in more detail to examine the enduring consequences of TIA.

RESULTS

Thirty nine patients aged between 31 and 89 years were interviewed. Accounts detailed the long term impact of the TIA and the subsequent 'at risk' status, on the physical and psychosocial wellbeing of participants. Some participants sought to proactively manage the consequences of their TIA but found it difficult to obtain the information and support they needed, whereas others felt that no further action was needed to prevent future stroke.

CONCLUSION

Current definitions conceptualise TIA as a transient event however our study suggests that some patients experienced long term consequences as a result of their TIA. These included anxiety and uncertainty in the light of their increased stroke risk. TIA patients need access to detailed, evidence based stroke prevention information from a credible source, and support to help them understand and apply the information over time, if they are to effectively self-manage the long term consequences of TIA and reduce their risk of future stroke.

An Update on Italian Stroke Organization Guidelines on Carotid Endarterectomy and Stenting

One hundred and fifty-three authors, 45 Italian scientific societies, and two Italian patients' associations participated in drafting the Italian Stroke Organization document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of the Italian Stroke Organization document, the main trials on carotid endoarterectomy and stenting were critically reviewed in order to formulate recommendations for these procedures. Recommendations are presented here for the referral of patients to either carotid endarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic.

Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death

INTRODUCTION

The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA.

METHODS

Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year.

RESULTS

We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified.

CONCLUSIONS

In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.

Physician clinical management strategies and reasoning: a cross-sectional survey using clinical vignettes of eight common medical admissions

BACKGROUND

Physicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions.

METHODS

We conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections.

RESULTS

Our sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies "always" or "most of the time" when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies.

CONCLUSIONS

For eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.

Differences in the knowledge and compliance with secondary prevention of stroke between transient ischaemic attack patients with and without subsequent stroke

AIMS AND OBJECTIVES

To evaluate the differences in the knowledge and compliance with secondary prevention of stroke between transient ischaemic attack patients with and without subsequent stroke.

BACKGROUND

No previous study has demonstrated whether there are differences in the knowledge and compliance with secondary prevention of stroke between transient ischaemic attack patients with and without subsequent stroke. If there are differences, the health education regarding the stroke knowledge should be conducted separately and differently for the two groups.

METHODS AND DESIGN

We consecutively recruited 355 transient ischaemic attack patients with/without subsequent stroke from our hospital from 1 December 2008-31 December 2011. There were 304 patients receiving health education both upon hospital discharge and 90 days after discharge. Through telephone interviews, six months after discharge, only 180 patients completed the survey to determine in detail their general knowledge and compliance with secondary prevention of stroke.

RESULTS

The transient ischaemic attack patients with subsequent stroke exhibited a higher identification rate of speech disorder, weakness and decreased sensation or inability to feel things, compared with those without subsequent stroke (76·1 vs. 66·3%, p < 0·05; 91·5 vs. 73·5%, p < 0·05; 62·2 vs. 46·9%, p < 0·05). The compliance rates to antiplatelet agents and statins therapy were higher in transient ischaemic attack patients with subsequent stroke compared with those without subsequent stroke (80·5 vs. 65·3%, p < 0·05; 53·7 vs. 35·7%, p < 0·05).

CONCLUSIONS

The transient ischaemic attack patients with subsequent stroke exhibit a higher identification rate of most of the warning signs of stroke and a better compliance with antiplatelet agents and statins therapy of stroke compared with those without subsequent stroke. Thus, we suggest that transient ischaemic attack patients should receive additional health education to increase their awareness of the harms of stroke.

RELEVANCE TO CLINICAL PRACTICE

Clinicians should be aware of conducting different health education to patients with transient ischaemic attack and stroke. Also, it is important to give health education to individualised patients based on their actual risk of stroke.

Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits

OBJECTIVE

The aim of the study was to assess the outcomes of carotid endarterectomy (CEA) performed in an urgent setting on acutely symptomatic patients selected through a very simple protocol.

METHODS

From January 2002 to January 2012, 193 symptomatic patients underwent CEA. Of these, 90 presented with acute symptoms, and after a congruous carotid stenosis was identified, underwent urgent operations (group 1): 27 patients had transient ischemic attack (group 1A), 52 patients had mild to moderate stroke (group 1B), and 11 patients had stroke in evolution (group 1C). The remaining 103 patients with a nonrecent neurologic deficit were treated by elective surgery in the same period (group 2). End points were 30-day neurologic morbidity and mortality.

RESULTS

The median delay of urgent CEA (U-CEA) from deficit onset was 48 hours (interquartile range, 13-117 hours). Groups 1 and 2 were comparable in demographics. Acute patients showed a higher rate of stroke at presentation (70% vs 37%; P = .001) and of history of coronary artery disease (30% vs 13.5%; P = .007). Acute patients sustained six postoperative strokes (6.6%). Neurologic outcomes were correlated to clinical presentation: no strokes occurred in group 1A patients, and 5.8% group 1B patients and 27.3% group 1C patients had postoperative stroke (P < .01). Postoperative mortality was 4.4% for U-CEA: one fatal myocardial infarction, one intracranial hemorrhage, and two thromboembolic strokes. Elective patients sustained four postoperative strokes (3.9%), with one death (0.9%) as a consequence of hyperperfusion cerebral edema. U-CEAs performed ≤48 hours from symptom onset had a lower postoperative stroke rate than those performed >48 hours (4.4% vs 8.8%; P = .3). Among patients presenting with a stroke (group 1B), the National Institutes of Health Stroke Scale (NIHSS) assessment at discharge showed improvement in 79% (although only 25% had ≥4 points in reduction), stability in 17%, and deterioration in 4%. Patients with moderate stroke were slightly better in NIHSS improvement than those with mild stroke (median NIHSS variation at discharge, -3 vs -1; P = .001).

CONCLUSIONS

Our results with U-CEA confirm that this population has a higher risk profile compared with elective surgery. The type of acute presentation is correlated with perioperative risk. U-CEA was safe when performed on patients presenting with transient ischemic attack. An acceptable complication rate was achieved for patients with minor to moderate strokes. The poorest outcomes occurred in patients presenting with stroke in evolution: U-CEA in these patients should be offered with extreme caution, although we are aware that a conservative treatment may not grant a better prognosis.

A proposed roadmap for inpatient neurology quality indicators

BACKGROUND/PURPOSE

In recent years, there has been increasing pressure to measure and report quality in health care. However, there has been little focus on quality measurement in the field of neurology for conditions other than stroke and transient ischemic attack. As the number of evidence-based treatments for neurological conditions grows, so will the demand to measure the quality of care delivered. The purpose of this study was to review essential components of hospital performance measures for neurological disease and propose potential quality indicators for commonly encountered inpatient neurological diagnoses.

METHODS

We determined the most common inpatient neurological diagnoses at a major tertiary care medical center by reviewing the billing database. We then searched PubMed and the National Guidelines Clearinghouse to identify treatment guidelines for these conditions. Guideline recommendations with class I/level A evidence were evaluated as possible quality indicators.

RESULTS

We found 94 guidelines for 14 inpatient neurological conditions other than stroke and transient ischemic attack. Of these, 36 guidelines contained at least 1 recommendation with class I evidence. Based on these, potential quality indicators for intracerebral hemorrhage, subarachnoid hemorrhage, pneumococcal meningitis, coma following cardiac arrest, encephalitis, Guillain-Barre syndrome, multiple sclerosis, and benign paroxysmal positional vertigo are proposed.

CONCLUSIONS

There are several inpatient neurological conditions with treatments or diagnostic test routines supported by high levels of evidence that could be used in the future as quality indicators.

Results of an outpatient transient ischemic attack evaluation: a 90-day follow-up study

BACKGROUND

Transient ischemic attack (TIA) is common and precedes 15% of strokes. TIA should be managed as a time-sensitive illness to prevent a subsequent stroke. However, management of TIA is heterogeneous, with little consensus about its optimal assessment.

OBJECTIVE

The objective of this study was to determine the outcome of patients with TIA evaluated in the Emergency Department (ED) and managed as outpatients within a 90-day period after discharge.

METHODS

All patients with symptoms of TIA admitted to the ED were eligible for inclusion. Patients were evaluated by an Emergency Physician who followed a decision algorithm used in the selection of patients for discharge. The main outcome variable was the occurrence of stroke during the 90 days after discharge from the ED.

RESULTS

During a 1-year period, a total of 118 patients were evaluated for TIA in the ED, representing 1.4% of ED medical admissions: 56 (47.5%) were hospitalized and 62 (52.5%) were discharged and enrolled in the outpatient TIA management. Two (3.2%) of the discharged patients could not be contacted for follow-up. Among the patients managed as outpatients, one (1.7%) presented with an ischemic stroke and 3 (5%) experienced a subsequent TIA within a period of 90 days after discharge from the ED. The rate of stroke predicted from the ABCD2 score was 9.7% at 90 days.

CONCLUSION

The results of our study suggest that outpatient management of TIA, as described in our institution's guidelines, may be a safe and effective strategy, but further confirmatory studies should be performed.

Knowledge of TIA among general practitioners and emergency department physicians. A questionnaire survey in a French semi-rural area

BACKGROUND AND OBJECTIVE

Management of transient ischemic attacks (TIAs) is of vital importance in an attempt to prevent stroke. However, suboptimal management still raise concern among general practitioners (GPs) and emergency department (ED) physicians-the first medical contact of most TIA patients. This may relate to their poorly updated knowledge about TIA. The study was designed to assess knowledge of TIA among these non-neurologists.

METHODS

The study was a post-mailed questionnaire survey among GPs and ED physicians. The questionnaire related to selective clinical aspects on TIA.

RESULTS

There were a total of 85 respondents for analysis, mostly GPs (n=64; 75.3%), out of 177 mailed physicians. Response rate was 52.7%. Many of these respondents were unaware of the newly proposed TIA definition (59%), unfamiliar with TIA mimics and predictors of post-TIA early stroke recurrence and therefore with the rationales underlying the need of emergency management of TIA. More than one third (39%) were unaware of the relevant national guidelines. Guidelines-aware respondents performed better in most part of the mailed questionnaire.

CONCLUSION

Our results show that poorly updated knowledge about TIA among non-neurologists represents a potential contributing factor to the persisting sub-optimal management of the disorder. Although further studies are needed to confirm this, improved continuous medical education of this group of health care professionals appears warranted.

Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study

BACKGROUND

Transient isolated brainstem symptoms (eg, isolated vertigo, dysarthria, diplopia) are not consistently classified as transient ischaemic attacks (TIAs) and data for prognosis are limited. If some of these transient neurological attacks (TNAs) are due to vertebrobasilar ischaemia, then they should be common during the days and weeks preceding posterior circulation strokes. We aimed to assess the frequency of TNAs before vertebrobasilar ischaemic stroke.

METHODS

We studied all potential ischaemic events during the 90 days preceding an ischaemic stroke in patients ascertained within a prospective, population-based incidence study in Oxfordshire, UK (Oxford Vascular Study; 2002-2010) and compared rates of TNA preceding vertebrobasilar stroke versus carotid stroke. We classified the brainstem symptoms isolated vertigo, vertigo with non-focal symptoms, isolated double vision, transient generalised weakness, and binocular visual disturbance as TNAs in the vertebrobasilar territory; atypical amaurosis fugax and limb-shaking as TNAs in the carotid territory; and isolated slurred speech, migraine variants, transient confusion, and hemisensory tingling symptoms as TNAs in uncertain territory.

FINDINGS

Of the 1141 patients with ischaemic stroke, vascular territory was categorisable in 1034 (91%) cases, with 275 vertebrobasilar strokes and 759 carotid strokes. Isolated brainstem TNAs were more frequent before a vertebrobasilar stroke (45 of 275 events) than before a carotid stroke (10 of 759; OR 14·7, 95% CI 7·3-29·5, p<0·0001), particularly during the preceding 2 days (22 of 252 before a vertebrobasilar stroke vs two of 751 before a carotid stroke, OR 35·8, 8·4-153·5, p<0·0001). Of all 59 TNAs preceding (median 4 days, IQR 1-30) vertebrobasilar stroke, only five (8%) fulfilled the National Institute of Neurological Disorders and Stroke (NINDS) criteria for TIA. The other 54 cases were isolated vertigo (n=23), non-NINDS binocular visual disturbance (n=9), vertigo with other non-focal symptoms (n=10), isolated slurred speech, hemisensory tingling, or diplopia (n=8), and non-focal events (n=4). Only 10 (22%) of the 45 patients with isolated brainstem TNAs sought medical attention before the stroke and a vascular cause was suspected by their physician in only one of these cases.

INTERPRETATION

In patients with definite vertebrobasilar stroke, preceding transient isolated brainstem symptoms are common, but most symptoms do not satisfy traditional definitions of TIA. More studies of the prognosis of transient isolated brainstem symptoms are required.

FUNDING

Wellcome Trust, UK Medical Research Council, Dunhill Medical Trust, Stroke Association, National Institute for Health Research (NIHR), Thames Valley Primary Care Research Partnership, and the NIHR Biomedical Research Centre, Oxford.

Magnified Effects of Changes in NIH Research Funding Levels

What happens within the university-based research enterprise when a federal funding agency abruptly changes research grant funding levels, up or down? We use simple difference equation models to show that an apparently modest increase or decrease in funding levels can have dramatic effects on researchers, graduate students, postdocs, and the overall research enterprise. The amplified effect is due to grants lasting for an extended period, thereby requiring the majority of funds available in one year to pay for grants awarded in previous years. We demonstrate the effect in various ways, using National Institutes of Health data for two situations: the historical doubling of research funding from 1998 to 2003 and the possible effects of "sequestration" in January 2013. We posit human responses to such sharp movements in funding levels and offer suggestions for amelioration.

Population-based study of capsular warning syndrome and prognosis after early recurrent TIA

OBJECTIVE

Many guidelines recommend emergency assessment for patients with ≥2 TIAs within 7 days, perhaps in recognition of the capsular warning syndrome. However, it is unclear whether all patients with multiple TIAs are at high early risk of stroke and whether treatable underlying pathologies are more prevalent in this group.

METHODS

We studied clinical characteristics, Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and risk of stroke in 1,000 consecutive patients with incident and recurrent TIAs in a prospective, population-based study (Oxford Vascular Study).

RESULTS

Of 1,000 patients with TIAs, 170 had a further TIA within 7 days (105 within 24 hours). Multiple TIAs were not associated with carotid stenosis or atrial fibrillation, and much of the 10.6 (95% confidence interval [CI] 6.5-15.9) risk of stroke during the 7 days after the first TIA was due to patients with small-vessel disease (SVD) etiology (10 of 24 vs 8 of 146, odds ratio [OR] = 12.3, 95% CI 3.7-41.9, p < 0.0001), particularly those with motor weakness (i.e., capsular warning syndrome) compared with hemisensory events (9 of 15 [60%], 95% CI 35.3-84.7 vs 1 of 9 [11.1%], 95% CI 0-31.7, p = 0.03). The 7-day risk of stroke after a recurrent TIA was similar to the risk after a single TIA in patients with non-SVD TIA (8 of 146 [5.5%] vs 76 of 830 [9.2%], OR = 0.58, 95% CI 0.25-1.3, p = 0.20). Of the 9 patients with stroke after a capsular warning syndrome, all had the recurrent TIA within 24 hours after the first TIA, and the subsequent stroke occurred within 72 hours of the second TIA in 8. The ABCD2 scores of all preceding TIAs were ≥4 in all 9 patients with capsular warning syndrome before stroke.

CONCLUSIONS

Capsular warning syndrome is rare (1.5% of TIA presentations) but has a poor prognosis (7-day stroke risk of 60%). Otherwise, recurrent TIA within 7 days is not associated with a greater stroke risk than that after a single TIA.

The prognostic impact of the stroke unit concept after transient ischemic attack

BACKGROUND AND PURPOSE

Transient ischemic attack (TIA) is associated with high short-term risk of stroke, especially in the early phase following the event. Data about the impact of the early hospitalization in a stroke unit on patients with TIA are sparse. This study compares the prognostic impact of the stroke unit concept with conventional care on patients with TIA.

METHODS

During a 30-month period (beginning April 2005), 878 patients (mean age, 70±12years; 44.3% female) with TIA admitted within 24h of symptom onset were prospectively evaluated. The adjusted logistic regression analyses were used to estimate the odds ratio for the stroke risk during hospitalization and the 90-day mortality.

RESULTS

Of 878 patients, 591 (67.3%) were treated in the stroke unit, and 287 (32.7%) underwent conventional care. Patients receiving stroke-unit care had significantly higher rates of cranial computed tomography (96.3% vs. 88.1%; P<.001) and brain-supplying artery ultrasound (97.1% vs. 91.3%; P<.001) investigations. The stroke risk during hospitalization was 1.7% in patients treated in stroke unit and 2.4% in patients received a conventional care. A relevant difference between the groups was not found (1.7% vs. 2.4%; P=.45). The 90-day mortality rate was 1.7% in the stroke unit group compared to 2.2% in the conventional care group (1.7% vs. 2.2%; P=.66). The adjusted logistic regression analyses revealed no difference in stroke rates (odds ratio, 0.68; 95% confidence interval, 0.24-1.9) and in the 90-day mortality (odds ratio, 0.63; 95% confidence interval, 0.2-1.96) between the stroke unit concept and conventional care.

CONCLUSION

The prognostic impact of the stroke unit care for patients with transient ischemic attack appears to be similar to that of the conventional care. Further randomized studies are needed to investigate the impact of stroke-unit care on patients with transient ischemic attack.

Use of cranial CT to identify a new infarct in patients with a transient ischemic attack

Research on infarct detection by noncontrast cranial computed tomography (CCT) in patients with transient ischemic attack (TIA) is sparse. However, the aims of this study are to determine the frequency of new infarcts in patients with TIA, to evaluate the independent predictors of infarct detection, and to investigate the association between a new infarct and early short-term risk of stroke during hospitalization. We prospectively evaluated 1533 consecutive patients (mean age, 75.3 ± 11 years; 54% female; mean National Institutes of Health Stroke Scale [NIHSS] score, 1.7 ± 2.9) with TIA who were admitted to hospital within 48 h of symptom onset. A new infarct was detected by CCT in 47 (3.1%) of the 1533 patients. During hospitalization, 17 patients suffered a stroke. Multivariate logistic regression analysis revealed the following independent predictors for infarct detection: NIHSS score ≥10 (odds ratio [OR], 4.8), time to CCT assessment >6 h (OR 2.2), and diabetes (OR 2.3). The evidence of a new infarct was not associated with the risk of stroke after TIA. The frequency of a new infarct in patients with TIA using CCT is low. The use of the CCT tool to predict the stroke risk during hospitalization in patients with TIA is found to be inappropriate. The estimated clinical predictors are easy to use and may help clinicians in the TIA work up.

Emergency department triaging of admitted stroke patients--a Bayesian Network analysis

This study uses hospital administrative data to ascertain the differences in the patient characteristics, process and outcomes of care between the Emergency Department (ED) triage categories of patients admitted from an ED presentation into a large metropolitan teaching hospital with a Stroke Care Unit. Bayesian Networks (BNs) derived from the administrative data were used to provide the descriptive models. Nearly half the patients in each stroke subtype were triaged as 'Urgent' (to be seen within 30 minutes). With a decrease in the urgency of triage categories, the proportion admitted within 8 hours decreased dramatically and the proportion of formal discharge increased. Notably, 45% of transient ischaemic attacks (TIAs) were categorized as 'Semi-urgent' (to be attended within 60 minutes), indicating an opportunity to improve emergency assessment of TIAs. The results illustrate the utility of hospital administrative data and the applicability of BNs for review of the current triage practices and subsequent impact.

Preventing recurrent cerebrovascular events in patients with stroke or transient ischemic attack: the current data

PURPOSE

To describe recurrent stroke in relation to the current data, treatment guidelines, diagnostic considerations, risk prevention, and management for the nurse practitioner (NP).

DATA SOURCES

An extensive review of the scientific literature, clinical trials, and clinical guidelines.

CONCLUSIONS

Recurrent stroke is a major health concern. A first ischemic cerebrovascular event or transient ischemic attack (TIA) is a risk factor for future strokes.

IMPLICATIONS FOR PRACTICE

The risk of recurring stroke has been demonstrated in multiple studies, yet only approximately 5% of stroke patients receive appropriate therapy in a timely manner. The stroke or TIA workup should be completed quickly so that the appropriate treatments and interventions can be initiated to reduce the risk of an additional event. The etiology of the stroke and identification of personal risk factors are important because treatment depends on the specific stroke mechanism. A variety of antiplatelet trials have specific implications for stroke and recurrent stroke. Present treatments include aspirin, aspirin plus extended-release dipyridamole and clopidogrel. The NP plays an important role in ongoing patient education about symptoms, the long-term management of the patient, and reduction of future stroke risk.