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Edlow JA, Bellolio F. Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness. Ann Emerg Med 2024:S0196-0644(24)00214-2. [PMID: 38795083 DOI: 10.1016/j.annemergmed.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 05/27/2024]
Abstract
Diagnosing patients presenting to the emergency department with self-limited episodes of isolated dizziness (the episodic vestibular syndrome) requires a broad differential diagnosis that includes posterior circulation transient ischemic attack. Because these patients are, by definition, asymptomatic without new neurologic findings on examination, the diagnosis, largely based on history and epidemiologic context, can be challenging. We review literature that addresses the frequency of posterior circulation transient ischemic attack in this group of patients compared with other potential causes of episodic vestibular syndrome. We present ways of distinguishing posterior circulation transient ischemic attack from vestibular migraine, the most common cause of episodic vestibular syndrome. We also present a diagnostic algorithm that may help clinicians to work their way through the differential diagnosis.
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Affiliation(s)
- Jonathan A Edlow
- Emergency Medicine, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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2
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Whiteley WN, MacRaild A, Wang Y, Dennis M, Al-Shahi Salman R, Gray A, Reed MJ, Graham C, Wardlaw JM. Clinical Diagnosis and Magnetic Resonance Imaging in Patients With Transient and Minor Neurological Symptoms: A Prospective Cohort Study. Stroke 2022; 53:3419-3428. [PMID: 35942881 PMCID: PMC9586820 DOI: 10.1161/strokeaha.122.039082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The utility of magnetic resonance imaging (MRI) brain in patients with transient or minor neurological symptoms is uncertain. We sought to determine the proportion of participants with transient or minor neurological symptoms who had MRI evidence of acute ischemia at different clinical probabilities of transient ischemic attack (TIA) or minor stroke. METHODS Cohort of participants with transient or minor neurological symptoms from emergency and outpatient settings. Clinicians at different levels of training gave each participant a diagnostic probability (probable when TIA/stroke was the most likely differential diagnosis; possible when TIA/stroke was not the most likely differential diagnosis; or uncertain when diagnostic probability could not be given) before 1.5 or 3T brain MRI ≤5 days from onset. Post hoc, each clinical syndrome was defined blind to MRI findings as National Institute of Neurological Disorders and Stroke criteria TIA/stroke; International Headache Society criteria migraine aura; non-TIA focal symptoms; or nonfocal symptoms. MRI evidence of acute ischemia was defined by 2 reads of MRI. Stroke was ascertained for at least 90 days and up to 18 months after recruitment. RESULTS Two hundred seventy-two participated (47% female, mean age 60, SD 14), 58% with MRI ≤2 days of onset. Most (92%) reported focal symptoms. MR evidence of acute ischemia was found, for stroke/TIA clinical probabilities of probable 23 out of 75 (31% [95% CI, 21%-42%]); possible 26 out of 151 (17% [12%-24%]); and uncertain 9 out of 43, (20% [10%-36%]). MRI evidence of acute ischemia was found in National Institute of Neurological Disorders and Stroke criteria TIA/stroke 40 out of 95 (42% [32%-53%]); migraine aura 4 out of 38 (11% [3%-25%]); non-TIA focal symptoms 16 out of 99 (16% [10%-25%]); and no focal features 1 out of 29 (3% [0%-18%]). After MRI, a further 14 (5% [95% CI, 3-8]) would be treated with an antiplatelet drug compared with treatment plan before MRI. By 18 months, a new ischemic stroke occurred in 9 out of 61 (18%) patients with MRI evidence of acute ischemia and 2 out of 211 (1%) without (age-adjusted hazard ratio, 13 [95% CI, 3-62]; P<0.0001). CONCLUSIONS MRI evidence of acute brain ischemia was found in about 1 in 6 transient or minor neurological symptoms patients with a nonstroke/TIA initial diagnosis or uncertain diagnosis. Methods to determine the clinical and cost-effectiveness of MRI are needed in this population.
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Affiliation(s)
- William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (W.N.W., A.M., M.D., R.A-.S.S., J.M.W.).,Nuffield Department of Population Health, University of Oxford, United Kingdom (W.N.W.).,Usher Institute, University of Edinburgh, United Kingdom (W.N.W., R.A-.S.S., A.G., M.J.R.)
| | - Allan MacRaild
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (W.N.W., A.M., M.D., R.A-.S.S., J.M.W.).,Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, United Kingdom (A.M., A.G., M.J.R.)
| | - Ying Wang
- Neurology Department in the Second Affiliated Hospital of Kunming Medical University, China (Y.W.)
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (W.N.W., A.M., M.D., R.A-.S.S., J.M.W.)
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (W.N.W., A.M., M.D., R.A-.S.S., J.M.W.).,Usher Institute, University of Edinburgh, United Kingdom (W.N.W., R.A-.S.S., A.G., M.J.R.)
| | - Alasdair Gray
- Usher Institute, University of Edinburgh, United Kingdom (W.N.W., R.A-.S.S., A.G., M.J.R.).,Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, United Kingdom (A.M., A.G., M.J.R.)
| | - Matthew J Reed
- Usher Institute, University of Edinburgh, United Kingdom (W.N.W., R.A-.S.S., A.G., M.J.R.).,Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, United Kingdom (A.M., A.G., M.J.R.)
| | - Catriona Graham
- Edinburgh Clinical Research Facility (C.G.), University of Edinburgh, United Kingdom
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (W.N.W., A.M., M.D., R.A-.S.S., J.M.W.).,Edinburgh Imaging (J.M.W.), University of Edinburgh, United Kingdom
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Ramírez-Moreno J, Bartolomé Alberca S, Muñoz Vega P, Guerrero Barona E. Screening for cognitive impairment with the Montreal Cognitive Assessment in Spanish patients with minor stroke or transient ischaemic attack. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:38-44. [DOI: 10.1016/j.nrleng.2018.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 11/17/2018] [Indexed: 10/23/2022] Open
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Katzan IL, Schuster A, Daboul L, Doherty C, Speaker S, Uchino K, Lapin B. Changes in Health-Related Quality of Life After Transient Ischemic Attack. JAMA Netw Open 2021; 4:e2117403. [PMID: 34283228 PMCID: PMC8293018 DOI: 10.1001/jamanetworkopen.2021.17403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Numerous studies have found that patients diagnosed with TIA have decreased health-related quality of life, which has been interpreted as suggesting that patients with TIA have residual symptoms after the event. Studies assessing health status in the same patients before and after an event are lacking but may allow a direct determination of the association of TIA with postevent health status. OBJECTIVE To examine patient-reported health before transient ischemic attack (TIA) among individuals diagnosed with this event and evaluate change in patient-reported health after the event overall and by TIA characterization subgroups. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among 236 patients with a clinical diagnosis of TIA from October 2015 to December 2017 in a large US health system that collects a patient-reported outcome measure in ambulatory setting as part of routine care. Included patients had patient-reported global health scale assessments completed as part of routine care before and after a TIA event. Data were analyzed from March through July 2020. MAIN OUTCOMES AND MEASURES The main outcome was Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale score before and after TIA. A change of 5 or more points in this score is considered clinically relevant. The secondary outcomes included change in patient-reported global health by clinical impression of the probability of a TIA event, pattern of neurological deficits, and short-term risk of stroke, as assessed by the ABCD2 score. RESULTS Among 263 patients who experienced TIA, mean (SD) age was 67.9 (13.4) years and 138 (52.5%) were women. The median (interquartile range) time between patient-reported global health scores was 152 (94-284) days. Mean (SD) baseline patient-reported global physical health and mental health scale summary scores were 43.4 (8.2) and 47.7 (9.7), respectively, and were statistically significantly decreased compared with the general population mean (SD) scores of 50 (10; P < .001) for physical and mental health. The difference between physical health summary score among study participants and the general population was clinically relevant. Mean (SD) summary scores were not statistically significantly different after the event compared with before the event overall (physical health: 44.1 [8.2], for a mean [SE] improvement of 0.65 [0.38] points; P = .09; mental health: 47.4 [9.1], for a mean [SE] worsening of 0.25 [0.38] points; P = .51) or within subgroups. CONCLUSIONS AND RELEVANCE These findings suggest that impaired health status among patients diagnosed with TIA reflect, at least in part, an impaired premorbid state of health. This study did not find that TIA events were associated with worsening of health status overall or within subgroups.
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Affiliation(s)
| | | | - Lynn Daboul
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | | | - Sidra Speaker
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Ken Uchino
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brittany Lapin
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Fonseca AC, Merwick Á, Dennis M, Ferrari J, Ferro JM, Kelly P, Lal A, Ois A, Olivot JM, Purroy F. European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack. Eur Stroke J 2021; 6:CLXIII-CLXXXVI. [PMID: 34414299 PMCID: PMC8370080 DOI: 10.1177/2396987321992905] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 01/16/2021] [Indexed: 01/14/2023] Open
Abstract
The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.
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Affiliation(s)
- Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Áine Merwick
- Department of Neurology, Cork University Hospital & University College Cork, Cork, Ireland
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Julia Ferrari
- Department of Neurology, St. John´s of God Hospital, Vienna, Austria
| | - José M Ferro
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Peter Kelly
- Stroke Service, Mater University Hospital and HRB Stroke Clinical Trials Network Ireland, University College Dublin, Ireland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Angel Ois
- Department of Neurology, Hospital del Mar, IMIM, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Jean Marc Olivot
- Acute Stroke Unit, Clinical Investigation Center and Toulouse Neuro Imaging Center, Toulouse University Medical Center, Toulouse, France
| | - Francisco Purroy
- Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomedica de Lleida (IRBLleida), Universitat de Lleida (UdL), Lleida, Spain
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Liberman AL, Zhang H, Rostanski SK, Cheng NT, Esenwa CC, Haranhalli N, Singh P, Labovitz DL, Lipton RB, Prabhakaran S. Cost-Effectiveness of Advanced Neuroimaging for Transient and Minor Neurological Events in the Emergency Department. J Am Heart Assoc 2021; 10:e019001. [PMID: 34056914 PMCID: PMC8477874 DOI: 10.1161/jaha.120.019001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Accurate diagnosis of patients with transient or minor neurological events can be challenging. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in low-risk patients with transient or minor neurological symptoms, but a cost-effective emergency department diagnostic evaluation strategy remains uncertain. Methods and Results We constructed a decision-analytic model to evaluate 2 diagnostic evaluation strategies for patients with low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (magnetic resonance imaging brain and magnetic resonance angiography head and neck) on every patient or (2) current emergency department standard-of-care clinical evaluation with basic neuroimaging. Main probability variables were: proportion of patients with true ischemic events, strategy specificity and sensitivity, and recurrent stroke rate. Direct healthcare costs were included. We calculated incremental cost-effectiveness ratios, conducted sensitivity analyses, and evaluated various diagnostic test parameters primarily using a 1-year time horizon. Cost-effectiveness standards would be met if the incremental cost-effectiveness ratio was less than willingness to pay. We defined willingness to pay as $100 000 US dollars per quality-adjusted life year. Our primary and sensitivity analyses found that the advanced neuroimaging strategy was more cost-effective than emergency department standard of care. The incremental effectiveness of the advanced neuroimaging strategy was slightly less than the standard-of-care strategy, but the standard-of-care strategy was more costly. Potentially superior diagnostic approaches to the modeled advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to standard-of-care strategy's cost. Conclusions Obtaining advanced neuroimaging on emergency department patient with low-risk transient or minor neurological symptoms was the more cost-effective strategy in our model.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Hui Zhang
- The Center for Health and the Social Sciences University of Chicago Chicago IL
| | - Sara K Rostanski
- Department of Neurology New York University Grossman School of Medicine New York NY
| | - Natalie T Cheng
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Charles C Esenwa
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Neil Haranhalli
- Department of Neurosurgery and Radiology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Puneet Singh
- Department of Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Daniel L Labovitz
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Richard B Lipton
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Shyam Prabhakaran
- Department of Neurology University of Chicago School of Medicine Chicago IL
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Lee SH, Aw KL, McVerry F, McCarron MO. Systematic Review and Meta-Analysis of Diagnostic Agreement in Suspected TIA. Neurol Clin Pract 2021; 11:57-63. [PMID: 33968473 DOI: 10.1212/cpj.0000000000000830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/07/2020] [Indexed: 12/13/2022]
Abstract
Objective To determine the interrater variability for TIA diagnostic agreement among expert clinicians (neurologists/stroke physicians), administrative data, and nonspecialists. Methods We performed a meta-analysis of studies from January 1984 to January 2019 using MEDLINE, EMBASE, and PubMed. Two reviewers independently screened for eligible studies and extracted interrater variability measurements using Cohen's kappa scores to assess diagnostic agreement. Results Nineteen original studies consisting of 19,421 patients were included. Expert clinicians demonstrate good agreement for TIA diagnosis (κ = 0.71, 95% confidence interval [CI] = 0.62-0.81). Interrater variability between clinicians' TIA diagnosis and administrative data also demonstrated good agreement (κ = 0.68, 95% CI = 0.62-0.74). There was moderate agreement (κ = 0.41, 95% CI = 0.22-0.61) between referring clinicians and clinicians at TIA clinics receiving the referrals. Sixty percent of 748 patient referrals to TIA clinics were TIA mimics. Conclusions Overall agreement between expert clinicians was good for TIA diagnosis, although variation still existed for a sizeable proportion of cases. Diagnostic agreement for TIA decreased among nonspecialists. The substantial number of patients being referred to TIA clinics with other (often neurologic) diagnoses was large, suggesting that clinicians, who are proficient in managing TIAs and their mimics, should run TIA clinics.
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Affiliation(s)
- Seong Hoon Lee
- School of Medicine, Dentistry and Biomedical Sciences (SHL, KLA), Queen's University Belfast, Belfast; and Department of Neurology (FM, MOM), Altnagelvin Hospital, Derry, United Kingdom
| | - Kah Long Aw
- School of Medicine, Dentistry and Biomedical Sciences (SHL, KLA), Queen's University Belfast, Belfast; and Department of Neurology (FM, MOM), Altnagelvin Hospital, Derry, United Kingdom
| | - Ferghal McVerry
- School of Medicine, Dentistry and Biomedical Sciences (SHL, KLA), Queen's University Belfast, Belfast; and Department of Neurology (FM, MOM), Altnagelvin Hospital, Derry, United Kingdom
| | - Mark O McCarron
- School of Medicine, Dentistry and Biomedical Sciences (SHL, KLA), Queen's University Belfast, Belfast; and Department of Neurology (FM, MOM), Altnagelvin Hospital, Derry, United Kingdom
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Clancy U, Gilmartin D, Jochems ACC, Knox L, Doubal FN, Wardlaw JM. Neuropsychiatric symptoms associated with cerebral small vessel disease: a systematic review and meta-analysis. Lancet Psychiatry 2021; 8:225-236. [PMID: 33539776 DOI: 10.1016/s2215-0366(20)30431-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/09/2020] [Accepted: 09/23/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cerebral small vessel disease, a common cause of vascular dementia, is often considered clinically silent before dementia or stroke become apparent. However, some individuals have subtle symptoms associated with acute MRI lesions. We aimed to determine whether neuropsychiatric and cognitive symptoms vary according to small vessel disease burden. METHODS In this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and PsycINFO for articles published in any language from database inception to Jan 24, 2020. We searched for studies assessing anxiety, apathy, delirium, emotional lability, fatigue, personality change, psychosis, dementia-related behavioural symptoms or cognitive symptoms (including subjective memory complaints), and radiological features of cerebral small vessel disease. We extracted reported odds ratios (OR), standardised mean differences (SMD), and correlations, stratified outcomes by disease severity or symptom presence or absence, and pooled data using random-effects meta-analyses, reporting adjusted findings when possible. We assessed the bias on included studies using the Risk of Bias for Non-randomized Studies tool. This study is registered with PROSPERO, CRD42018096673. FINDINGS Of 7119 papers identified, 81 studies including 79 cohorts in total were eligible for inclusion (n=21 730 participants, mean age 69·2 years). Of these 81 studies, 45 (8120 participants) reported effect estimates. We found associations between worse white matter hyperintensity (WMH) severity and apathy (OR 1·41, 95% CI 1·05-1·89) and the adjusted SMD in apathy score between WMH severities was 0·38 (95% CI 0·15-0·61). Worse WMH severity was also associated with delirium (adjusted OR 2·9, 95% CI 1·12-7·55) and fatigue (unadjusted OR 1·63, 95% CI 1·20-2·22). WMHs were not consistently associated with subjective memory complaints (OR 1·34, 95% CI 0·61-2·94) and unadjusted SMD for WMH severity between these groups was 0·08 (95% CI -0·31 to 0·47). Anxiety, dementia-related behaviours, emotional lability, and psychosis were too varied or sparse for meta-analysis; these factors were reviewed narratively. Overall heterogeneity varied from 0% to 79%. Only five studies had a low risk of bias across all domains. INTERPRETATION Apathy, fatigue, and delirium associated independently with worse WMH, whereas subjective cognitive complaints did not. The association of anxiety, dementia-related behaviours, emotional lability, and psychosis with cerebral small vessel disease require further investigation. These symptoms should be assessed longitudinally to improve early clinical detection of small vessel disease and enable prevention trials to happen early in the disease course, long before cognition declines. FUNDING Chief Scientist Office of the Scottish Government, UK Dementia Research Institute, Fondation Leducq, Stroke Association Garfield-Weston Foundation, Alzheimer's Society, and National Health Service Research Scotland.
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Affiliation(s)
- Una Clancy
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Daniel Gilmartin
- Department of Geriatric Medicine, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Angela C C Jochems
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Lucy Knox
- Department of Medicine, Borders General Hospital, NHS Borders, Melrose, UK
| | - Fergus N Doubal
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK.
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Yu AYX, Hill MD, Asdaghi N, Boulanger JM, Camden MC, Campbell BCV, Demchuk AM, Field TS, Goyal M, Krause M, Mandzia J, Menon BK, Mikulik R, Moreau F, Penn AM, Swartz RH, Coutts SB. Sex Differences in Diagnosis and Diagnostic Revision of Suspected Minor Cerebral Ischemic Events. Neurology 2020; 96:e732-e739. [PMID: 33184228 DOI: 10.1212/wnl.0000000000011212] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 09/21/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe sex differences in the presentation, diagnosis, and revision of diagnosis after early brain MRI in patients who present with acute transient or minor neurologic events. METHODS We performed a secondary analysis of a prospective multicenter cohort study of patients referred to neurology between 2010 and 2016 with a possible cerebrovascular event and evaluated with brain MRI within 8 days of symptom onset. Investigators documented the characteristics of the event, initial diagnosis, and final diagnosis. We used multivariable logistic regression analyses to evaluate the association between sex and outcomes. RESULTS Among 1,028 patients (51% women, median age 63 years), more women than men reported headaches and fewer reported chest pain, but there were no sex differences in other accompanying symptoms. Women were more likely than men to be initially diagnosed with stroke mimic (54% of women vs 42% of men, adjusted odds ratio (OR) 1.60, 95% confidence interval [CI] 1.24-2.07), and women were overall less likely to have ischemia on MRI (10% vs 17%, OR 0.52, 95% CI 0.36-0.76). Among 496 patients initially diagnosed with mimic, women were less likely than men to have their diagnosis revised to minor stroke or TIA (13% vs 20%, OR 0.53, 95% CI 0.32-0.88) but were equally likely to have acute ischemia on MRI (5% vs 8%, OR 0.56, 95% CI 0.26-1.21). CONCLUSIONS Stroke mimic was more frequently diagnosed in women than men, but diagnostic revisions were common in both. Early brain MRI is a useful addition to clinical evaluation in diagnosing transient or minor neurologic events.
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Affiliation(s)
- Amy Y X Yu
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada.
| | - Michael D Hill
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Negar Asdaghi
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Jean-Martin Boulanger
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Marie-Christine Camden
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Bruce C V Campbell
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Andrew M Demchuk
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Thalia S Field
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Mayank Goyal
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Martin Krause
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Jennifer Mandzia
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Bijoy K Menon
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Robert Mikulik
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Francois Moreau
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Andrew M Penn
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Richard H Swartz
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Shelagh B Coutts
- From the Department of Medicine (Neurology) (A.Y.X.Y., R.H.S.), University of Toronto, Ontario; Department of Clinical Neurosciences (M.D.H., A.M.D., M.G., B.K.M., S.B.C.), University of Calgary, Alberta, Canada; Department of Neurology (N.A.), University of Miami, FL; Department of Neurology (J.-M.B.), Sherbrooke University, Longueil; Department of Neurosciences (M.-C.C.), Laval University, Québec City, Québec, Canada; Department of Medicine and Neurology (B.C.V.C.), University of Melbourne, Parkville, Australia; Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada; Northern Clinical School (M.K.), University of Sydney, Australia; Department of Clinical Neurosciences (J.M.), Western University, London, Ontario, Canada; Neurological Department (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Medicine (F.M.), Neurology, Université de Sherbrooke, Québec; and Division of Neurology (A.M.P.), Vancouver Island Health Authority, Victoria, British Columbia, Canada
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10
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Abstract
ABSTRACT Cerebral small vessel disease (SVD) is a common global brain disease that causes cognitive impairment, ischemic or hemorrhagic stroke, problems with mobility, and neuropsychiatric symptoms. The brain damage, seen as focal white and deep grey matter lesions on brain magnetic resonance imaging (MRI) or computed tomography (CT), typically accumulates "covertly" and may reach an advanced state before being detected incidentally on brain scanning or causing symptoms. Patients have typically presented to different clinical services or been recruited into research focused on one clinical manifestation, perhaps explaining a lack of awareness, until recently, of the full range and complexity of SVD.In this review, we discuss the varied clinical presentations, established and emerging risk factors, relationship to SVD features on MRI or CT, and the current state of knowledge on the effectiveness of a wide range of pharmacological and lifestyle interventions. The core message is that effective assessment and clinical management of patients with SVD, as well as future advances in diagnosis, care, and treatment, will require a more "joined-up"' approach. This approach should integrate clinical expertise in stroke neurology, cognitive, and physical dysfunctions. It requires more clinical trials in order to improve pharmacological interventions, lifestyle and dietary modifications. A deeper understanding of the pathophysiology of SVD is required to steer the identification of novel interventions. An essential prerequisite to accelerating clinical trials is to improve the consistency, and standardization of clinical, cognitive and neuroimaging endpoints.
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11
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Clancy U, Garcia DJ, Stringer MS, Thrippleton MJ, Valdés-Hernández MC, Wiseman S, Hamilton OK, Chappell FM, Brown R, Blair GW, Hewins W, Sleight E, Ballerini L, Bastin ME, Maniega SM, MacGillivray T, Hetherington K, Hamid C, Arteaga C, Morgan AG, Manning C, Backhouse E, Hamilton I, Job D, Marshall I, Doubal FN, Wardlaw JM. Rationale and design of a longitudinal study of cerebral small vessel diseases, clinical and imaging outcomes in patients presenting with mild ischaemic stroke: Mild Stroke Study 3. Eur Stroke J 2020; 6:81-88. [PMID: 33817338 PMCID: PMC7995323 DOI: 10.1177/2396987320929617] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/14/2020] [Indexed: 12/21/2022] Open
Abstract
Background Cerebral small vessel disease is a major cause of dementia and stroke, visible on brain magnetic resonance imaging. Recent data suggest that small vessel disease lesions may be dynamic, damage extends into normal-appearing brain and microvascular dysfunctions include abnormal blood–brain barrier leakage, vasoreactivity and pulsatility, but much remains unknown regarding underlying pathophysiology, symptoms, clinical features and risk factors of small vessel disease. Patients and Methods: The Mild Stroke Study 3 is a prospective observational cohort study to identify risk factors for and clinical implications of small vessel disease progression and regression among up to 300 adults with non-disabling stroke. We perform detailed serial clinical, cognitive, lifestyle, physiological, retinal and brain magnetic resonance imaging assessments over one year; we assess cerebrovascular reactivity, blood flow, pulsatility and blood–brain barrier leakage on magnetic resonance imaging at baseline; we follow up to four years by post and phone. The study is registered ISRCTN 12113543. Summary Factors which influence direction and rate of change of small vessel disease lesions are poorly understood. We investigate the role of small vessel dysfunction using advanced serial neuroimaging in a deeply phenotyped cohort to increase understanding of the natural history of small vessel disease, identify those at highest risk of early disease progression or regression and uncover novel targets for small vessel disease prevention and therapy.
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Affiliation(s)
- Una Clancy
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Michael S Stringer
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Stewart Wiseman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Olivia Kl Hamilton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Rosalind Brown
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Gordon W Blair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Will Hewins
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Emilie Sleight
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Lucia Ballerini
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mark E Bastin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Tom MacGillivray
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Charlene Hamid
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Carmen Arteaga
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alasdair G Morgan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Cameron Manning
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ellen Backhouse
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Iona Hamilton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Dominic Job
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ian Marshall
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Fergus N Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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12
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Jia Z, Song Y, Hu W. Dysphasia is associated with diffusion-weighted MRI abnormalities in patients with transient neurological symptoms. Neurol Sci 2020; 41:1765-1771. [PMID: 32034558 PMCID: PMC7359169 DOI: 10.1007/s10072-020-04258-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/15/2020] [Indexed: 01/17/2023]
Abstract
Background The clinical characteristics of diffusion-weighted imaging (DWI) abnormalities after transient neurological symptoms are of great significance for the early diagnosis and urgent intervention of transient ischemic attack (TIA). This study was aimed to investigate the clinical characteristics associated with acute DWI lesions in transient neurological symptoms. Methods We retrospectively recruited 302 patients with transient neurological symptoms. According to DWI findings, they were divided into DWI positive and DWI negative group. The clinical characteristics and the TIA-related scores such as ABCD2, ABCD3, ABCD3I, Dawson score, and the Diagnosis of TIA (DOT) score were compared between the two groups. Logistic regression analysis and receiver operating characteristic curves were used to identify the independent factors and compare the predictive value of different TIA scores for acute DWI lesions. Results A total of 302 patients were enrolled in this study. The mean age was 61.8 years, and 67.2% were male. We found 89 (29.5%) patients with DWI positivity. Logistic regression analysis showed the characteristic associated with DWI lesions was dysphasia (OR 2.226, 95% CI 1.220–4.062). The area under the curve for Dawson score and the DOT score was 0.610 (95% CI 0.543–0.678) and 0.625 (95% CI 0.559–0.691), respectively. Conclusion We found that DWI lesions were detected in 29.5% of patients with transient neurological symptoms and were associated with dysphasia. Dawson score and DOT score could have a higher predictability of DWI lesions in patients with transient neurological symptoms.
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Affiliation(s)
- Zejin Jia
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yangguang Song
- Department of Pathology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Wenli Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
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13
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Transient Ischemic Attack: Which Determines Diffusion-Weighted Image Positivity? J Stroke Cerebrovasc Dis 2019; 28:104397. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 08/22/2019] [Accepted: 09/05/2019] [Indexed: 11/20/2022] Open
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14
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Wang Y, Xiao J, Luo Y, Wang S, Liang H, Jin L. Risk factors of perfusion and diffusion abnormalities on MRI in hemispheric TIA: a case-control study. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:808. [PMID: 32042824 DOI: 10.21037/atm.2019.12.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To assess the prevalence and potential predictors of MR diffusion and perfusion abnormalities in a Chinese population with hemispheric transient ischemic attacks (TIA). Methods Patients with temporary (<24 hours) focal cerebral dysfunction of probable vascular origin were considered to be potential candidates for this study in the emergency room. Those who were admitted to the stroke center of Shanghai Fourth People's Hospital affiliated to Tongji University between January 2015 and December 2018 were recruited to the present study. MRI, including both diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI), was performed within 7 days after the last symptom attack. Time to maximum of the residue function (Tmax) maps were auto-evaluated using the RAPID software to determine hypoperfusion. Multivariate analysis was used to assess the correlation of MR findings with clinical variables, medical history, cardio-metabolic characteristics, and the ABCD2 scores (age, blood pressure, clinical features, symptom duration and diabetes). Results Sixty-six out of 207 patients met the inclusion criteria. Baseline MRI showed DWI lesions in 20 patients (30.3%). The prevalence of MR perfusion Tmax >4 s >0 mL and ≥10 mL were 77.3% (51/66) and 50% (33/66), respectively. Male patients tended to develop DWI lesions after a TIA. Limb weakness was an independent factor associated with MR perfusion abnormalities (Tmax >4 s ≥10 mL) in this Chinese population (adjusted OR =7.41, 95% CI: 1.57-34.89, P=0.011). Conclusions Our results suggest that limb weakness is a strong predictor of perfusion abnormalities calculated by RAPID on Tmax maps of hemispheric TIA patients without DWI positive findings. Male patients are more likely to develop cerebral infarction.
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Affiliation(s)
- Yue Wang
- Department of Neurology, Shanghai Fourth People's Hospital affiliated to Tongji University School of Medicine, Shanghai 200081, China.,Department of Neurology, Shanghai Tongji Hospital, Tongji University, Shanghai 200065, China.,Department of Neurology, Translational Research Institute of Brain and Brain-like Intelligence, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai 200081, China
| | - Jingjing Xiao
- Department of Neurology, Shanghai Fourth People's Hospital affiliated to Tongji University School of Medicine, Shanghai 200081, China
| | - Yu Luo
- Department of Radiology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai 200081, China
| | - Shaoshi Wang
- Department of Neurology, Shanghai Fourth People's Hospital affiliated to Tongji University School of Medicine, Shanghai 200081, China
| | - Huazheng Liang
- Department of Neurology, Shanghai Fourth People's Hospital affiliated to Tongji University School of Medicine, Shanghai 200081, China.,Department of Neurology, Translational Research Institute of Brain and Brain-like Intelligence, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai 200081, China
| | - Lingjing Jin
- Department of Neurology, Shanghai Tongji Hospital, Tongji University, Shanghai 200065, China
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15
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Oudeman EA, Greving JP, Van den Berg-Vos RM, Biessels GJ, Bron EE, van Oostenbrugge R, de Bresser J, Kappelle LJ. Nonfocal Transient Neurological Attacks Are Associated With Cerebral Small Vessel Disease. Stroke 2019; 50:3540-3544. [PMID: 31637974 DOI: 10.1161/strokeaha.119.025328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Nonfocal transient neurological attacks (TNAs), such as unsteadiness, bilateral weakness, or confusion, are associated with an increased risk of stroke and dementia. Cerebral ischemia plays a role in their pathogenesis, but the precise mechanisms are unknown. We hypothesized that cerebral small vessel disease is involved in the pathogenesis of TNAs and assessed the relation between TNAs and manifestations of cerebral small vessel disease on magnetic resonance imaging. Methods- We included participants from the HBC (Heart-Brain Connection) study. In this study, hemodynamic and cardiovascular contributions to cognitive impairment have been studied in patients with heart failure, carotid artery occlusion, or possible vascular cognitive impairment, as well as in a reference group. We excluded participants with a history of stroke or transient ischemic attacks. The occurrence of the following 8 TNAs was assessed with a standardized interview: unconsciousness, confusion, amnesia, unsteadiness, bilateral leg weakness, blurred vision, nonrotatory dizziness, and paresthesias. The occurrence of TNAs was related to the presence of lacunes or white matter hyperintensities (Fazekas score, ≥2; early confluent or confluent lesions) in logistic regression analysis, adjusted for age, sex, and hypertension. Results- Of 304 participants (60% men; mean age, 67±9 years), 63 participants (21%) experienced ≥1 TNAs. Lacunes and early confluent or confluent white matter hyperintensities were more common in participants with TNAs than in participants without TNAs (35% versus 20%; adjusted odds ratio, 2.32 [95% CI, 1.22-4.40] and 48% versus 27%; adjusted odds ratio, 2.65 [95% CI, 1.44-4.90], respectively). Conclusions- In our study, TNAs are associated with the presence of lacunes and early confluent or confluent white matter hyperintensities of presumed vascular origin, which indicates that cerebral small vessel disease might play a role in the pathogenesis of TNAs.
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Affiliation(s)
- Eline A Oudeman
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.A.O., G.J.B., L.J.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.,Department of Neurology, OLVG West, Amsterdam, the Netherlands (E.A.O., R.M.V.d.B.-V.)
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care (J.P.G.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | | | - Geert Jan Biessels
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.A.O., G.J.B., L.J.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Esther E Bron
- Biomedical Imaging Group Rotterdam, Department of Radiology and Nuclear Medicine (E.E.B.), Erasmus MC, the Netherlands
| | | | - Jeroen de Bresser
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (R.v.O.)
| | - L Jaap Kappelle
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.A.O., G.J.B., L.J.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
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16
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Hotter B, Galinovic I, Kunze C, Brunecker P, Jungehulsing GJ, Villringer A, Endres M, Villringer K, Fiebach JB. High‐resolution diffusion‐weighted imaging identifies ischemic lesions in a majority of transient ischemic attack patients. Ann Neurol 2019; 86:452-457. [DOI: 10.1002/ana.25551] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 07/10/2019] [Accepted: 07/10/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Benjamin Hotter
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Klinik und Hochschulambulanz für NeurologieCharité Universitätsmedizin Berlin Berlin Germany
| | - Ivana Galinovic
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
| | - Claudia Kunze
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
| | - Peter Brunecker
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health Berlin Germany
| | - Gerhard J. Jungehulsing
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Department of NeurologyJewish Hospital Berlin Germany
| | - Arno Villringer
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Max Planck Institute for Human Cognitive and Brain Sciences Leipzig Germany
| | - Matthias Endres
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Klinik und Hochschulambulanz für NeurologieCharité Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health Berlin Germany
- Max Planck Institute for Human Cognitive and Brain Sciences Leipzig Germany
- German Centre for Cardiovascular Research (DZHK) Berlin Germany
| | - Kersten Villringer
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Klinik und Hochschulambulanz für NeurologieCharité Universitätsmedizin Berlin Berlin Germany
| | - Jochen B. Fiebach
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
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17
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Bang OY, Li W. Applications of diffusion-weighted imaging in diagnosis, evaluation, and treatment of acute ischemic stroke. PRECISION AND FUTURE MEDICINE 2019. [DOI: 10.23838/pfm.2019.00037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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18
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Oudeman EA, Volkers EJ, Greving JP, Klijn CJM, Algra A, Kappelle L. Nonfocal transient neurological attacks in patients with carotid artery occlusion. Eur Stroke J 2019; 4:50-54. [PMID: 31165094 PMCID: PMC6533861 DOI: 10.1177/2396987318818779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/10/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Nonfocal transient neurological attacks (TNAs) are episodes with atypical,
nonlocalizing cerebral symptoms. We examined the prevalence of nonfocal
TNAs, in patients with and without carotid artery occlusion (CAO). Methods We included 67 patients with CAO and 62 patients without CAO. In both groups,
patients had a history of transient ischemic attack (TIA) or nondisabling
ischemic stroke in the anterior circulation that had occurred >6 months
before inclusion. Patients without CAO did not have ipsilateral or
contralateral carotid artery stenosis of ≥50%. All patients were interviewed
with a standardized questionnaire on the occurrence of nonfocal TNA symptoms
during the preceding six months. We calculated risk ratios (RRs) with 95%
confidence intervals (CIs) for the occurrence of ≥1 and ≥2 different
nonfocal TNAs after adjustments for age, sex, systolic blood pressure and
time interval between most recent TIA or ischemic stroke and administration
of the questionnaire. Results Forty-three of all patients (33%) had had one or more nonfocal TNAs in the
preceding six months. Nonrotatory dizziness (24%) was reported most often.
The prevalence of ≥1 nonfocal TNAs was not significantly different between
patients with and without CAO (39% vs. 27%; adjusted RR 1.47, 95% CI
0.83–2.61), but the prevalence of ≥2 or more different nonfocal TNAs was
higher in patients with CAO (16% vs. 3%; adjusted RR 4.77, 95% CI
1.20–18.98). In patients with CAO who also had a contralateral carotid or
vertebral artery steno-occlusion, nonfocal TNAs occurred more often than in
patients without any carotid or vertebral artery steno-occlusion (46% vs.
27%; adjusted RR 2.22, 95% CI 1.08–4.60 for ≥1 and 21% vs. 3%; adjusted RR
8.27, 95% CI 1.83–37.32 for ≥2 nonfocal TNAs). Conclusions Patients with CAO more often experienced multiple nonfocal TNAs than patients
without CAO.
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Affiliation(s)
- Eline A Oudeman
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
- Department of Neurology, OLVG west, Amsterdam, the
Netherlands
- Eline A Oudeman, Department of Neurology,
University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508, GA, The
Netherlands.
| | - Eline J Volkers
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
- Julius Centre for Health Sciences and Primary Care, University
Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jacoba P Greving
- Julius Centre for Health Sciences and Primary Care, University
Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Catharina JM Klijn
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
- Department of Neurology, Donders Institute for Brain, Cognition,
and Behavior, Center for Neuroscience, Radboud University Medical Center,
Nijmegen, the Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
- Julius Centre for Health Sciences and Primary Care, University
Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L.Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
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19
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Aparicio HJ, Himali JJ, Satizabal CL, Pase MP, Romero JR, Kase CS, Beiser AS, Seshadri S. Temporal Trends in Ischemic Stroke Incidence in Younger Adults in the Framingham Study. Stroke 2019; 50:1558-1560. [PMID: 31084341 PMCID: PMC6538454 DOI: 10.1161/strokeaha.119.025171] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background and Purpose- Stroke at midlife has a disproportionately large impact on disability-adjusted life-years lost. Ischemic stroke incidence may be increasing at this age. We investigated long-term trends in ischemic stroke incidence and changes in stroke risk factors in a community sample stratified by stroke onset at middle and older age. Methods- In the Framingham Study, surveillance for incident stroke is ongoing since 1948. We examined age-adjusted and sex-adjusted 10-year incidence of ischemic stroke using Cox models in persons aged 35 to 54 and ≥55 years at start of follow-up. Tests for linear trend were performed over 4 epochs, controlling for the distance in time between intervals. Further, we calculated the mean 10-year risk of stroke at each epoch and for both age groups, based on vascular risk factors from the Framingham Stroke Risk Profile. Results- There were 153, 197, 176, and 165 incident ischemic strokes within each epoch beginning in 1962 (n=3966), 1971 (n=5779), 1987 (n=5133), and 1998 (n=6964). Most ischemic strokes at midlife (n=71) were because of atherosclerotic brain infarction (n=50) or cardioembolism (n=19). Using the risk in the 1962 epoch as the reference, the risk of ischemic stroke at midlife did not significantly decline (hazard ratio, 0.87; 95% CI, 0.74-1.02; P trend =0.09). Incidence of ischemic stroke declined in the older group (hazard ratio, 0.82; 95% CI, 0.77-0.88; P trend <0.001). Between epochs 1 and 4, the average 10-year risk of stroke, as estimated by the Framingham Stroke Risk Profile, declined by 0.7% at midlife and 1.1% at older age. Conclusions- Long-term rates of ischemic stroke declined in our community sample; the decline was greater in older as compared with younger adults. Early prevention, focused on modification of cardiovascular risk factors, is important to see sustained declines in stroke incidence and mortality at midlife.
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Affiliation(s)
| | | | - Claudia L. Satizabal
- Boston University School of Medicine, MA, USA
- University of Texas Health Sciences Center, TX, USA
| | - Matthew P. Pase
- The Florey Institute for Neuroscience and Mental Health,
Melbourne, Australia
- The University of Melbourne, Australia
- Swinburne University of Technology, Hawthorne,
Australia
| | | | - Carlos S. Kase
- Boston University School of Medicine, MA, USA
- Emory University, Atlanta, GA, USA
| | | | - Sudha Seshadri
- Boston University School of Medicine, MA, USA
- University of Texas Health Sciences Center, TX, USA
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20
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Nonfocal transient neurological attacks are related to cognitive impairment in patients with heart failure. J Neurol 2019; 266:2035-2042. [PMID: 31115679 PMCID: PMC6647193 DOI: 10.1007/s00415-019-09376-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/17/2019] [Accepted: 05/13/2019] [Indexed: 12/01/2022]
Abstract
Introduction Nonfocal transient neurological attacks (TNAs) are associated with an increased risk of future dementia, but it is unclear whether TNAs are also associated with concurrent cognitive impairment. We hypothesized that recent TNAs are related to worse cognitive functioning. We tested our hypothesis in patients with heart failure, as these patients are at risk of cerebral hypoperfusion, which might play a role in the etiology of TNAs. Methods We performed neuropsychological testing in all patients with heart failure enrolled in the Heart Brain Connection study. We assessed global cognition, attention-psychomotor speed, executive functioning, memory and language. All patients were interviewed with a standardized questionnaire on the occurrence of TNAs in the preceding 6 months. We studied associations between TNAs and cognitive functioning with linear and logistic regression analyses, adjusted for age, sex and education. We performed additional analyses in patients without previous stroke or TIA and in patients without brain infarction on MRI. Results Thirty-seven (23%) of 158 patients (mean age 70 years, 67% men) experienced one or more TNAs. Patients with a recent TNA were more likely to be impaired on ≥ 1 cognitive domains than patients without TNAs [41% vs. 18%, adjusted odds ratio 4.6, 95% confidence interval (CI) 1.8–11.8]. Patients with TNAs performed worse than patients without TNAs on global cognition (mean difference in z scores − 0.36, 95% CI − 0.54 to − 0.18), and on the cognitive domains attention-psychomotor speed (mean difference − 0.40, 95% CI − 0.66 to − 0.14), memory (mean difference − 0.57, 95% CI − 0.98 to − 0.15) and language (mean difference − 0.47, 95% CI − 0.79 to − 0.16). These associations were independent of cardiac output and volume of white matter hyperintensities. Subgroup analyses in patients without previous stroke or TIA or brain infarction on MRI (n = 78) yielded comparable results, with the exception of the cognitive domain language, which was no longer different between patients with and without TNAs. Conclusion Among patients with heart failure, TNAs are associated with cognitive impairment, which warrants the need for more clinical awareness of this problem. Electronic supplementary material The online version of this article (10.1007/s00415-019-09376-z) contains supplementary material, which is available to authorized users.
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21
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Krishnan K, Bassilious K, Eriksen E, Bath PM, Sprigg N, Brækken SK, Ihle-Hansen H, Horn MA, Sandset EC. Posterior circulation stroke diagnosis using HINTS in patients presenting with acute vestibular syndrome: A systematic review. Eur Stroke J 2019; 4:233-239. [PMID: 31984230 DOI: 10.1177/2396987319843701] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/20/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose Acute vestibular syndrome - vertigo, nausea/vomiting, nystagmus and gait unsteadiness - is common, and differentiating posterior circulation stroke from a peripheral cause can be challenging. The National Institute of Health Stroke Scale (NIHSS) does not include acute vestibular syndrome, and early computed tomography scanning cannot rule out acute ischaemia. A positive Head Impulse-Nystagmus-Test of Skew (HINTS) test suggests posterior circulation stroke in acute vestibular syndrome when any of three signs are present: normal horizontal head impulse, gaze-direction nystagmus or eye skew deviation. This systematic review examined the accuracy of positive HINTS in identifying posterior circulation stroke in acute vestibular syndrome patients. Methods We searched MEDLINE (1966 to 21 December 2017), EMBASE (1980 to December 2017), Web of Science and scanned bibliographies. Two authors independently screened relevant articles and extracted data. We included studies where HINTS was used to identify posterior circulation stroke with diagnosis confirmed using magnetic resonance imaging. Findings Six studies (n = 644 patients) were identified. Acute stroke was confirmed in 200 (31.1%) patients. There was a 15-fold increased risk of posterior circulation stroke in patients with positive HINTS test compared to those with no abnormality (RR: 15.84, 95% CI: 5.25-47.79). For any stroke, the pooled sensitivity was 95.5% (95% CI: 92.6-98.4%) and specificity was 71.2% (95% CI: 67.0-75.4%). Discussion and Conclusion The data suggest that the HINTS test as one element of clinical evaluation is useful to differentiate posterior circulation stroke from peripheral causes in acute vestibular syndrome. Further studies are needed to validate HINTS as a clinical prediction tool in emergency department settings and selection of patients for reperfusion treatment.
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Affiliation(s)
- Kailash Krishnan
- Stroke, Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | | | - Erik Eriksen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Philip M Bath
- Stroke, Acute Medicine, Nottingham University Hospitals, Nottingham, UK.,Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Acute Medicine, Nottingham University Hospitals, Nottingham, UK.,Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | | | | | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Research and Development, The Norwegian Air Ambulance Foundation, Oslo, Norway
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22
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Ramírez-Moreno JM, Bartolomé Alberca S, Muñoz Vega P, Guerrero Barona EJ. Screening for cognitive impairment with the Montreal Cognitive Assessment in Spanish patients with minor stroke or transient ischaemic attack. Neurologia 2019; 37:38-44. [PMID: 30737125 DOI: 10.1016/j.nrl.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 11/08/2018] [Accepted: 11/17/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The symptoms of minor stroke and transient ischemic attack (TIA) are temporary and mild. Despite the transient nature of the focal symptoms and the absence of visible brain lesions in some patients, many experience persistent cognitive problems subsequently. We aimed to establish the discriminant capacity of the Montreal Cognitive Assessment (MoCA) in screening for cognitive impairment (CI) within 90 days of TIA. METHOD A total of 50 patients with minor stroke or TIA were recruited. Patients were administered the MoCA test and a formal neuropsychological test battery. CI was defined clinically according to neuropsychological test findings. RESULTS The average age of recruited patients was 57.7±8.0 years; 70.0% were men; all patients had completed at least primary education. Thirty-seven patients (74.0%) presented CI. Receiver operating characteristic curve analysis obtained an optimal MoCA cut-off point of 25 for discriminating between patients with CI and those without, with an area under the curve of 0.835 (95% confidence interval [95% CI] 0.720-0.949), sensitivity of 78.4% (95% CI 62.8-88.6%), specificity of 76.9% (95% CI 49.7-91.8%), positive predictive value of 90.6% (95% CI 81.0-95.6%), and negative predictive value of 55.6% (95% CI 39.5-70.4%). CONCLUSIONS More than half of the patients presented CI as determined by the formal battery of neuropsychological tests. A MoCA cut-off point of 25 is sufficiently sensitive and specific for detecting CI after minor stroke or TIA, and may be implemented as a screening technique in routine clinical practice.
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Affiliation(s)
- J M Ramírez-Moreno
- Departamento de Ciencias Biomédicas, Universidad de Extremadura, Badajoz, España; Centro de Ictus, Sección de Neurología, Hospital Universitario Infanta Cristina, Badajoz, España; Grupo de Investigación Multidisciplinar de Extremadura (GRIMEX), Villanueva de la Serena, España.
| | - S Bartolomé Alberca
- Centro de Ictus, Sección de Neurología, Hospital Universitario Infanta Cristina, Badajoz, España
| | - P Muñoz Vega
- Centro de Neurorrehabilitación Casaverde, Mérida, España
| | - E J Guerrero Barona
- Departamento de Psicología y Antropología, Universidad de Extremadura, Badajoz, España
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23
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Choi JH, Oh EH, Park MG, Baik SK, Cho HJ, Choi SY, Lee TH, Kim JS, Choi KD. Early MRI-negative posterior circulation stroke presenting as acute dizziness. J Neurol 2018; 265:2993-3000. [PMID: 30341546 DOI: 10.1007/s00415-018-9097-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 10/14/2018] [Indexed: 11/26/2022]
Abstract
The aim of this study was to determine the frequency, clinical and radiological features, and efficacy of clinical evaluation and perfusion-weighted imaging (PWI) for the prediction of final stroke in patients with DWI/MRI-negative posterior circulation stroke (PCS) presenting acute dizziness/vertigo. From our comprehensive prospective stroke registry of acute ischemic stroke during a 7-year period, we identified 1846 consecutive patients with PCS, 850 of whom presented with acute dizziness/vertigo. Of these 850 patients, initial DWI-MRI was negative in 35 (4.1%). In these 35 patients, dizziness/vertigo was acute prolonged in 31 and recurrent transient in 4. Focal neurological signs or profound imbalance were present in 16/35 or 18/34, respectively. Spontaneous nystagmus was absent in 21/35; the HINTS protocol (head impulse, nystagmus, and test-of-skew) was not applicable to them. In 12/26 patients, PWI was positive and the same time as DWI was negative. The usual site of lesion was the lateral medulla (n = 18). Twenty-nine patients (83%) had small strokes, while 19 (54%) had large vessel strokes. The sensitivity of systematic clinical evaluation adopting neurological examination, HINTS plus, and assessment of equilibrium was 83%, for prediction of final stroke and 100% when combined with PWI. An integrated approach using systematic neurological and neuro-otological examinations combined with PWI accurately diagnoses PCS presenting with acute dizziness/vertigo. Although most patients with acute vertigo and MRI-negative PCS have small brainstem strokes, about a half have large vessel stroke with greater risk of progression requiring prompt treatment.
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Affiliation(s)
- Jae-Hwan Choi
- Department of Neurology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Eun Hye Oh
- Department of Neurology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Min-Gyu Park
- Department of Neurology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Seung Kug Baik
- Department of Radiology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Han-Jin Cho
- Department of Neurology, College of Medicine, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, 179, Gudeok-ro, Seo-gu, 602-739, Busan, South Korea
| | - Seo Young Choi
- Department of Neurology, College of Medicine, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, 179, Gudeok-ro, Seo-gu, 602-739, Busan, South Korea
| | - Tae-Hong Lee
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, South Korea
| | - Ji Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang, South Korea
| | - Kwang-Dong Choi
- Department of Neurology, College of Medicine, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, 179, Gudeok-ro, Seo-gu, 602-739, Busan, South Korea.
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25
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Ding J, Zhou D, Shang S, Pan L, Ya J, Ding Y, Ji X, Meng R. Impact of seasonal variations on the first ischemic events in patients with moyamoya disease. Clin Neurol Neurosurg 2018; 173:65-69. [PMID: 30089245 DOI: 10.1016/j.clineuro.2018.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/16/2018] [Accepted: 07/29/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This retrospective study aimed to explore the impact of seasonal variations on the first ischemic events in patients with moyamoya disease (MMD). PATIENTS AND METHODS Based on the first-time ischemic event occurrence, 113 patients, including 84 with cerebral infarction and 29 with transient ischemic attack, who were diagnosed with ischemic MMD were divided into four groups: spring (March-May), summer (June-August), autumn (September-November) and winter (December-February). The incidence of cerebral infarction was considered as the primary parameter. The impact of seasonal variations on the occurrence of cerebral infarction was analyzed by Poisson regression model and seasonal analysis. RESULTS When summer was set as the reference, patients in summer were more significantly susceptible to develop cerebral infarction as compared with spring (IRR, 0.529, 95%CI, 0.299-0.937, p = 0.03), autumn (IRR, 0.441, 95%CI, 0.240-0.810, p < 0.01) and winter (0.500, 95%CI, 0.279-0.895, p = 0.02). The seasonality of the time series in summer (1.231) was substantially higher than that in the other three seasons (-0.269 in spring, -0.656 in autumn and -0.306 in winter). No discrepancy in either NIHSS or mRS scores at admission was observed among the four seasons. CONCLUSION Patients with MMD may be more vulnerable to cerebral infarction in summer compared with the other three seasons, and seasonal onset of cerebral infarction does not seem to be associated with the severity of neurological disability at admission.
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Affiliation(s)
- Jiayue Ding
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China; Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Da Zhou
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China; Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Shuling Shang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China; Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Neurology, Tangshan Union Medical College Hospital, Tangshan, 063000, China
| | - Liqun Pan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China; Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Jingyuan Ya
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China; Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yuchuan Ding
- Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
| | - Xunming Ji
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China; Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China; Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
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26
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Ishihara T, Sato S, Uehara T, Ohara T, Hayakawa M, Kimura K, Okada Y, Hasegawa Y, Tanahashi N, Suzuki A, Nakagawara J, Arii K, Nagahiro S, Ogasawara K, Uchiyama S, Matsumoto M, Iihara K, Toyoda K, Minematsu K. Significance of Nonfocal Symptoms in Patients With Transient Ischemic Attack. Stroke 2018; 49:1893-1898. [PMID: 30012818 DOI: 10.1161/strokeaha.118.022009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Patients with transient ischemic attack (TIA) occasionally show nonfocal symptoms, such as unconsciousness, amnesia, and unsteadiness. The purpose of this study was to clarify the characteristics and prognosis of patients with TIA with nonfocal symptoms, using data from the PROMISE-TIA (Prospective Multicenter Registry to Identify Subsequent Cardiovascular Events After Transient Ischemic Attack). Methods- Patients with TIA within 7 days of onset were consecutively enrolled in the Japanese nationwide registry. Factors associated with nonfocal symptoms and 1-year risks of ischemic stroke and coronary artery diseases were assessed in multivariate-adjusted models. Results- We studied 1362 patients with TIA (879 men; mean age, 69±12 years), including 219 (16%) with nonfocal symptoms. Patients with TIA with nonfocal symptoms were more likely to show acute ischemic lesions in the posterior circulation on diffusion-weighted imaging (multivariate-adjusted odds ratio, 3.07; 95% confidence interval, 1.57-5.82) and arterial stenosis or occlusion in the posterior circulation on vascular examination (odds ratio, 1.94; 95% confidence interval, 1.19-3.09) than those without nonfocal symptoms. Although 1-year risk of ischemic stroke did not differ significantly between groups (adjusted hazard ratio, 0.79; 95% confidence interval, 0.42-1.37), risk of coronary artery disease was higher in patients with TIA with nonfocal symptoms (hazard ratio, 3.37; 95% confidence interval, 1.14-9.03). Conclusions- Both acute ischemic lesions and arterial stenosis and occlusion in the posterior circulation were more frequently observed in patients with TIA with nonfocal symptoms.
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Affiliation(s)
- Toshiya Ishihara
- From the Department of Cerebrovascular Medicine (T.I., S.S., T.U., T.O., M.H., K.T., K.M.)
| | - Shoichiro Sato
- From the Department of Cerebrovascular Medicine (T.I., S.S., T.U., T.O., M.H., K.T., K.M.)
| | - Toshiyuki Uehara
- From the Department of Cerebrovascular Medicine (T.I., S.S., T.U., T.O., M.H., K.T., K.M.)
| | - Tomoyuki Ohara
- From the Department of Cerebrovascular Medicine (T.I., S.S., T.U., T.O., M.H., K.T., K.M.)
| | - Mikito Hayakawa
- From the Department of Cerebrovascular Medicine (T.I., S.S., T.U., T.O., M.H., K.T., K.M.)
| | - Kazumi Kimura
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K.K.)
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Yasuhiro Hasegawa
- Department of Neurology, Nagoya Daini Red Cross Hospital, Japan (Y.H.)
| | - Norio Tanahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama International Medical Center, Saitama Medical University, Hidaka, Japan (N.T.)
| | - Akifumi Suzuki
- Department of Stroke Science, Research Institute for Brain and Blood Vessels-Akita, Japan (A.S.)
| | - Jyoji Nakagawara
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan (J.N.)
| | - Kazumasa Arii
- Department of Neurology, Ebara Hospital, Tokyo, Japan (K.A.)
| | - Shinji Nagahiro
- Department of Neurosurgery, Tokushima University, Japan (S.N.)
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan (K.O.)
| | | | - Masayasu Matsumoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Japan (M.M.)
| | - Koji Iihara
- Department of Neurosurgery (K.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- From the Department of Cerebrovascular Medicine (T.I., S.S., T.U., T.O., M.H., K.T., K.M.)
| | - Kazuo Minematsu
- From the Department of Cerebrovascular Medicine (T.I., S.S., T.U., T.O., M.H., K.T., K.M.)
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Parikh NS, Merkler AE, Kummer BR, Kamel H. Ischemic Stroke After Emergency Department Discharge for Symptoms of Transient Neurological Attack. Neurohospitalist 2018; 8:135-140. [PMID: 29977444 DOI: 10.1177/1941874417750996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose The significance of transient neurological attack (TNA) symptoms is unclear. We sought to determine the risk of ischemic stroke after discharge from the emergency department (ED) with a diagnosis consistent with symptoms of TNA. Methods Using administrative claims data, we identified patients discharged from EDs in New York between 2006 and 2012 with a primary discharge diagnosis of a TNA symptom, defined as altered mental status, generalized weakness, and sensory changes. The primary outcome was ischemic stroke. We used Kaplan-Meier survival statistics to calculate cumulative rates, and Cox regression to compare stroke risk after TNA versus after transient ischemic attack (TIA; positive control) or renal colic (negative control) while adjusting for demographics and vascular risk factors. Results Of 499 369 patients diagnosed with a TNA symptom and discharged from the ED, 7756 were hospitalized for ischemic stroke over a period of 4.7 (±1.9) years. At 90 days, the cumulative stroke rate was 0.29% (95% confidence interval [CI]: 0.28%-0.31%) after TNA symptoms versus 2.08% (95% CI: 1.89%-2.28%) after TIA and 0.03% (95% CI: 0.02%-0.04%) after renal colic. The hazard ratio (HR) of stroke was higher after TNA than after renal colic (HR: 2.13; 95% CI: 1.90-2.40) but significantly lower than after TIA (HR: 0.47; 95% CI: 0.44-0.50). Compared to TIA, TNA was less strongly associated with stroke among patients under 60 years of age compared to those over 60. Conclusions Patients discharged from the ED with TNA symptoms faced a higher risk of ischemic stroke than patients with renal colic, but the magnitude of stroke risk was low, particularly compared to TIA.
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Affiliation(s)
- Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.,Department of Neurology, Columbia University, New York, NY, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.,Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Benjamin R Kummer
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.,Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.,Department of Neurology, Weill Cornell Medicine, New York, NY, USA
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Abstract
PURPOSE OF REVIEW An increasing number of patients are receiving oral anticoagulants. Since non-vitamin K antagonist oral anticoagulants (NOACs) were approved, primary prevention of ischemic stroke has become simpler. However, managing ischemic stroke and intracerebral hemorrhage while on oral anticoagulation (OAC) has become more complex. This review covers the latest developments in managing ischemic and hemorrhagic stroke in patients receiving vitamin K antagonists (VKA) and NOACs. RECENT FINDINGS Testing coagulation in patients with acute ischemic stroke and receiving NOACs is complex, and observational data challenge guideline recommendations. Initial registry and cohort data support the safety of endovascular therapy despite OAC. In intracerebral hemorrhage, rapid reversal of VKA can be achieved better with prothrombin complex concentrates than with fresh frozen plasma. Furthermore, rapid reversal seems to be associated with less hematoma expansion and better functional outcome. In addition, new evidence strongly supports resuming OAC after intracerebral hemorrhage. The unfavorable properties of NOAC-related intracerebral hemorrhage are similar to those associated with VKA. SUMMARY Translation of recent findings might improve both outcome in acute ischemic and hemorrhagic stroke in patients on oral anticoagulants and help refine clinical management. Data from randomized clinical trials are scarce.
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Executive Function Declines in the First 6 Months After a Transient Ischemic Attack or Transient Neurological Attack. Stroke 2017; 48:3323-3328. [DOI: 10.1161/strokeaha.117.018298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/30/2017] [Accepted: 10/04/2017] [Indexed: 11/16/2022]
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Subjective Cognitive Impairment, Depressive Symptoms, and Fatigue after a TIA or Transient Neurological Attack: A Prospective Study. Behav Neurol 2017; 2017:5181024. [PMID: 29348702 PMCID: PMC5733631 DOI: 10.1155/2017/5181024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 09/30/2017] [Accepted: 10/08/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction Subjective cognitive impairment (SCI), depressive symptoms, and fatigue are common after stroke and are associated with reduced quality of life. We prospectively investigated their prevalence and course after a transient ischemic attack (TIA) or nonfocal transient neurological attack (TNA) and the association with diffusion-weighted imaging (DWI) lesions. Methods The Cognitive Failures Questionnaire, Hospital Anxiety and Depression Scale, and Subjective Fatigue subscale from the Checklist Individual Strength were used to assess subjective complaints shortly after TIA or TNA and six months later. With repeated measure analysis, the associations between DWI lesion presence or clinical diagnosis (TIA or TNA) and subjective complaints over time were determined. Results We included 103 patients (28 DWI positive). At baseline, SCI and fatigue were less severe in DWI positive than in DWI negative patients, whereas at follow-up, there were no differences. SCI (p = 0.02) and fatigue (p = 0.01) increased in severity only in DWI positive patients. There were no differences between TIA and TNA. Conclusions Subjective complaints are highly prevalent in TIA and TNA patients. The short-term prognosis is not different between DWI-positive and DWI negative patients, but SCI and fatigue increase in severity within six months after the event when an initial DWI lesion is present.
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van Rooij FG, Kessels RPC, Richard E, De Leeuw FE, van Dijk EJ. Cognitive Impairment in Transient Ischemic Attack Patients: A Systematic Review. Cerebrovasc Dis 2017; 42:1-9. [PMID: 26886189 DOI: 10.1159/000444282] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 01/05/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although by definition a transient ischemic attack (TIA) lasts less than 24 h, many patients experience cognitive complaints beyond focal symptom resolution. However, their prevalence, causes and profile are unclear. We therefore performed a systematic review on cognitive impairment after TIA. SUMMARY Medline and Embase were searched for relevant studies. Risk of bias was assessed, and data synthesis was performed according to the severity of cognitive impairment. Thirteen studies were included, with considerable heterogeneity concerning methods and timing of cognitive testing. Confounding, detection bias and attrition were the main causes of a high risk of bias in several studies. The prevalence of post-TIA mild cognitive impairment ranged from 29 to 68%. Severe cognitive impairment was found in 8-22% of patients. Studies using a cognitive screening instrument and those performed shortly after TIA or several years later, reported the highest frequencies of impairment. Patients evaluated with a screening tool were substantially older than those who underwent a full neuropsychological assessment (weighted mean age difference 10.9 years). Based on limited data, the post-TIA cognitive profile showed prominent executive function deficits. Insufficient data refrained us from drawing conclusions on causality. The few studies that reported neuroimaging results found a minor correlation with cognitive impairment. KEY MESSAGES Mild cognitive impairment is present in more than a third of the TIA patients and has a profile comparable with vascular cognitive impairment. Reported rates of post-TIA cognitive impairment are highly variable and higher frequencies are found with cognitive screening tools. Considerable heterogeneity and insufficient data limit further conclusions about potential causative factors.
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Affiliation(s)
- Frank G van Rooij
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
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Abbott AL, Silvestrini M, Topakian R, Golledge J, Brunser AM, de Borst GJ, Harbaugh RE, Doubal FN, Rundek T, Thapar A, Davies AH, Kam A, Wardlaw JM. Optimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice. Front Neurol 2017; 8:537. [PMID: 29104559 PMCID: PMC5654955 DOI: 10.3389/fneur.2017.00537] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/25/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Until now, stroke and transient ischemic attack (TIA) have been clinically based terms which describe the presence and duration of characteristic neurological deficits attributable to intrinsic disorders of particular arteries supplying the brain, retina, or (sometimes) the spinal cord. Further, infarction has been pathologically defined as death of neural tissue due to reduced blood supply. Recently, it has been proposed we shift to definitions of stroke and TIA determined by neuroimaging results alone and that neuroimaging findings be equated with infarction. METHODS We examined the scientific validity and clinical implications of these proposals using the existing published literature and our own experience in research and clinical practice. RESULTS We found that the proposals to change to imaging-dominant definitions, as published, are ambiguous and inconsistent. Therefore, they cannot provide the standardization required in research or its application in clinical practice. Further, we found that the proposals are scientifically incorrect because neuroimaging findings do not always correlate with the clinical status or the presence of infarction. In addition, we found that attempts to use the proposals are disrupting research, are otherwise clinically unhelpful and do not solve the problems they were proposed to solve. CONCLUSION We advise that the proposals must not be accepted. In particular, we explain why the clinical focus of the definitions of stroke and TIA should be retained with continued sub-classification of these syndromes depending neuroimaging results (with or without other information) and that infarction should remain a pathological term. We outline ways the established clinically based definitions of stroke and TIA, and use of them, may be improved to encourage better patient outcomes in the modern era.
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Affiliation(s)
- Anne L. Abbott
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- The Neurology Department, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - Alejandro M. Brunser
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana – Universidad del Desarrollo, Santiago, Chile
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Centre of Utrecht, Utrecht, Netherlands
| | - Robert E. Harbaugh
- Department of Neurosurgery, Penn State University, State College, PA, United States
| | - Fergus N. Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Department of Medicine, Elderly Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, Miami, FL, United States
| | - Ankur Thapar
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College, London, United Kingdom
| | - Alun H. Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom
| | - Anthony Kam
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, UK Dementia Research Institute at the University of Edinburgh, Edinburgh, United Kingdom
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van Hoof RHM, Schreuder FHBM, Nelemans P, Truijman MTB, van Orshoven NP, Schreuder TH, Mess WH, Heeneman S, van Oostenbrugge RJ, Wildberger JE, Kooi ME. Ischemic Stroke Patients Demonstrate Increased Carotid Plaque Microvasculature Compared to (Ocular) Transient Ischemic Attack Patients. Cerebrovasc Dis 2017; 44:297-303. [PMID: 28946147 DOI: 10.1159/000481146] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 08/24/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Patients with a recent ischemic stroke have a higher risk of recurrent stroke compared to (ocular) transient ischemic attack (TIA) patients. Plaque microvasculature is considered as a feature of plaque vulnerability and can be quantified with carotid dynamic contrast-enhanced MRI (DCE-MRI). The purpose of this cross-sectional study was to explore the association between plaque microvasculature and the type of recent cerebrovascular events in symptomatic patients with mild-to-moderate carotid stenosis. METHODS A total of 87 symptomatic patients with a recent stroke (n = 35) or (ocular) TIA (n = 52) underwent carotid DCE-MRI examination. Plaque microvasculature was studied in the vessel wall and adventitia using DCE-MRI and the pharmacokinetic modeling parameter Ktrans. Statistical analysis was performed with logistic regression, correcting for associated clinical risk factors. RESULTS The 75th percentile adventitial (OR 1.97, 95% CI 1.18-3.29) Ktrans was significantly associated with a recent ischemic stroke compared to (ocular) TIA in multivariate analysis, while clinical risk factors were not significantly associated with the type of event. CONCLUSIONS This study indicates a positive association of leaky plaque microvasculature with a recent ischemic stroke compared to (ocular) TIA. Prospective longitudinal studies are needed to investigate whether Ktrans or other plaque characteristics may serve as an imaging marker for predicting (the type of) future cerebrovascular events.
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Affiliation(s)
- Raf H M van Hoof
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Brainstem stroke preceded by transient isolated vertigo attacks. J Neurol 2017; 264:2170-2172. [PMID: 28894926 PMCID: PMC5617861 DOI: 10.1007/s00415-017-8610-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 11/03/2022]
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Lee J, Inoue M, Mlynash M, Mann SK, Cereda CW, Ke M, Albers GW, Olivot JM. MR perfusion lesions after TIA or minor stroke are associated with new infarction at 7 days. Neurology 2017; 88:2254-2259. [PMID: 28500226 DOI: 10.1212/wnl.0000000000004039] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/24/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the relationship between acute perfusion-weighted imaging (PWI) lesions occurring within the first hours after a TIA or a minor brain infarction (BI) and the incidence of new BI detected on a systematic MRI at 1 week. METHODS Consecutive patients who experienced a TIA or BI with a neurologic deficit that lasted <24 hours, did not receive any revascularization therapy (thrombolysis/thrombectomy), and underwent DWI/PWI at baseline and fluid-attenuated inversion recovery (FLAIR)/DWI 1 week after symptom onset were enrolled. Investigators blinded to clinical information independently assessed the presence of acute ischemic lesions on baseline DWI/PWI and follow-up DWI and FLAIR. Baseline and follow-up MRIs were then compared to determine the occurrence and location of new infarctions. RESULTS Sixty-four patients met the inclusion criteria. Median (IQR) ABCD2 score was 4 (3-5). Median delay from onset to baseline and follow-up MRI was 5 (2-10) hours and 6 (5-7) days, respectively. MRI revealed an acute ischemic lesion on DWI and/or PWI in 38 patients. Nine patients (14%) had a new infarction on follow-up MRI. Each had a PWI and 4 had a DWI lesion on baseline MRI. All new BIs except one were asymptomatic and in the same location as the acute PWI lesion. CONCLUSIONS Our results showed that 30% of the acute focal PWI lesions detected after a TIA are associated with a new BI at 1 week. Those new BIs may result from the progression of the initial ischemic injury.
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Affiliation(s)
- Jun Lee
- From Yeungnam University Medical Center (J.L.), Daegu, South Korea; Department of Vascular Medicine (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Stanford Stroke Center (M.M., G.W.A.), Stanford University, CA; Division of Neurology (S.K.M.), University of British Columbia, Vancouver, Canada; Stroke Center Neurocenter of Southern Switzerland (C.W.C.), Ospedale Civico, Switzerland; California Pacific Medical Center (M.K.), San Francisco; and Toulouse Neuroimaging Center UMR 1214 (J.M.O.), Stroke Unit, Toulouse University Hospital, France
| | - Manabu Inoue
- From Yeungnam University Medical Center (J.L.), Daegu, South Korea; Department of Vascular Medicine (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Stanford Stroke Center (M.M., G.W.A.), Stanford University, CA; Division of Neurology (S.K.M.), University of British Columbia, Vancouver, Canada; Stroke Center Neurocenter of Southern Switzerland (C.W.C.), Ospedale Civico, Switzerland; California Pacific Medical Center (M.K.), San Francisco; and Toulouse Neuroimaging Center UMR 1214 (J.M.O.), Stroke Unit, Toulouse University Hospital, France
| | - Michael Mlynash
- From Yeungnam University Medical Center (J.L.), Daegu, South Korea; Department of Vascular Medicine (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Stanford Stroke Center (M.M., G.W.A.), Stanford University, CA; Division of Neurology (S.K.M.), University of British Columbia, Vancouver, Canada; Stroke Center Neurocenter of Southern Switzerland (C.W.C.), Ospedale Civico, Switzerland; California Pacific Medical Center (M.K.), San Francisco; and Toulouse Neuroimaging Center UMR 1214 (J.M.O.), Stroke Unit, Toulouse University Hospital, France
| | - Sharanpal K Mann
- From Yeungnam University Medical Center (J.L.), Daegu, South Korea; Department of Vascular Medicine (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Stanford Stroke Center (M.M., G.W.A.), Stanford University, CA; Division of Neurology (S.K.M.), University of British Columbia, Vancouver, Canada; Stroke Center Neurocenter of Southern Switzerland (C.W.C.), Ospedale Civico, Switzerland; California Pacific Medical Center (M.K.), San Francisco; and Toulouse Neuroimaging Center UMR 1214 (J.M.O.), Stroke Unit, Toulouse University Hospital, France
| | - Carlo W Cereda
- From Yeungnam University Medical Center (J.L.), Daegu, South Korea; Department of Vascular Medicine (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Stanford Stroke Center (M.M., G.W.A.), Stanford University, CA; Division of Neurology (S.K.M.), University of British Columbia, Vancouver, Canada; Stroke Center Neurocenter of Southern Switzerland (C.W.C.), Ospedale Civico, Switzerland; California Pacific Medical Center (M.K.), San Francisco; and Toulouse Neuroimaging Center UMR 1214 (J.M.O.), Stroke Unit, Toulouse University Hospital, France
| | - Michael Ke
- From Yeungnam University Medical Center (J.L.), Daegu, South Korea; Department of Vascular Medicine (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Stanford Stroke Center (M.M., G.W.A.), Stanford University, CA; Division of Neurology (S.K.M.), University of British Columbia, Vancouver, Canada; Stroke Center Neurocenter of Southern Switzerland (C.W.C.), Ospedale Civico, Switzerland; California Pacific Medical Center (M.K.), San Francisco; and Toulouse Neuroimaging Center UMR 1214 (J.M.O.), Stroke Unit, Toulouse University Hospital, France
| | - Gregory W Albers
- From Yeungnam University Medical Center (J.L.), Daegu, South Korea; Department of Vascular Medicine (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Stanford Stroke Center (M.M., G.W.A.), Stanford University, CA; Division of Neurology (S.K.M.), University of British Columbia, Vancouver, Canada; Stroke Center Neurocenter of Southern Switzerland (C.W.C.), Ospedale Civico, Switzerland; California Pacific Medical Center (M.K.), San Francisco; and Toulouse Neuroimaging Center UMR 1214 (J.M.O.), Stroke Unit, Toulouse University Hospital, France
| | - Jean M Olivot
- From Yeungnam University Medical Center (J.L.), Daegu, South Korea; Department of Vascular Medicine (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Stanford Stroke Center (M.M., G.W.A.), Stanford University, CA; Division of Neurology (S.K.M.), University of British Columbia, Vancouver, Canada; Stroke Center Neurocenter of Southern Switzerland (C.W.C.), Ospedale Civico, Switzerland; California Pacific Medical Center (M.K.), San Francisco; and Toulouse Neuroimaging Center UMR 1214 (J.M.O.), Stroke Unit, Toulouse University Hospital, France.
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Choi JH, Park MG, Choi SY, Park KP, Baik SK, Kim JS, Choi KD. Acute Transient Vestibular Syndrome. Stroke 2017; 48:556-562. [DOI: 10.1161/strokeaha.116.015507] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/28/2016] [Accepted: 12/05/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The aim of this study was to determine the prevalence of stroke and efficacy of bedside evaluation in diagnosing stroke in acute transient vestibular syndrome (ATVS).
Methods—
We performed a prospective, single-center, observational study that had consecutively recruited 86 patients presenting with ATVS to the emergency department of Pusan National University Yangsan Hospital from January to December 2014. All patients received a constructed evaluation, including HINTS plus (head impulse, nystagmus patterns, test of skew, and finger rubbing) and brain magnetic resonance imagings. Patients without an obvious cause further received perfusion-weighted imaging. Multivariable logistic regression was used to determine clinical parameters to identify stroke in ATVS.
Results—
The prevalence of stroke was 27% in ATVS. HINTS plus could not be applied to the majority of patients because of the resolution of the vestibular symptoms, and magnetic resonance imagings were falsely negative in 43% of confirmed strokes. Ten patients (12%) showed unilateral cerebellar hypoperfusion on perfusion-weighted imaging without an infarction on diffusion-weighted imaging, and 8 of them had a focal stenosis or hypoplasia of the corresponding vertebral artery. The higher risk of stroke in ATVS was found in association with craniocervical pain (odds ratio, 9.6; 95% confidence interval, 2.0–45.2) and focal neurological symptoms/signs (odds ratio, 15.2; 95% confidence interval, 2.5–93.8).
Conclusions—
Bedside examination and routine magnetic resonance imagings have a limitation in diagnosing strokes presenting with ATVS, and perfusion imaging may help to identify strokes in ATVS of unknown cause. Associated craniocervical pain and focal neurological symptoms/signs are the useful clues for strokes in ATVS.
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Affiliation(s)
- Jae-Hwan Choi
- From the Department of Neurology (J.-H.C., M.-G.P., K.-P.P.) and Radiology (S.K.B.), Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea; Department of Neurology, Seoul National University Bundang Hospital, South Korea (S.Y.C., J.-S.K.); and Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute
| | - Min-Gyu Park
- From the Department of Neurology (J.-H.C., M.-G.P., K.-P.P.) and Radiology (S.K.B.), Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea; Department of Neurology, Seoul National University Bundang Hospital, South Korea (S.Y.C., J.-S.K.); and Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute
| | - Seo Young Choi
- From the Department of Neurology (J.-H.C., M.-G.P., K.-P.P.) and Radiology (S.K.B.), Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea; Department of Neurology, Seoul National University Bundang Hospital, South Korea (S.Y.C., J.-S.K.); and Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute
| | - Kyung-Pil Park
- From the Department of Neurology (J.-H.C., M.-G.P., K.-P.P.) and Radiology (S.K.B.), Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea; Department of Neurology, Seoul National University Bundang Hospital, South Korea (S.Y.C., J.-S.K.); and Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute
| | - Seung Kug Baik
- From the Department of Neurology (J.-H.C., M.-G.P., K.-P.P.) and Radiology (S.K.B.), Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea; Department of Neurology, Seoul National University Bundang Hospital, South Korea (S.Y.C., J.-S.K.); and Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute
| | - Ji-Soo Kim
- From the Department of Neurology (J.-H.C., M.-G.P., K.-P.P.) and Radiology (S.K.B.), Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea; Department of Neurology, Seoul National University Bundang Hospital, South Korea (S.Y.C., J.-S.K.); and Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute
| | - Kwang-Dong Choi
- From the Department of Neurology (J.-H.C., M.-G.P., K.-P.P.) and Radiology (S.K.B.), Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea; Department of Neurology, Seoul National University Bundang Hospital, South Korea (S.Y.C., J.-S.K.); and Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute
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37
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Lee EJ, Cho YP, Lee SH, Lee JS, Nam HJ, Kim BJ, Kwon TW, Kang DW, Kim JS, Kwon SU. Hemodynamic Tandem Intracranial Lesions on Magnetic Resonance Angiography in Patients Undergoing Carotid Endarterectomy. J Am Heart Assoc 2016; 5:JAHA.116.004153. [PMID: 27702804 PMCID: PMC5121513 DOI: 10.1161/jaha.116.004153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Hemodynamic tandem intracranial lesions (TILs) on intracranial magnetic resonance angiography, which develop flow dependently, have been overlooked clinically in patients undergoing carotid endarterectomy. As they represent severe baseline hemodynamic compromise at the segment, they may be associated with distinctive clinical outcomes. Methods and Results We assessed 304 consecutive carotid endarterectomy cases treated over 3 years. Included cases had both preoperative and postoperative intracranial 3‐dimensional time‐of‐flight magnetic resonance angiography, of which signal intensities are flow dependent, and postoperative diffusion‐weighted imaging (≤3 days following carotid endarterectomy). Preoperative TILs in the ipsilateral intracranial arteries were evaluated by the presence of nonexclusive components: focal stenosis (>50%), diffuse stenosis (>50%), and decreased signal intensities (>50%). The components showing postoperative normalization were considered hemodynamic. TILs with hemodynamic components were defined as hemodynamic TILs, while others as consistent TILs. Baseline characteristics and postoperative outcomes were analyzed among 3 groups: no TILs, consistent TILs, and hemodynamic TILs. Preoperative TILs were identified in 104 (34.2%) cases; 54 (17.8%) had hemodynamic components. Diffuse stenosis and decreased signal intensities were usually reversed postoperatively. Patients with hemodynamic TILs tended to have severe proximal carotid stenosis and recent strokes (≤14 days). For the outcome, hemodynamic TILs were independently associated with the advent of postoperative ischemic lesions on diffusion‐weighted imaging (odds ratio: 2.50; 95% CI, 1.20–5.20). Conclusions In patients undergoing carotid endarterectomy, a significant number of preoperative TILs demonstrated hemodynamic components, which were reversed postoperatively. The presence of such components was distinctively associated with the postoperative incidence of new ischemic lesions.
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Affiliation(s)
- Eun-Jae Lee
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Yong-Pil Cho
- Department of Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Sang-Hun Lee
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Hyo Jung Nam
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, KyungHee University, Seoul, Korea
| | - Tae-Won Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
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38
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Tanislav C, Grittner U, Fazekas F, Thijs V, Tatlisumak T, Huber R, von Sarnowski B, Putaala J, Schmidt R, Kropp P, Norrving B, Martus P, Gramsch C, Giese AK, Rolfs A, Enzinger C. Frequency and predictors of acute ischaemic lesions on brain magnetic resonance imaging in young patients with a clinical diagnosis of transient ischaemic attack. Eur J Neurol 2016; 23:1174-82. [PMID: 27105904 DOI: 10.1111/ene.13012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/01/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Acute lesions in patients with transient ischaemic attack (TIA) are important as they are associated with increased risk for recurrence. Characteristics associated with acute lesions in young TIA patients were therefore investigated. METHODS The sifap1 study prospectively recruited a multinational European cohort (n = 5023) of patients aged 18-55 years with acute cerebrovascular event. The detection of acute ischaemic lesions was based on diffusion-weighted imaging (DWI). The frequency of DWI lesions was assessed in 829 TIA patients who met the criteria of symptom duration <24 h and their association with demographic, clinical and imaging variables was analysed. RESULTS The median age was 46 years (interquartile range 40-51 years); 45% of the patients were female. In 121 patients (15%) ≥1 acute DWI lesion was detected. In 92 patients, DWI lesions were found in the anterior circulation, mostly located in cortical-subcortical areas (n = 63). Factors associated with DWI lesions in multiple regression analysis were left hemispheric presenting symptoms [odds ratio (OR) 1.92, 95% confidence interval (CI) 1.27-2.91], dysarthria (OR 2.17, 95% CI 1.38-3.43) and old brain infarctions on MRI (territories of the middle and posterior cerebral artery: OR 2.43, 95% CI 1.42-4.15; OR 2.41, 95% CI 1.02-5.69, respectively). CONCLUSIONS In young patients with a clinical TIA 15% demonstrated acute DWI lesions on brain MRI, with an event pattern highly suggestive of an embolic origin. Except for the association with previous infarctions there was no clear clinical predictor for acute ischaemic lesions, which indicates the need to obtain MRI in young individuals with TIA.
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Affiliation(s)
- C Tanislav
- Department of Neurology, Justus Liebig University, Giessen, Germany
| | - U Grittner
- Department for Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - F Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - V Thijs
- Clinical and Experimental Neurology, Leuven, Belgium
| | - T Tatlisumak
- Institute of Neuroscience and Physiology and Department of Neurology, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.,Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - R Huber
- Department of Neurology, Klinikum Friedrichshafen, Friedrichshafen, Germany
| | - B von Sarnowski
- Department of Neurology, University of Greifswald, Greifswald, Germany
| | - J Putaala
- Institute of Neuroscience and Physiology and Department of Neurology, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - R Schmidt
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - P Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock, Rostock, Germany
| | - B Norrving
- Department of Clinical Neuroscience, Lund University Hospital, Lund, Sweden
| | - P Martus
- Department for Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - C Gramsch
- Department of Neurology, Justus Liebig University, Giessen, Germany
| | - A K Giese
- Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany
| | - A Rolfs
- Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany
| | - C Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
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