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Caruso P, Prandin G, Rossi L, Cegalin M, Lugnan C, Pasquin F, Sisto UG, Furlanis G, Naccarato M, Cominotto F, Manganotti P. Epidemiology and management of transient ischemic attack in Trieste district, how day hospital assessment improves outcomes: a five-year retrospective study. Neurol Sci 2024; 45:3861-3867. [PMID: 38467952 DOI: 10.1007/s10072-024-07443-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Transient ischemic attack (TIA) is defined as a transient episode of neurologic dysfunction, without acute infarction or tissue injury lasting less than 24 h. Previous data suggest TIA precedes 15% of ischemic strokes, with a higher risk in the first week. Current practice guidelines advise evaluation through rapid neurological visit or admission to hospital. We provide data on TIA incidence in Trieste, and we compare three different types of assessment: day hospital (DH), stroke unit (SU), and emergency department/outpatients (ED). METHODS This is a 5-year retrospective study of transient cerebrovascular events admitted in the University Hospital of Trieste (230.623 inhabitants), between 2016 and 2020. We calculated TIA prevalence in Trieste district's general population. Our primary endpoint is ischemic recurrences within 90 days, and we evaluate the possible association between different types of management. RESULTS TIA incidence rate was 0.54/1000 inhabitants. In the multivariate analysis remained significantly associated with primary endpoint: ABCD2 (OR 1.625, CI 95% 1.114-2.369, p = 0.012) and DH evaluation (OR 0.260, CI 95% 0.082-0.819, p = 0.021). CONCLUSIONS Incidence of TIA in Trieste district is in line with previous data. We demonstrate the crucial role of DH evaluation over the outpatient/ED in reducing overall mortality and recurrence rate. Prompt recognition of patients at high risk for cerebrovascular events and specialist follow-up may reduce the incidence of major vascular events and death.
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Affiliation(s)
- Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Gabriele Prandin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy.
| | - Lucrezia Rossi
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Matteo Cegalin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Fulvio Pasquin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Ugo Giulio Sisto
- Emergency Department, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Franco Cominotto
- Emergency Department, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
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Yi Y, Zhang G, Lv S, Rong Y, Liu H, Li M. Comparative efficacy and safety of traditional Chinese medicine injections in patients with transient ischemic attack: A systematic review and network meta-analysis. PLoS One 2024; 19:e0307663. [PMID: 39047053 PMCID: PMC11268667 DOI: 10.1371/journal.pone.0307663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 07/04/2024] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVES Traditional Chinese medicine (TCM) injections are extensively utilized for the treatment of transient ischemic attack (TIA). However, it remains unclear which specific TCM injection exhibits superior efficacy. In this study, we conducted a network meta-analysis to compare the clinical efficacy and safety of various TCM injections in the treatment of TIA, with the aim of identifying the optimal treatment regimen. DESIGN We searched seven databases to collect information on nine TCM injections for the treatment of transient randomized controlled trials (RCTs) for the treatment of transient ischemic attacks were collected from the establishment to August 2023. The methodological quality and risk of bias were assessed using the RoB 2.0 evaluation tool, and reticulated Meta-analysis was performed using R software and Stata software. RESULTS We ultimately included 58 RCTs involving 5502 patients and comprising 9 TCM injections. In terms of improving the total effective rate, Shuxuetong injection (P-score = 0.69) was the most effective. In addition, Shuxuetong injection was most effective in lowering total cholesterol (P-score = 1.00) and triglyceride (P-score = 1.00) levels. Notably, Shuxuetong injection remained the most prominent in reducing fibrinogen (P-score = 0.91). However, among other blood hemorheology indicators, Dengzhanhuasu injection was the best regimen in reducing plasma viscosity (P-score = 1.00), whole blood viscosity (high shear rate) (P-score = 0.87), and whole blood viscosity (low shear rate) (P-score = 0.90). It was found that Yinxingyetiquwu injection (P-score = 0.72) was the most effective in reducing the incidence of cerebral infarction. In terms of safety, 22 studies reported adverse effects and descriptive analyses showed that the number of adverse effects of combination therapy was comparable to that of conventional therapy and that the safety profile was good. CONCLUSIONS TCM injections in combination with CT may be a safe and effective intervention for patients with TIA, of which Shuxuetong injection, Dengzhanhuasu injection, and Yinxingyetiquwu injection may be more noteworthy. The quality of the literature included in the study was low, so further validation is needed with larger sample sizes, higher quality, and more rigorously designed RCTs. SYSTEMATIC REVIEW REGISTRATION [PROSPERO], identifier [CRD42023443652].
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Affiliation(s)
- Yunhao Yi
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Guangheng Zhang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Shimeng Lv
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yuanhang Rong
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Hui Liu
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Ming Li
- Office of Academic Affairs, Shandong University of Traditional Chinese Medicine, Jinan, China
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Hacialioglu RA, Kielkopf M, Branca M, Clenin L, Boronylo A, Silimon N, Göldlin MB, Scutelnic A, Kaesmacher J, Mujanovic A, Meinel TR, Seiffge DJ, Heldner MR, Liberman AL, Navi BB, Fischer U, Arnold M, Jung S, Bücke P, Beyeler M. Factors impacting D-dimer levels in patients with acute ischemic cerebrovascular events. J Stroke Cerebrovasc Dis 2024; 33:107834. [PMID: 38936311 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/12/2024] [Accepted: 06/23/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND AND OBJECTIVES A better understanding of the factors influencing D-dimer levels in code stroke patients is needed to guide further investigations of concomitant thrombotic conditions. This study aimed to investigate the impact of time from symptom onset and other factors on D-dimer levels in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). METHODS Data on consecutive AIS and TIA patients treated at our tertiary-care stroke center between January 2015 and December 2020 were retrospectively assessed. Patients with available D-dimer levels were evaluated for eligibility. Multivariable non-linear regression analyses were performed. RESULTS In total, 2467 AIS patients and 708 TIA patients were included. The median D-dimer levels differed between the AIS and TIA groups (746 µg/L [interquartile range 381-1468] versus 442 µg/L [interquartile range 244-800], p<0.001). In AIS patients, an early increase in D-dimer levels was demonstrated within the first 6 h (standardized beta coefficient [β] 0.728; 95% confidence interval [CI] 0.324-1.121). This was followed by an immediate decrease (β -13.022; 95% CI -20.401 to -5.643) and then by a second, late increase after 35 h (β 11.750; 95% CI 4.71-18.791). No time-dependent fluctuation in D-dimer levels was observed in TIA patients. CONCLUSION The time from symptom onset may affect D-dimer levels in patients with AIS but not those with TIA. Further studies confirming these findings and validating time-specific variations are needed to enable D-dimer levels to be used efficiently as an acute stroke and thrombotic risk biomarker.
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Affiliation(s)
- Recep-Ali Hacialioglu
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Moritz Kielkopf
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mattia Branca
- CTU Bern, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Leander Clenin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Anna Boronylo
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Norbert Silimon
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Martina B Göldlin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA; Graduate School for Health Sciences, University of Bern, Switzerland.
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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Lima Neto AC, Bittar RSM. Vascular vertigo and dizziness: managing and treating outpatients. Braz J Otorhinolaryngol 2024; 90:101453. [PMID: 38991403 PMCID: PMC11295563 DOI: 10.1016/j.bjorl.2024.101453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/14/2024] [Accepted: 05/23/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVE Due the lack of data on the treatment of Vascular Vertigo and Dizziness, this study aimed to report how we managed and treated those outpatients according to the recently introduced American Heart Association and Stroke Association guidelines. METHODS We conducted a longitudinal case series from May 2022 to February 2023. We included patients who met the Bárány Society's Vascular Vertigo and Dizziness classification and were eligible for therapy in accordance with the American Heart Association and Stroke Association guidelines, featuring aspects of the stroke group and transient attack group. RESULTS Overall, 41 patients (51.2% female; median age 72 years) were enrolled; 10 (24.3%) had ischemic strokes, 30 (73.1%) had transient ischemic attack, and 1 (2.4%) had a probable isolated labyrinthine infarction. The patients received dual antiplatelet (48.7%), single antiplatelet therapy (48.7%), and anticoagulant therapy (2.4%). No new crises occurred in 95.2% of the patients, and the transient ischemic attack group showed a significant decrease in discomfort from imbalance on the visual analog scale. CONCLUSIONS Antiplatelets and anticoagulants are safe and effective in treating Vascular Vertigo and Dizziness as they prevent new ischemic events and increase the flow of the posterior circulation, reducing vertigo/dizziness attacks and imbalance complaints. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Arlindo Cardoso Lima Neto
- Setor de Otoneurologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - FMUSP, Brazil.
| | - Roseli Saraiva Moreira Bittar
- Setor de Otoneurologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - FMUSP, Brazil
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Chang YS, Tsai MJ, Hsieh CY, Sung SF. Characteristics and risk of stroke in emergency department patients with acute dizziness. Heliyon 2024; 10:e30953. [PMID: 38770312 PMCID: PMC11103531 DOI: 10.1016/j.heliyon.2024.e30953] [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: 08/23/2023] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024] Open
Abstract
Background Acute dizziness is a common symptom in the emergency department (ED), with strokes accounting for 3 %-5 % of cases. We investigated the risk of stroke in ED patients with acute dizziness and compared stroke characteristics diagnosed during and after the ED visit. Methods We identified adult patients with acute dizziness, vertigo, or imbalance using a hospital research-based database. Patients with abdominal or flank pain were used as the comparison group. Patients with dizziness were 1:1 matched to comparison patients. Each patient was traced for up to one year until being hospitalized for a stroke. Results Out of the 24,266 eligible patients, 589 (2.4 %) were hospitalized for stroke during the ED visit. For the remaining 23,677 patients, the risk of stroke at 7, 30, 90, and 365 days after ED discharge was 0.40 %, 0.52 %, 0.71 %, and 1.25 % respectively. Patients with dizziness had a higher risk of stroke compared to the comparison group at 7, 30, 90, and 365 days. The risk ratios decreased from 5.69 (95 % confidence interval [CI], 3.34-9.68) to 2.03 (95 % CI, 1.65-2.49). Compared to patients hospitalized for stroke during the ED visit, those hospitalized for stroke after the ED visit had greater stroke severity despite a lower initial triage acuity. Patients with early stroke (≤7 days) after ED discharge were less likely to have hypertension, diabetes, hyperlipidemia, and atrial fibrillation. They mostly experienced posterior circulation stroke. Patients with late stroke (>7 days) were older and less likely to have hypertension and hyperlipidemia but more likely to have a history of prior stroke and ischemic heart disease. Their strokes were mainly located in the anterior circulation territory. Conclusions The risk of stroke after ED discharge was higher in patients with dizziness than in the comparison group, with gradually decreasing risk ratios in the following year. Patients hospitalized for stroke during and after the ED visit had different profiles of vascular risk factors and clinical characteristics.
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Affiliation(s)
- Yu-Sung Chang
- Department of Otolaryngology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Ming-Jen Tsai
- Department of Emergency Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
- Department of Beauty & Health Care, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
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Lu WZ, Lin HA, Hou SK, Lin SF. ABCD2-I Score Predicts Unplanned Emergency Department Revisits within 72 Hours Due to Recurrent Acute Ischemic Stroke. Diagnostics (Basel) 2024; 14:1118. [PMID: 38893644 PMCID: PMC11172352 DOI: 10.3390/diagnostics14111118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/24/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND the ABCD2 score is valuable for predicting early stroke recurrence after a transient ischemic attack (TIA), and Doppler ultrasound can aid in expediting stroke triage. The study aimed to investigate whether combining the ABCD2 score with carotid duplex results can enhance the identification of early acute ischemic stroke after TIA. METHODS we employed a retrospective cohort design for this study, enrolling patients diagnosed with TIA who were discharged from the emergency department (ED). The modified ABCD2-I (c50) score, which incorporates a Doppler ultrasound assessment of internal carotid artery stenosis > 50%, was used to evaluate the risk of acute ischemic stroke within 72 h. Patients were categorized into three risk groups: low risk (with ABCD2 and ABCD2-I scores = 0-4), moderate risk (ABCD2 score = 4-5 and ABCD2-I score = 5-7), and high risk (ABCD2 score = 6-7 and ABCD2-I score = 8-9). RESULTS between 1 January 2014, and 31 December 2019, 1124 patients with new neurological deficits were screened, with 151 TIA patients discharged from the ED and included in the analysis. Cox proportional hazards analysis showed that patients in the high-risk group, as per the ABCD2-I (c50) score, were significantly associated with revisiting the ED within 72 h due to acute ischemic stroke (HR: 3.12, 95% CI: 1.31-7.41, p = 0.0102), while the ABCD2 alone did not show significant association (HR: 1.12, 95% CI: 0.57-2.22, p = 0.7427). CONCLUSION ABCD2-I (c50) scores effectively predict early acute ischemic stroke presentations to the ED within 72 h after TIA.
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Affiliation(s)
- Wei-Zhen Lu
- Department of Emergency Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei 23561, Taiwan;
| | - Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 11031, Taiwan; (H.-A.L.); (S.-K.H.)
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 11031, Taiwan; (H.-A.L.); (S.-K.H.)
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Sheng-Feng Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 11031, Taiwan; (H.-A.L.); (S.-K.H.)
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- School of Public Health, College of Public Health, Taipei Medical University, 250 Wu-Hsing Street, Taipei 11031, Taiwan
- Center of Evidenced-Based Medicine, Taipei Medical University Hospital, Taipei 11031, Taiwan
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Zhang J, Li J, Ding Y. Diagnostic value of cervical vascular ultrasound in large arterial lesions of the neck in patients with transient ischemic attack. Int J Neurosci 2024:1-7. [PMID: 38708961 DOI: 10.1080/00207454.2024.2352041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/30/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE To assess the diagnostic value of cervical vascular ultrasound in identifying large arterial lesions in patients with transient ischemic attack (TIA). METHODS The current study matched 84 TIA patients (disease group) with 66 healthy controls (control group). The baseline patient profiles and biochemical indices of the patients were analyzed. All patients received color Doppler ultrasonography, and outcome measures of its diagnostic efficiency included plaque status, plaque properties, and the degree of carotid stenosis. The patients in the disease group were assigned to group A (TIA of the internal carotid artery system, n = 40) and group B (TIA of the vertebrobasilar artery system, n = 44), and the plaque distribution of the patients was analyzed. RESULTS TIA patients had higher rates of diabetes, hypertension, hyperlipidemia, obesity, and smoking compared to controls (p < 0.05). Their serum TC, LDL-C, and FBG levels were significantly elevated, while HDL-C levels were decreased (p < 0.05). TIA patients had more plaques, especially soft plaques, than controls (p < 0.05). They also showed higher rates of moderate to severe carotid stenosis (p < 0.05). TIA involving the internal carotid artery system was associated with a higher risk of plaques at the entrance of the subclavian artery compared to TIA involving the vertebrobasilar artery system (p < 0.05). CONCLUSION The diagnostic value of cervical vascular ultrasound in patients with TIA is remarkable, and it provides a reliable monitoring approach as well as an essential screening modality for TIA. The rational use of this technique will markedly benefit the diagnosis, treatment, and prevention of TIA.
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Affiliation(s)
- Jianjun Zhang
- Functional Section Department, The Third People's Hospital of Hefei, Hefei, China
| | - Jiaju Li
- Functional Section Department, The Third People's Hospital of Hefei, Hefei, China
| | - Ying Ding
- Functional Section Department, The Third People's Hospital of Hefei, Hefei, China
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Chen H, Colasurdo M, Phipps MS, Miller TR, Cherian J, Marino J, Cronin CA, Wozniak MA, Gandhi D, Chaturvedi S, Jindal G. The BAND score: A simple model for upfront prediction of poor outcomes despite successful stroke thrombectomy. J Stroke Cerebrovasc Dis 2024; 33:107608. [PMID: 38286159 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 01/13/2024] [Accepted: 01/26/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND While endovascular thrombectomy (EVT) is beneficial for patients with acute large vessel occlusion ischemic strokes, a significant portion of patients still do poorly despite successful recanalization. Identifying patients at high risk for poor outcomes can be helpful for future clinical trial design and optimizing acute stroke triage. METHODS Consecutive EVT patients were identified from 2016 to 2021 at a Comprehensive Stroke Center, and clinical information was recorded. Poor outcome was defined as a 90-day modified Rankin Scale (mRS) of 4 or greater despite achieving a modified thrombolysis in cerebral infarction (mTICI) score of 2b or greater. Multivariable regression analyses were used to identify risk factors for poor outcomes, and a scoring system was constructed. RESULTS 483 patients with successful recanalization were identified. From a randomly selected training cohort (n = 357), the 10-point BAND score was constructed from independent risk factors for poor outcomes: baseline disability (1 point: baseline mRS ≥ 2), age (1 point: 60-69 years, 2 points: 70-79 years, 3 points: 80-84 years, 4 points: 85 years or older), NIHSS (2 points: 13-17, 3 points: 18-22, and 4 points: ≥ 23), and delay from last known normal (1 point: ≥ 6 h). The BAND score was significantly associated with rates of poor outcomes (p < 0.001), and it achieved an area under the receiver-operating characteristic curve (AUC) of 0.80 (95 %CI 0.76-0.85) in our training cohort and 0.78 (95 %CI 0.70-0.86) in our validation cohort (n = 126). Overall, the BAND score had a significantly higher AUC value than the widely validated THRIVE score and the THRIVE-EVT calculation (p = 0.001 and 0.029, respectively). Among patients with high BAND scores (7 or higher), 88.2 % had poor outcomes. CONCLUSION The BAND score is a simple tool to predict poor outcomes despite successful recanalization. Future studies are needed to confirm the BAND score's external validity.
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Affiliation(s)
- Huanwen Chen
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore MD 21201, USA; National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda MD 20814, USA; Department of Neurology, Georgetown University Hospital, Washington DC 20007, USA
| | - Marco Colasurdo
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Michael S Phipps
- Department of Neurology, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Timothy R Miller
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Jacob Cherian
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Jose Marino
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Carolyn A Cronin
- Department of Neurology, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Marcella A Wozniak
- Department of Neurology, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland Medical Center, Baltimore MD 21201, USA
| | - Gaurav Jindal
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore MD 21201, USA.
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10
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Liu X, Li Z, Ju Y, Zhao X. Application of bedside HINTS, ABCD 2 score and truncal ataxia to differentiate cerebellar-brainstem stroke from vestibular neuritis in the emergency room. Stroke Vasc Neurol 2024:svn-2023-002779. [PMID: 38531544 DOI: 10.1136/svn-2023-002779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 02/17/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND PURPOSE Acute vestibular syndrome (AVS) typically manifests as isolated dizziness or vertigo with no apparent neurological impairments. However, distinguishing life-threatening stroke from innocuous peripheral vestibular lesions in the emergency room (ER) remains challenging. This study aimed to explore the ability of the head impulse-nystagmus-test of skew (HINTS) combined with truncal ataxia or ABCD2 score to differentiate stroke from peripheral vestibular disease in patients with AVS in the ER. METHODS We prospectively recruited 121 patients with AVS from December 2022 to June 2023, 69 of whom presented with vestibular neuritis (VN) and the remaining with posterior circulation stroke (PCS). We analysed the HINTS results, truncal ataxia and ABCD2 score and compared the sensitivity and specificity among HINTS, truncal ataxia, ABCD2 score and their combinations using the McNemar test for paired samples. RESULTS HINTS combined with grade 2-3 truncal ataxia achieved significantly higher sensitivity than that of isolated HINTS in differentiating PCS from VN (100% vs 88.5%, p=0.031). The specificity of HINTS plus grade 2-3 truncal ataxia did not significantly differ from that of isolated HINTS (p=0.125); however, the combination of ABCD2 score and HINTS did not improve the diagnostic accuracy. The sensitivity of ABCD2 score ≥4 plus grade 2-3 truncal ataxia was significantly higher than those of isolated ABCD2 score ≥4 or isolated grade 2-3 truncal ataxia (p=0.016 and p<0.001, respectively) and not significantly lower than that of isolated HINTS (p=0.508). CONCLUSION Compared with the ABCD2 score, the truncal ataxia is of more valuable assistance to HINTS in differentiating PCS. Although the combination of ABCD2 score and truncal ataxia has a significant implication, it is not a replacement for HINTS.
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Affiliation(s)
- Xinmin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhaoxia Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Clinical Center for Vertigo and Balance Disturbance, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Ju
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Clinical Center for Vertigo and Balance Disturbance, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Clinical Center for Vertigo and Balance Disturbance, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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11
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Philippe D, Bernard A, Ricolfi F, Béjot Y, Duloquin G, Comby PO, Guenancia C. Prevalence of major embolic findings and incidental findings on early cardiac CT in patients with suspected ischemic stroke. Diagn Interv Imaging 2024:S2211-5684(24)00047-0. [PMID: 38431431 DOI: 10.1016/j.diii.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The purpose of this study was to assess the type and prevalence of stroke and non-stroke-related findings diagnosed on early cardiac computed tomography (CT) in patients with suspected stroke. The secondary objective was to assess the clinical consequences on the management of patients with non-stroke-related conditions identified by early cardiac CT. MATERIALS AND METHODS This single-center, retrospective, observational study included 1111 consecutive patients with suspected ischemic stroke between November 2018 and March 2020 who underwent cardiac CT examination in addition to the usual brain CT protocol (i.e., non-enhanced brain CT, perfusion brain CT when needed, aortic arch and supra-aortic CT angiography, and post contrast brain CT). There were 562 women and 549 men with a median age of 74 years (range: 60-85 years). Of these, 415 (415/1111; 37.4%) patients had ischemic stroke and 692 (692/1111; 62.3%) had no stroke. Cardiac CT examinations were retrospectively reviewed for cardiac CT findings at high embolic risk and clinically significant extracardiac incidental findings. RESULTS Among 1111 included patients, 89 (89/1111; 8.0%) had a stroke-related condition identified on early cardiac CT. This was significantly more frequent in patients with ischemic stroke (66/415; 15.9%) by comparison with those without ischemic stroke (23/696; 3.3%) (P < 0.001), with 41 patients (41/415; 9.9%) diagnosed with left atrial thrombus. Cardiac CT revealed a clinically significant non-stroke-related finding in 173 patients (173/1111; 15.6%), including 17 pulmonary embolisms (1.5%), seven suspicious pulmonary lesions (0.6%), and three breast lesions suspected to be malignant (0.3%). Twenty out of 173 patients (20/173; 11.5%) with incidental findings on early cardiac CT had a change in their management. CONCLUSION This study shows that adding early cardiac CT to brain CT during the acute phase of an ischemic stroke leads to a higher rate of etiological diagnoses and highlights the major interest of looking at the bigger picture.
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Affiliation(s)
- Diane Philippe
- Department of Radiology, University Hospital, 21709 Dijon, France
| | | | - Frédéric Ricolfi
- Department of Radiology, University Hospital, 21709 Dijon, France
| | - Yannick Béjot
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Gauthier Duloquin
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Pierre-Olivier Comby
- Department of Radiology, University Hospital, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Charles Guenancia
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Cardiology, University Hospital, 21709 Dijon, France.
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12
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Daghlas I, Johnston SC, Easton D, Kim AS. Baseline Stroke Risk and Efficacy of Dual-Antiplatelet Therapy: A Post Hoc Analysis of the POINT Trial. Stroke 2024; 55:385-391. [PMID: 38174567 PMCID: PMC10857750 DOI: 10.1161/strokeaha.123.044927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND High-risk transient ischemic attacks and minor ischemic strokes are followed by a variable risk of ischemic stroke. We aimed to determine how baseline stroke risk modified the efficacy of clopidogrel-aspirin (referred to here as dual-antiplatelet therapy [DAPT]) for transient ischemic attack and minor ischemic stroke. METHODS We performed an unplanned secondary analysis of the POINT trial (Platelet-Oriented Inhibition in New Transient Ischemic Attack and Minor Ischemic Stroke). We first evaluated the associations of the CHA2DS2-VASc and stroke prognosis instrument II (SPI-II) scores with the risk of incident ischemic stroke and major hemorrhage (intracranial hemorrhage or major systemic hemorrhage). We then tested for heterogeneity of the relative and absolute treatment effect of DAPT relative to aspirin across low- and high-risk patient subgroups. RESULTS A total of 4841 trial participants were included in this analysis, with 2400 participants assigned to treatment with short-term DAPT and 2430 participants to treatment with aspirin and placebo. The dichotomized SPI-II score, but not the CHA2DS2-VASc score (P=0.18), was associated with the risk of incident ischemic stroke. A high-risk SPI-II score (>3) was associated with greater risk of incident ischemic stroke (hazard ratio of incident ischemic stroke relative to low-risk SPI-II score of 1.84 [95% CI, 1.44-2.35]; P<0.001) and numerically greater risk of major hemorrhage though not meeting statistical significance (hazard ratio, 1.80 [95% CI, 0.90-3.57]; P=0.10). The relative risk reduction with DAPT was similar across SPI-II strata (Pinteraction=0.31). The absolute risk reduction for ischemic stroke with DAPT compared with aspirin was nearly 4-fold higher (2.80% versus 0.76%; number needed to treat, 31 versus 131) in the high-risk SPI-II stratum relative to the low-risk stratum. The absolute risk increase for major hemorrhage with DAPT compared with aspirin was 3-fold higher (0.84% versus 0.30%; number needed to harm, 119 versus 331) in the high-risk SPI-II stratum relative to the low-risk stratum. CONCLUSIONS Stratification by baseline stroke risk identifies a patient subgroup that derives greater absolute benefit from treatment with DAPT. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00991029.
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Affiliation(s)
- Iyas Daghlas
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - S. Claiborne Johnston
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
- Harbor Health, Austin, TX
| | - Donald Easton
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Anthony S. Kim
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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13
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Chan BPL, Wong LYH, Tan BYQ, Yeo LLL, Venketasubramanian N. Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review. J Cardiovasc Dev Dis 2024; 11:48. [PMID: 38392262 PMCID: PMC10889184 DOI: 10.3390/jcdd11020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.
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Affiliation(s)
- Bernard P L Chan
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Lily Y H Wong
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Leonard L L Yeo
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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14
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Zaharia AL, Tutunaru D, Oprea VD, Tănase CE, Croitoru A, Stan B, Voinescu DC, Ionescu AM, Coadǎ CA, Lungu M. Thrombomodulin Serum Levels-A Predictable Biomarker for the Acute Onset of Ischemic Stroke. Curr Issues Mol Biol 2024; 46:677-688. [PMID: 38248346 PMCID: PMC10813863 DOI: 10.3390/cimb46010044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/07/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
The early diagnosis of acute ischemic stroke (AIS) can be challenging in cases presenting with a scarcity of clinical signs, normal cerebral imaging in early stages and a lack of specific serum markers. Thrombomodulin has been shown to be associated with cerebrovascular ischemic events and can be considered an important biomarker for the acute onset of ischemic stroke. In our study, we compared the serum levels of thrombomodulin (sTM) between a relevant patient group of 70 AIS patients and a control group of patients without AIS admitted into the neurology department between June 2022 and May 2023. sTM levels were measured at 24 h and 48 h after patients' admissions into the hospital. There was a significant difference between the two groups (AIS: 23.2 ± 9.17 ng/mL vs. controls: 3.64 ± 1.72 ng/mL; p-value < 0.001). sTM values were correlated with the score of neurological deficits, with gender and dyslipidemia. The association of sTM values with the acute onset of AIS as an end point was significant, which allows rapid therapeutic interventions, even in the absence of a well-defined clinical syndrome (AUC = 0.99). Reanalysis of the patients after propensity score matching increased the power of sTM as a biomarker (AUC = 1). sTM represents a potentially useful biomarker to diagnose the onset of an AIS, even in scarce clinical presentations, which makes thrombomodulin a valuable indicator for early treatment initiation.
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Affiliation(s)
- Andrei-Lucian Zaharia
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Dana Tutunaru
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Violeta Diana Oprea
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Claudiu Elisei Tănase
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
- “St. Joan” Pediatric Clinical Emergency Hospital Galati, 800487 Galati, Romania
| | - Ana Croitoru
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Bianca Stan
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Doina Carina Voinescu
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Ana-Maria Ionescu
- Faculty of Medicine and Pharmacy, Ovidius University of Constanța, 900470 Constanța, Romania;
| | - Camelia Alexandra Coadǎ
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Mihaiela Lungu
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
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15
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Chen M, Qian D, Wang Y, An J, Meng K, Xu S, Liu S, Sun M, Li M, Pang C. Systematic Review of Machine Learning Applied to the Secondary Prevention of Ischemic Stroke. J Med Syst 2024; 48:8. [PMID: 38165495 DOI: 10.1007/s10916-023-02020-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Ischemic stroke is a serious disease posing significant threats to human health and life, with the highest absolute and relative risks of a poor prognosis following the first occurrence, and more than 90% of strokes are attributable to modifiable risk factors. Currently, machine learning (ML) is widely used for the prediction of ischemic stroke outcomes. By identifying risk factors, predicting the risk of poor prognosis and thus developing personalized treatment plans, it effectively reduces the probability of poor prognosis, leading to more effective secondary prevention. This review includes 41 studies since 2018 that used ML algorithms to build prognostic prediction models for ischemic stroke, transient ischemic attack (TIA), and acute ischemic stroke (AIS). We analyzed in detail the risk factors used in these studies, the sources and processing methods of the required data, the model building and validation, and their application in different prediction time windows. The results indicate that among the included studies, the top five risk factors in terms of frequency were cardiovascular diseases, age, sex, national institutes of health stroke scale (NIHSS) score, and diabetes. Furthermore, 64% of the studies used single-center data, 65% of studies using imbalanced data did not perform data balancing, 88% of the studies did not utilize external validation datasets for model validation, and 72% of the studies did not provide explanations for their models. Addressing these issues is crucial for enhancing the credibility and effectiveness of the research, consequently improving the development and implementation of secondary prevention measures.
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Affiliation(s)
- Meng Chen
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China
| | - Dongbao Qian
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China
| | - Yixuan Wang
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China
| | - Junyan An
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China
| | - Ke Meng
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China
| | - Shuai Xu
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China
| | - Sheng Liu
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China
| | - Meiyan Sun
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China
| | - Miao Li
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China.
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China.
| | - Chunying Pang
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China.
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16
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Sharma M, Molina CA, Toyoda K, Bereczki D, Bangdiwala SI, Kasner SE, Lutsep HL, Tsivgoulis G, Ntaios G, Czlonkowska A, Shuaib A, Amarenco P, Endres M, Yoon BW, Tanne D, Toni D, Yperzeele L, von Weitzel-Mudersbach P, Sampaio Silva G, Avezum A, Dawson J, Strbian D, Tatlisumak T, Eckstein J, Ameriso SF, Weber JR, Sandset EC, Goar Pogosova N, Lavados PM, Arauz A, Gailani D, Diener HC, Bernstein RA, Cordonnier C, Kahl A, Abelian G, Donovan M, Pachai C, Li D, Hankey GJ. Safety and efficacy of factor XIa inhibition with milvexian for secondary stroke prevention (AXIOMATIC-SSP): a phase 2, international, randomised, double-blind, placebo-controlled, dose-finding trial. Lancet Neurol 2024; 23:46-59. [PMID: 38101902 PMCID: PMC10822143 DOI: 10.1016/s1474-4422(23)00403-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND People with factor XI deficiency have lower rates of ischaemic stroke than the general population and infrequent spontaneous bleeding, suggesting that factor XI has a more important role in thrombosis than in haemostasis. Milvexian, an oral small-molecule inhibitor of activated factor XI, added to standard antiplatelet therapy, might reduce the risk of non-cardioembolic ischaemic stroke without increasing the risk of bleeding. We aimed to estimate the dose-response of milvexian for recurrent ischaemic cerebral events and major bleeding in patients with recent ischaemic stroke or transient ischaemic attack (TIA). METHODS AXIOMATIC-SSP was a phase 2, randomised, double-blind, placebo-controlled, dose-finding trial done at 367 hospitals in 27 countries. Eligible participants aged 40 years or older, with acute (<48 h) ischaemic stroke or high-risk TIA, were randomly assigned by a web-based interactive response system in a 1:1:1:1:1:2 ratio to receive one of five doses of milvexian (25 mg once daily, 25 mg twice daily, 50 mg twice daily, 100 mg twice daily, or 200 mg twice daily) or matching placebo twice daily for 90 days. All participants received clopidogrel 75 mg daily for the first 21 days and aspirin 100 mg daily for the first 90 days. Investigators, site staff, and participants were masked to treatment assignment. The primary efficacy endpoint was the composite of ischaemic stroke or incident covert brain infarct on MRI at 90 days, assessed in all participants allocated to treatment who completed a follow-up MRI brain scan, and the primary analysis assessed the dose-response relationship with Multiple Comparison Procedure-Modelling (MCP-MOD). The main safety outcome was major bleeding at 90 days, assessed in all participants who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov (NCT03766581) and the EU Clinical Trials Register (2017-005029-19). FINDINGS Between Jan 27, 2019, and Dec 24, 2021, 2366 participants were randomly allocated to placebo (n=691); milvexian 25 mg once daily (n=328); or twice-daily doses of milvexian 25 mg (n=318), 50 mg (n=328), 100 mg (n=310), or 200 mg (n=351). The median age of participants was 71 (IQR 62-77) years and 859 (36%) were female. At 90 days, the estimates of the percentage of participants with either symptomatic ischaemic stroke or covert brain infarcts were 16·8 (90·2% CI 14·5-19·1) for placebo, 16·7 (14·8-18·6) for 25 mg milvexian once daily, 16·6 (14·8-18·3) for 25 mg twice daily, 15·6 (13·9-17·5) for 50 mg twice daily, 15·4 (13·4-17·6) for 100 mg twice daily, and 15·3 (12·8-19·7) for 200 mg twice daily. No significant dose-response was observed among the five milvexian doses for the primary composite efficacy outcome. Model-based estimates of the relative risk with milvexian compared with placebo were 0·99 (90·2% CI 0·91-1·05) for 25 mg once daily, 0·99 (0·87-1·11) for 25 mg twice daily, 0·93 (0·78-1·11) for 50 mg twice daily, 0·92 (0·75-1·13) for 100 mg twice daily, and 0·91 (0·72-1·26) for 200 mg twice daily. No apparent dose-response was observed for major bleeding (four [1%] of 682 participants with placebo, two [1%] of 325 with milvexian 25 mg once daily, two [1%] of 313 with 25 mg twice daily, five [2%] of 325 with 50 mg twice daily, five [2%] of 306 with 100 mg twice daily, and five [1%] of 344 with 200 mg twice daily). Five treatment-emergent deaths occurred, four of which were considered unrelated to the study drug by the investigator. INTERPRETATION Factor XIa inhibition with milvexian, added to dual antiplatelet therapy, did not substantially reduce the composite outcome of symptomatic ischaemic stroke or covert brain infarction and did not meaningfully increase the risk of major bleeding. Findings from our study have informed the design of a phase 3 trial of milvexian for the prevention of ischaemic stroke in patients with acute ischaemic stroke or TIA. FUNDING Bristol Myers Squibb and Janssen Research & Development.
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Affiliation(s)
- Mukul Sharma
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Helmi L Lutsep
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta Hospital, Edmonton, AB, Canada
| | - Pierre Amarenco
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Neurology and Stroke Center, University of Paris, Bichat Hospital, Paris, France
| | - Matthias Endres
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Byung-Woo Yoon
- Uijeongbu Eulji Medical Center, Eulji University, Gyeonggi-do, South Korea
| | - David Tanne
- Stroke and Cognition Institute, Rambam Health Care Campus, Haifa, Technion, Israel
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Laetitia Yperzeele
- Stroke Unit and Neurovascular Center Antwerp, Department of Neurology, Antwerp University Hospital, Antwerp (Edegem), Belgium
| | | | - Gisele Sampaio Silva
- Universidade Federal de São Paulo/UNIFESP and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alvaro Avezum
- Centro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience/Neurology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jens Eckstein
- Department of Internal Medicine and Department of Digitalization & ICT, University Hospital Basel, Basel, Switzerland
| | - Sebastián F Ameriso
- Servicio de Neurología Vascular, Departamento de Neurología, FLENI, Buenos Aires, Argentina
| | - Joerg R Weber
- Department of Neurology, Klinikum Klagenfurt, Austria
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital and The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Nana Goar Pogosova
- National Medical Research Center of Cardiology after E Chazov, Moscow, Russia
| | - Pablo M Lavados
- Departamento de Neurología y Psiquiatría, Unidad de Investigación y Ensayos Clínicos, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Antonio Arauz
- Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, México
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University Duisburg-Essen, Essen, Germany
| | - Richard A Bernstein
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Charlotte Cordonnier
- University of Lille, Lille, Inserm, CHU Lille, U1172 - LiINCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Anja Kahl
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | | | - Danshi Li
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Graeme J Hankey
- Medical School, Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Perth, WA, Australia; Perron Institute for Neurological and Translational Science, Perth, Australia
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Vera A, Cecconi A, Ximénez-Carrillo Á, Ramos C, Martínez-Vives P, Lopez-Melgar B, Sanz-García A, Ortega G, Aguirre C, Montes Á, Vivancos J, Jiménez-Borreguero LJ, Alfonso F. Left Atrial Strain Predicts Stroke Recurrence and Death in Patients With Cryptogenic Stroke. Am J Cardiol 2024; 210:51-57. [PMID: 37898159 DOI: 10.1016/j.amjcard.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/24/2023] [Accepted: 10/01/2023] [Indexed: 10/30/2023]
Abstract
Left atrial strain (LAS) has been widely studied as a predictor of atrial fibrillation (AF) after cryptogenic stroke (CS). However, the evidence about its prognostic role in terms of stroke recurrence and death in this setting remains scarce. A total of 92 consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography, including LAS was performed during admission. The primary outcome measure was the composite of stroke recurrence or death. The mean age was 77.5 ± 7.7, and 58% of patients were female. After a median follow up of 28 months, the primary outcome measure occurred in 15 patients (16%). The primary outcome was more frequent in patients with diabetes (53% vs 21%, p = 0.02), chronic kidney disease (33% vs 10%, p = 0.034), and a history of heart failure (13% vs 0%, p = 0.025). LAS reservoir (LASr) and LAS conduit (LAScd) were lower in patients developing the primary outcome (21% ± 7% vs 28.8% ± 11%, p = 0.017 and 7.7% ± 3.9% vs 13.7% ± 7%, p = 0.007, respectively). On multivariate analysis, LASr (hazard ratio 0.9, 95% confidence interval 0.85 to 0.99, p = 0.048) and diabetes (hazard ratio 3.3, 95% confidence interval 1.03 to 10.4, p = 0.045) were associated with stroke recurrence or all-cause death after CS. On the log-rank test (using the discriminatory cut-off value of LASr <23%), LASr (p = 0.009) was associated with higher risk of the primary outcome. In conclusion, lower values of the LAS reservoir were associated with a higher risk of stroke recurrence or death after CS. LAS may identify patients at higher risk of thromboembolism and stress conditions.
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Affiliation(s)
- Alberto Vera
- Cardiology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, CIBER-CV, Madrid, Spain
| | - Alberto Cecconi
- Cardiology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, CIBER-CV, Madrid, Spain.
| | - Álvaro Ximénez-Carrillo
- Stroke Center, Neurology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, Madrid, Spain
| | - Carmen Ramos
- Stroke Center, Neurology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, Madrid, Spain
| | - Pablo Martínez-Vives
- Cardiology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, CIBER-CV, Madrid, Spain
| | - Beatriz Lopez-Melgar
- Cardiology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, CIBER-CV, Madrid, Spain
| | - Ancor Sanz-García
- Faculty of Health Sciences, Castilla la Mancha University, Talavera de la Reina, Spain
| | - Guillermo Ortega
- Data Analysis Unit, Health Research Institute, La Princesa University Hospital, Madrid, Spain
| | - Clara Aguirre
- Stroke Center, Neurology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, Madrid, Spain
| | - Álvaro Montes
- Cardiology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, CIBER-CV, Madrid, Spain
| | - José Vivancos
- Stroke Center, Neurology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, Madrid, Spain
| | - Luis Jesús Jiménez-Borreguero
- Cardiology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, CIBER-CV, Madrid, Spain
| | - Fernando Alfonso
- Cardiology Department, La Princesa University Hospital, Autonomous University of Madrid, IIS-IP, CIBER-CV, Madrid, Spain
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18
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Kim AS. Extending Dual Antiplatelet Therapy for TIA or Stroke. N Engl J Med 2023; 389:2478-2479. [PMID: 38157504 DOI: 10.1056/nejme2311961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Anthony S Kim
- From the UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco
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19
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Al Salman S, Al Sultan AA, Aldawood MA, Alradhi HK, AlMuhaish MA, Alsumaeel SA. Bridge to Better Care: Investigating Transient Ischemic Attack (TIA) Management Expertise Among Primary Healthcare Providers in Al-Ahsa, Saudi Arabia. Cureus 2023; 15:e50420. [PMID: 38222199 PMCID: PMC10784710 DOI: 10.7759/cureus.50420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Transient ischemic attacks (TIAs) are brief episodes of neurological impairment caused by reduced blood flow to the brain, spinal cord, or retina, typically lasting under an hour. Recent advances in neuroimaging suggest that some TIAs may actually be small strokes with resolved symptoms. This study focuses on assessing the knowledge and management of TIAs among primary care physicians and nurses in Al-Ahsa, Saudi Arabia. Methodology This is a cross-sectional study, conducted in Al-Ahsa, Saudi Arabia, during the period July to August 2023. Data were collected using an electronic questionnaire and was analyzed using IBM SPSS Statistics for Windows, version 27.0.1 (released 2020, IBM Corp., Armonk, New York, United States). Results Among the participants, 64.0% correctly identified TIA as an ischemic neurological deficit. However, only 20.2% provided correct responses for all TIA symptoms. Regarding diagnostic tests, 47.4% acknowledged the need for neuroimaging immediately after TIA, while 17.5% recognized the importance of ultrasonography of the supra-aortic trunks. In terms of TIA management, 38.6% preferred referral to the emergency service, and 41.2% correctly perceived the risk of TIA recurrence as similar to that of established cerebral ischemic stroke. Significant disparities were observed in the recognition of TIA symptoms, with physicians outperforming nurses, particularly in identifying motor deficits (82.4% vs. 65.2%) and speech alterations (86.8% vs. 76.1%, p = 0.004). However, nurses exhibited better knowledge in recognizing the need for a neuroimaging test (48.5% vs. 45.7%, p = 0.849) and the urgency of conducting a transcranial Doppler (TCD) (19.1% vs. 23.9%, p = 0.641). Conclusion A considerable proportion of healthcare providers demonstrate a good understanding of TIA definition and management. However, the lack of significant predictors for good knowledge and attitude suggests the need for more comprehensive strategies to enhance TIA management expertise across healthcare professionals.
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Wahi S, Michaleff ZA, Lomax P, Brand A, van der Merwe M, Jones M, Glasziou P, Keijzers G. Evaluating the use of the ABCD2 score as a clinical decision aid in the emergency department: Retrospective observational study. Emerg Med Australas 2023; 35:934-940. [PMID: 37344364 DOI: 10.1111/1742-6723.14260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/15/2023] [Accepted: 05/31/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE Clinical decision aids (CDAs) can help clinicians with patient risk assessment. However, there is little data on CDA calculation, interpretation and documentation in real-world ED settings. The ABCD2 score (range 0-7) is a CDA used for patients with transient ischaemic attack (TIA) and assesses risk of stroke, with a score of 0-3 being low risk. The aim of this study was to describe ABCD2 score documentation in patients with an ED diagnosis of TIA. METHODS Retrospective observational study of patients with a working diagnosis of a TIA in two Australian EDs. Data were gathered using routinely collected data from health informatics sources and medical records reviewed by a trained data abstractor. ABCD2 scores were calculated and compared with what was documented by the treating clinician. Data were presented using descriptive analysis and scatter plots. RESULTS Among the 367 patients with an ED diagnosis of TIA, clinicians documented an ABCD2 score in 45% (95% CI 40-50%, n = 165). Overall, there was very good agreement between calculated and documented scores (Cohen's kappa 0.90). The mean documented and calculated ABCD2 score were similar (3.8, SD = 1.5, n = 165 vs 3.7, SD = 1.8, n = 367). Documented scores on the threshold of low and high risk were more likely to be discordant with calculated scores. CONCLUSIONS The ABCD2 score was documented in less than half of eligible patients. When documented, clinicians were generally accurate with their calculation and application of the ABCD2. No independent predictors of ABCD2 documentation were identified.
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Affiliation(s)
- Siddhant Wahi
- Gold Cost University Hospital, Gold Coast, Queensland, Australia
| | - Zoe A Michaleff
- Northern NSW Local Health District, Lismore, New South Wales, Australia
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Paige Lomax
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Adam Brand
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Madeleen van der Merwe
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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21
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Nizar D, Amine MSM, Aissi M, Machraoui R, Adel S, Khaoula BHA, Blel S, Younes S, Boukef R, Henteti F, Nouira S, Hamdi B, Frih M. External validations of the ABCD2 score in prediction of stroke risk after transient ischemic attack. A Tunisian hospital-based cohort study. Int J Neurosci 2023; 133:1218-1223. [PMID: 33059508 DOI: 10.1080/00207454.2020.1835897] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 09/18/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE Identification of patients with high risk of stroke after transient ischemic attack (TIA) could be helpful to optimize stroke prevention. We aimed to externally validate the ABCD2 score for the prediction of stroke after TIA in a Tunisian population. METHODS We conducted a retrospective observational study of consecutive patients admitted for TIA in four university hospitals in Tunisia. Patients were screened for onset of stroke. Sensitivity, specificity, positive and negative predictive values with areas under the receiver operating characteristic (ROC) curves were calculated for risk of stroke at 2, 7, 30 and 90 days after the index event. RESULTS Of 415 patients screened in this study, the total cumulative subsequent stroke rates after TIA at 2, 7, 30 and 90 days were respectively, 4.8%, 10.6%, 13.5% and 20.2%. Using a cut-off value of 4, the ABCD2 showed an overall good sensitivity (95%, 97.7%, 96.4% and 97.6% respectively at 2, 7, 30 and 90 days). Areas under ROC cure of the ABCD2 score in patients with TIA for stroke onset at 2, 7, 30 and 90 days were respectively 0.67 (95% CI, 0.55-0.79), 0.79 (95% CI, 0.71-0.85), 0.79 (95% CI, 0.72-0.85), and 0.76 (95% CI, 0.70-0.81). CONCLUSION Our findings suggest that the ABCD2 score could be used in our population to discriminate patient with TIA at low and high risk of developing recurrent stroke.
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Affiliation(s)
- Daoussi Nizar
- Department of Neurology, University Hospital of Monastir, Monastir, Tunisia
| | - MSolli M Amine
- Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
- Emergency Department, University Hospital of Monastir, Monastir, Tunisia
| | - Mouna Aissi
- Department of Neurology, University Hospital of Monastir, Monastir, Tunisia
| | - Rafik Machraoui
- Department of Endocrinology and Internal Medicine, Tahar Sfar Hospital of Mahdia, Mahdia, Tunisia
| | - Sekma Adel
- Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
- Emergency Department, University Hospital of Monastir, Monastir, Tunisia
| | - Bel Haj Ali Khaoula
- Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
- Emergency Department, University Hospital of Monastir, Monastir, Tunisia
| | - Semir Blel
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, Tunis, Tunisia
| | - Samia Younes
- Department of Endocrinology and Internal Medicine, Tahar Sfar Hospital of Mahdia, Mahdia, Tunisia
| | - Riadh Boukef
- Emergency Department, Sahloul University Hospital, Sousse, Tunisia
| | - Fayçal Henteti
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, Tunis, Tunisia
| | - Semir Nouira
- Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
- Emergency Department, University Hospital of Monastir, Monastir, Tunisia
| | - Boubaker Hamdi
- Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
- Emergency Department, University Hospital of Monastir, Monastir, Tunisia
| | - Mahbouba Frih
- Department of Neurology, University Hospital of Monastir, Monastir, Tunisia
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22
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Zhou J, Li G, Meng Y, Hu F, Wang W, Chen X. Analysis of the posterior cerebral perfusion status and clinical prognostic value in chronic unilateral middle cerebral artery occlusion using SWAN combined with 3D-ASL. Medicine (Baltimore) 2023; 102:e35836. [PMID: 37960815 PMCID: PMC10637506 DOI: 10.1097/md.0000000000035836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/06/2023] [Indexed: 11/15/2023] Open
Abstract
To investigate the predictive value of T2 star-weighted angiography (SWAN) combined with 3-dimensional (3D) arterial spin labeling (3D-ASL) to assess cerebral perfusion status and clinical prognosis in chronic unilateral middle cerebral artery (MCA) M1 occlusion. This study included 55 patients diagnosed with chronic unilateral MCA M1 occlusion using 3D time-of-flight magnetic resonance angiography between January 2018 and July 2022. Based on the prominent vessel sign (PVS) shown in the SWAN sequence, the patients were divided into PVS-positive (n = 26) and PVS-negative (n = 29) groups. Cerebral blood flow (CBF) was selected in the affected regions of the frontal, parietal, and temporal lobes (regions of interest = 200 ± 20 mm2) using pseudo-color maps in the 3D-ASL sequence. Each patient was followed up for ischemic cerebrovascular disease within 12 months of diagnosis. The collected data were statistically analyzed to evaluate the predictive value of SWAN and 3D-ASL for the clinical prognosis of patients with chronic unilateral MCA M1 occlusion. Patients were divided into 2 groups based on the occurrence of an ischemic cerebrovascular event within 12 months (ischemic cerebrovascular event [acute ischemic stroke + transient ischemic attack] and non-ischemic cerebrovascular event groups, including 30 and 25 cases, respectively). The incidence of ischemic cerebrovascular events within 12 months was significantly higher in the PVS-positive group than in the PVS-negative group (92.31% vs 20.69%). Furthermore, the CBF values of the affected frontal, parietal, and temporal lobes were significantly lower in the ischemic cerebrovascular event group than in the non-ischemic cerebrovascular event group (P < .05). According to the receiver operating characteristic curve, the CBF values of the affected frontal, parietal, and temporal lobes in patients with chronic unilateral MCA M1 occlusion strongly correlated with ischemic cerebrovascular disease within 12 months. PVS-negative display and good collateral circulation were closely related to clinical prognosis in patients with chronic unilateral MCA M1 occlusion.
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Affiliation(s)
- Jianguo Zhou
- Department of Radiology, Lianyungang City Chinese Medicine Hospital, Lianyungfang, Jiangsu, China
| | - Guifen Li
- Department of Radiology, The Second People’s Hospital of Lianyungang City, Lianyungfang, Jiangsu, China
| | - Yun Meng
- Department of Radiology, Lianyungang City Chinese Medicine Hospital, Lianyungfang, Jiangsu, China
| | - Fangyun Hu
- Department of Radiology, Lianyungang City Chinese Medicine Hospital, Lianyungfang, Jiangsu, China
| | - Wei Wang
- Department of Radiology, The Peoples Hospital of Xuyi County, Huaian, Jiangsu, China
| | - Xunjun Chen
- Department of Radiology, The Peoples Hospital of Xuyi County, Huaian, Jiangsu, China
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23
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Timpone VM, Reid M, Jensen A, Poisson SN, Callen AL, Costa B, Trivedi PS. Association of Incomplete Neurovascular Imaging After Emergency Department Encounters for Transient Ischemic Attack and Odds of Subsequent Stroke: A National Medicare Analysis. AJR Am J Roentgenol 2023; 221:673-686. [PMID: 37255044 DOI: 10.2214/ajr.23.29352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND. Multisociety guidelines recommend urgent brain and neurovascular imaging for patients with transient ischemic attack (TIA), to identify and treat modifiable stroke risk factors. Prior research suggests that most patients with TIA who present to the emergency department (ED) do not receive prompt neurovascular imaging. OBJECTIVE. The purpose of this study was to evaluate the association between incomplete neurovascular imaging workup during ED encounters for TIA and the odds of subsequent stroke. METHODS. This retrospective study obtained data from the Medicare Standard Analytical Files for calendar years 2016 and 2017; these files contain 100% samples of claims for Medicare beneficiaries. Information was extracted using ICD 10th revision (ICD-10) and CPT codes. Those patients who were discharged from an ED encounter with a TIA diagnosis and who underwent brain CT or brain MRI during or within 2 days of the encounter were identified. Patients were considered to have complete neurovascular imaging if they underwent cross-sectional vascular imaging of both the brain (brain CTA or brain MRA) and neck (neck CTA, neck MRA, or carotid ultrasound) during or within 2 days of the encounter. The association between incomplete neurovascular imaging and a new stroke diagnosis within the subsequent 90 days was tested by multivariable logistic regression analysis. RESULTS. The sample included 111,417 patients (47,370 men, 64,047 women; 26.0% older than 84 years) who had TIA ED encounters. A total of 37.3% of patients (41,592) had an incomplete neurovascular imaging workup. A new stroke diagnosis within 90 days of the TIA ED encounter occurred in 4.4% (3040/69,825) of patients with complete neurovascular imaging versus 7.0% (2898/41,592) of patients with incomplete neurovascular imaging. Incomplete neurovascular imaging was associated with increased likelihood of stroke within 90 days (OR, 1.30 [95% CI, 1.23-1.38]) after adjustment for patient characteristics (age, sex, race and ethnicity, high-risk comorbidities, median county household income) and hospital characteristics (region, rurality, number of beds, major teaching hospital designation). CONCLUSION. TIA ED encounters with incomplete neurovascular imaging were associated with higher odds of subsequent stroke occurring within 90 days. CLINICAL IMPACT. Increased access to urgent neurovascular imaging for patients with TIA may represent a target that could facilitate detection and treatment of modifiable stroke risk factors.
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Affiliation(s)
- Vincent M Timpone
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Margaret Reid
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, CO
| | - Alexandria Jensen
- Department of Biostatistics & Informatics, Stanford School of Medicine, Palo Alto, CA
| | - Sharon N Poisson
- Department of Neurology, University of Colorado Hospital, Aurora, CO
| | - Andrew L Callen
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Bernardo Costa
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Premal S Trivedi
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
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24
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Wu L. Editorial Comment: Improved Access to Neurovascular Imaging, a Critical Component of Transient Ischemic Attack Workup, Could Help Mitigate Stroke Risk. AJR Am J Roentgenol 2023; 221:685. [PMID: 37459473 DOI: 10.2214/ajr.23.29719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Affiliation(s)
- Lei Wu
- University of Washington, Seattle, WA,
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25
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Germans MR, Rohr J, Globas C, Schubert T, Kaserer A, Brandi G, Studt JD, Greutmann M, Geiling K, Verweij L, Regli L. Challenges in Coagulation Management in Neurosurgical Diseases: A Scoping Review, Development, and Implementation of Coagulation Management Strategies. J Clin Med 2023; 12:6637. [PMID: 37892774 PMCID: PMC10607506 DOI: 10.3390/jcm12206637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Bleeding and thromboembolic (TE) complications in neurosurgical diseases have a detrimental impact on clinical outcomes. The aim of this study is to provide a scoping review of the available literature and address challenges and knowledge gaps in the management of coagulation disorders in neurosurgical diseases. Additionally, we introduce a novel research project that seeks to reduce coagulation disorder-associated complications in neurosurgical patients. The risk of bleeding after elective craniotomy is about 3%, and higher (14-33%) in other indications, such as trauma and intracranial hemorrhage. In spinal surgery, the incidence of postoperative clinically relevant bleeding is approximately 0.5-1.4%. The risk for TE complications in intracranial pathologies ranges from 3 to 20%, whereas in spinal surgery it is around 7%. These findings highlight a relevant problem in neurosurgical diseases and current guidelines do not adequately address individual circumstances. The multidisciplinary COagulation MAnagement in Neurosurgical Diseases (COMAND) project has been developed to tackle this challenge by devising an individualized coagulation management strategy for patients with neurosurgical diseases. Importantly, this project is designed to ensure that these management strategies can be readily implemented into healthcare practices of different types and with sustainable integration.
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Affiliation(s)
- Menno R. Germans
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
| | - Jonas Rohr
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
| | - Christoph Globas
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
- Department of Neurology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland
| | - Tilman Schubert
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
- Department of Neuroradiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Giovanna Brandi
- Neurocritical Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Matthias Greutmann
- University Heart Center, Department of Cardiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Katharina Geiling
- Department of Geriatrics, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Lotte Verweij
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006 Zurich, Switzerland;
- Centre of Clinical Nursing Science, University Hospital Zurich, Universitätstrasse 84, 8006 Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
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26
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Hamedani AG, De Lott LB, Willis AW. Nationwide trends in emergency department utilisation for acute retinal ischaemia in the USA, 2011-2018. Br J Ophthalmol 2023; 107:1490-1495. [PMID: 35760457 PMCID: PMC10196936 DOI: 10.1136/bjo-2022-321418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Guidelines recommend urgent evaluation for transient monocular vision loss (TMVL) and retinal artery occlusion (RAO), but emergency department (ED) utilisation for these conditions is unknown. METHODS We performed a retrospective longitudinal cross-sectional analysis of the Nationwide Emergency Department Sample (2011-2018), a database of all ED visits from a representative 20% sample of US hospital-based EDs. We identified patients aged 40 and older with a primary diagnosis of TMVL or RAO and calculated the weighted number of total visits and admission rate by year. We used joinpoint regression to analyse time trends and logistic regression to measure differences according to demographic characteristics and comorbidities. RESULTS There were an estimated 2451 ED visits for TMVL and 2472 for RAO annually in the USA from 2011 to 2018. Approximately 36% of TMVL and 51% of RAO patients were admitted. The admission rate decreased by an average of 4.9% per year for TMVL (95% CI -7.5% to -2.3%) and 2.2% per year for RAO (95% CI -4.1% to -0.4%), but the total number of ED visits did not change significantly over time. Elixhauser Comorbidity Index and hyperlipidaemia were associated with increased odds of hospital admission for both TMVL and RAO. There were also differences in admission rate by insurance payer and hospital region. CONCLUSION Of the estimated 48 000 patients with TMVL or RAO annually in the USA, few are evaluated in the ED, and admission rates are less than for transient ischaemic attack or ischaemic stroke and are decreasing over time.
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Affiliation(s)
- Ali G Hamedani
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA, USA
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Allison W Willis
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
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Goh R, Bacchi S, Lam L, Kleinig T, Jannes J. Rational clinical approach to transient ischaemic attack, stroke and associated mimics: A retrospective cohort study. Emerg Med Australas 2023; 35:821-827. [PMID: 37190670 DOI: 10.1111/1742-6723.14238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE The present study was performed to identify the individual clinical features and risk factors most strongly associated with the diagnosis of transient neurological symptoms with a cerebrovascular cause (transient ischaemic attack (TIA) or stroke), as compared to common TIA mimics (including retinal ischaemia, migraine and seizure). METHODS In a retrospective cohort study, consecutive patients presenting with transient neurological symptoms to TIA clinic in Royal Adelaide Hospital were included. Clinical features and risk factors were recorded in a standardised form, categorised into subgroups, and analysed using descriptive statistics and diagnostic performance indicators, such as sensitivity, specificity and likelihood ratios. RESULTS For 218/1273 individuals diagnosed with stroke, the three features with the highest positive likelihood ratio were the presence of diffusion weighted imaging positive lesion on magnetic resonance imaging (23.66, 95% confidence interval (CI) 14.35-51.08), extracranial carotid atherosclerosis (3.98, 95% CI 1.19-6.87) and a history of peripheral vascular disease (3.33, 95% CI 1.64-6.27). For TIA, the three features with the highest positive likelihood ratio were extracranial carotid atherosclerosis (3.98, 95% CI 1.19-8.27), presence of atrial fibrillation (2.43, 95% CI 1.54-3.46) and pre-existing anticoagulant therapy (2.39, 95% CI 1.61-3.29). For stroke and TIA, the respective features with the lowest negative likelihood ratios were limb weakness (0.71, 95% CI 0.65-0.77) and hypertension (0.66, 95% CI 0.49-0.84). CONCLUSIONS The present study demonstrated that specific clinical features and risk factors were associated with the final diagnosis at TIA clinic. These clinical features may assist with diagnosis of TIA in centres without access to a vascular neurologist.
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Affiliation(s)
- Rudy Goh
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lydia Lam
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jim Jannes
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
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Kida H, Sakai K, Sato T, Nakada R, Kitagawa T, Takatsu H, Komatsu T, Sakuta K, Mitsumura H, Iguchi Y. Follow-Up Diffusion-Weighted Image Reveals Delayed Appearance of Ischemic Lesions in Suspected Transient Ischemic Attack. Cureus 2023; 15:e47405. [PMID: 38022071 PMCID: PMC10657785 DOI: 10.7759/cureus.47405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION In patients suspected of transient ischemic attack (TIA), it is not uncommon to find no lesion on the diffusion-weighted image (DWI) on admission but a delayed appearance on the follow-up DWI. METHODS Enrolled patients met the following criteria: (1) MRI performed within 24 hours of onset and seven days after admission; (2) National Institutes of Health Stroke Scale (NIHSS) score ≦4 on admission; (3) pre-stroke modified Rankin scale (mRS) score of 0-1. Patients were divided as follows: no lesion on the first DWI and a new lesion on the second DWI (delayed-specified ischemic stroke; DSIS); and no lesion on either the first or second DWI (well-screened TIA; WSTIA). We compared both groups regarding the clinical background and the outcome at three months. RESULTS We identified 144 cases (male 70%; median age 64 years; DSIS, n=34) between October 2012 and March 2019. DSIS was older (71 vs. 60 years, p=0.006) and had a higher NIHSS score on admission (1 vs. 0, p=0.041), a higher rate of large vessel occlusion (LVO) (17% vs. 2%, p=0.008), and symptom duration over one hour (82% vs. 64%, p=0.041). A favorable outcome mRS score of 0-1 at three months was less frequent in DSIS (85% vs. 96%, p=0.004). Age/10 (OR 1.62, 95%CI 1.17-2.24; p=0.004) and LVO (OR 10.84, 95%CI 1.87-63.06; p=0.008) were independent factors for DSIS. CONCLUSIONS In suspected TIA with age or LVO but no lesion in the initial DWI, the second DWI should be considered to identify the delayed appearance of an ischemic stroke.
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Affiliation(s)
- Hiroyuki Kida
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Kenichiro Sakai
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Takeo Sato
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Ryoji Nakada
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Tomomichi Kitagawa
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Hiroki Takatsu
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Teppei Komatsu
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Kenichi Sakuta
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Hidetaka Mitsumura
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Yasuyuki Iguchi
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
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Sui Y, Sun J, Chen Y, Wang W. Multimodal MRI study of the relationship between plaque characteristics and hypoperfusion in patients with transient ischemic attack. Front Neurol 2023; 14:1242923. [PMID: 37840913 PMCID: PMC10568067 DOI: 10.3389/fneur.2023.1242923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/14/2023] [Indexed: 10/17/2023] Open
Abstract
Objective Transient ischemic attack is a significant risk factor for acute cerebral infarction. Previous studies have demonstrated that hypoperfusion in patients with transient ischemic attack was associated with the recurrence of transient ischemic attack, stroke, and persistent worsening of neurological symptoms. Moreover, transient ischemic attack patients classified as high-risk group according to the ABCD2 score have a higher incidence of stroke. Therefore, the objective of this study was to investigate the plaque characteristics of transient ischemic attack patients with concomitant cerebral hypoperfusion using multimodal MRI, as well as hemodynamic changes in the high-risk group with transient ischemic attack patients. Materials and methods A total of 151 patients with transient ischemic attack were prospectively recruited for this study. All enrolled patients underwent multimodal MRI, including DWI, TOF-MRA, HR-VWI, and DSC-PWI. Finally, 56 patients met the inclusion criteria. Based on DSC-PWI images, patients were divided into two groups: hypoperfusion (n = 41) and non-hypoperfusion (n = 15). Clinical baseline characteristics and plaque characteristics were analyzed between the two groups. Furthermore, within the hypoperfusion group, patients were further classified into low-risk (n = 11) and high-risk (n = 30) subgroups based on the ABCD2 score. Hemodynamic differences between these subgroups were also analyzed. Results Compared with the non-hypoperfusion group, the hypoperfusion group had a significantly higher prevalence of hypertension (68.3% vs. 33.3%, p = 0.019) and hyperhomocysteinemia (65.9% vs. 33.3%, p = 0.029). Moreover, the hypoperfusion group exhibited more significant luminal stenosis degree [41.79 ± 31.36 vs. 17.62± 13.62, p = 0.006] and greater NWI (57.1%± 20.47% vs. 40.21%± 21.56%, p = 0.009) compared to the non-hypoperfusion group. In addition, the high-risk group identified by the ABCD2 score had a higher rMTT [117.6(109.31-128.14) vs. 108.36(100.67-119.92), p = 0.037]. Conclusion Transient ischemic attack patients with hypoperfusion exhibited a higher prevalence of hypertension and hyperhomocysteinemia, as well as higher luminal stenosis degree, and greater NWI. Furthermore, Transient ischemic attack patients in the high-risk group demonstrated higher MTT.
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Affiliation(s)
| | | | | | - Wei Wang
- Department of MRI, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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30
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Vinding NE, Butt JH, Lauridsen MD, Kristensen SL, Johnsen SP, Krøll J, Graversen PL, Kruuse C, Torp-Pedersen C, Køber L, Fosbøl EL. Long-Term Incidence of Ischemic Stroke After Transient Ischemic Attack: A Nationwide Study From 2014 to 2020. Circulation 2023; 148:1000-1010. [PMID: 37622531 DOI: 10.1161/circulationaha.123.065446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/26/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND The short-term incidence of ischemic stroke after a transient ischemic attack (TIA) is high. However, data on the long-term incidence are not well known but are needed to guide preventive strategies. METHODS Patients with first-time TIA (index date) in the Danish Stroke Registry (January 2014-December 2020) were included and matched 1:4 with individuals from the background population and 1:1 with patients with a first-time ischemic stroke on the basis of age, sex, and calendar year. The incidences of ischemic stroke and mortality from index date were estimated by Aalen-Johansen and Kaplan-Meier estimators, respectively, and compared between groups using multivariable Cox regression. RESULTS We included 21 500 patients with TIA, 86 000 patients from the background population, and 21 500 patients with ischemic stroke (median age, 70.8 years [25th-75th percentile, 60.8-78.7]; 53.1% males). Patients with TIA had more comorbidities than the background population, yet less than the control stroke population. The 5-year incidence of ischemic stroke after TIA (6.1% [95% CI, 5.7-6.5]) was higher than the background population (1.5% [95% CI, 1.4-1.6], P<0.01; hazard ratio, 5.14 [95% CI, 4.65-5.69]) but lower than the control stroke population (8.9% [95% CI, 8.4-9.4], P<0.01; hazard ratio, 0.58 [95% CI, 0.53-0.64]). The 5-year mortality for patients with TIA (18.6% [95% CI, 17.9-19.3]) was higher than the background population (14.8% [95% CI, 14.5-15.1], P<0.01; hazard ratio, 1.26 [95% CI, 1.20-1.32]) but lower than the control stroke population (30.1% [95% CI, 29.3-30.9], P<0.01; hazard ratio, 0.41 [95% CI, 0.39-0.44]). CONCLUSIONS Patients with first-time TIA had an ischemic stroke incidence of 6.1% during the 5-year follow-up period. After adjustment for relevant comorbidities, this incidence was approximately 5-fold higher than what was found for controls in the background population and 40% lower than for patients with recurrent ischemic stroke.
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Affiliation(s)
- Naja Emborg Vinding
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (N.E.V., J.H.B., M.D.L., S.L.K., J.K., P.L.G., L.K., E.L.F.)
| | - Jawad H Butt
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (N.E.V., J.H.B., M.D.L., S.L.K., J.K., P.L.G., L.K., E.L.F.)
| | - Marie Dam Lauridsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (N.E.V., J.H.B., M.D.L., S.L.K., J.K., P.L.G., L.K., E.L.F.)
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University (M.D.L., S.P.J.)
- Respiratory Research Unit, Aalborg University Hospital, Denmark (M.D.L.)
| | - Søren Lund Kristensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (N.E.V., J.H.B., M.D.L., S.L.K., J.K., P.L.G., L.K., E.L.F.)
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University (M.D.L., S.P.J.)
| | - Johanna Krøll
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (N.E.V., J.H.B., M.D.L., S.L.K., J.K., P.L.G., L.K., E.L.F.)
| | - Peter L Graversen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (N.E.V., J.H.B., M.D.L., S.L.K., J.K., P.L.G., L.K., E.L.F.)
| | - Christina Kruuse
- Department of Neurology, Copenhagen University Hospital, Herlev and Gentofte, Herlev, Denmark (C.K.)
| | - Christian Torp-Pedersen
- Danish Heart Foundation, Copenhagen (C.T.P.)
- Department of Cardiology and Clinical Investigation, Nordsjællands Hospital, Hillerød, Denmark (C.T.P.)
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (N.E.V., J.H.B., M.D.L., S.L.K., J.K., P.L.G., L.K., E.L.F.)
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (N.E.V., J.H.B., M.D.L., S.L.K., J.K., P.L.G., L.K., E.L.F.)
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Uchiyama S, Suzuki-Inoue K, Wada H, Okada Y, Hirano T, Nagao T, Kinouchi H, Itabashi R, Hoshino H, Oki K, Honma Y, Ito N, Sugimori H, Kawamura M. Soluble C-type lectin-like receptor 2 in stroke (CLECSTRO) study: protocol of a multicentre, prospective cohort of a novel platelet activation marker in acute ischaemic stroke and transient ischaemic attack. BMJ Open 2023; 13:e073708. [PMID: 37723115 PMCID: PMC10510909 DOI: 10.1136/bmjopen-2023-073708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
INTRODUCTION Soluble C-type lectin-like receptor 2 (sCLEC-2) is a new biomarker for platelet activation, which can be easily measured by usual blood collection. We conducted the CLECSTRO, a prospective, observational cohort study, to evaluate the clinical implications of sCLEC-2 in patients with acute ischaemic stroke (AIS) and transient ischaemic attack (TIA). METHODS AND ANALYSIS The participants are patients with AIS/TIA and control patients required for differentiation from AIS/TIA. The target population is 600, including the patients and controls, who would be recruited from eight stroke centres across Japan. The inclusion criteria are AIS within 24 hours of onset and a modified Rankin Scale (mRS) score of 0-2, TIA within 7 days of onset, and contemporary patients required for differentiation from AIS/TIA. Plasma sCLEC-2 will be measured by high-sensitive chemiluminescent enzyme immunoassay using residual blood samples from routine laboratory examinations at the first visit in all patients and 7 days later or at discharge in patients with AIS/TIA. The outcomes include plasma levels of sCLEC-2 in patients with AIS/TIA and controls, sCLEC-2/D-dimer ratio in non-cardioembolic and cardioembolic AIS/TIA, correlation of sCLEC-2 with recurrence or worsening of stroke, severity of stroke, infarct size, ABCD2 score in TIA and outcome (mRS) at 7 days and 3 months. ETHICS AND DISSEMINATION This study was approved by the Ethical Committee of the University of Yamanashi as the central ethical committee in agreement with the ethical committees of all collaborative stroke centres. Informed consent will be obtained by an opt-out form from the patients at each stroke centre according to the Ethical Guidelines for Medical and Biological Research Involving Human Subjects by the Japanese Ministry of Health, Labour and Welfare. TRIAL REGISTRATION NUMBERS NCT05579405, UMIN000048954.
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Affiliation(s)
- Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Tokyo, Japan
| | - Katsue Suzuki-Inoue
- Department of Clinical and Laboratory Medicine, University of Yamanashi, Chuo, Japan
| | - Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Centre, Yokkaichi, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Centre, Fukuoka, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
| | - Takehiko Nagao
- Department of Neurology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | | | - Ryo Itabashi
- Division of Neurology & Gerontology, Iwate Medical University, Shiwa, Japan
| | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Koichi Oki
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Yutaka Honma
- Department of Neurology, Showa General Hospital, Kodaira, Japan
| | - Nobuo Ito
- Department of Neurology, Mie Prefectural General Medical Centre, Yokkaichi, Japan
| | - Hiroshi Sugimori
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Centre, Fukuoka, Japan
| | - Masahide Kawamura
- Department of Research and Development, LSI Medience Corporation, Tokyo, Japan
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Tarnutzer AA, Edlow JA. Bedside Testing in Acute Vestibular Syndrome-Evaluating HINTS Plus and Beyond-A Critical Review. Audiol Res 2023; 13:670-685. [PMID: 37736940 PMCID: PMC10514811 DOI: 10.3390/audiolres13050059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/16/2023] [Accepted: 08/28/2023] [Indexed: 09/23/2023] Open
Abstract
Acute vertigo and dizziness are frequent presenting symptoms in patients in the emergency department. These symptoms, which can be subtle and transient, present diagnostic challenges because they can be caused by a broad range of conditions that cut across many specialties and organ systems. Previous work has emphasized the value of combining structured history taking and a targeted examination focusing on subtle oculomotor signs. In this review, we discuss various diagnostic bedside algorithms proposed for the acutely dizzy patient. We analyzed these different approaches by calculating their area-under-the-curve (ROC) characteristics and sensitivity/specificity. We found that the algorithms that incorporated structured history taking and the use of subtle oculomotor signs had the highest diagnostic accuracy. In fact, both the HINTS+ bedside exam and the STANDING algorithm can more accurately diagnose acute strokes than early (<24 to 48 h after symptom onset) MRI with diffusion-weighted imaging (DWI). An important caveat is that HINTS and STANDING require moderate training to achieve this accuracy. Therefore, for physicians who have not undergone adequate training, other approaches are needed. These other approaches (e.g., ABCD2 score, PCI score, and TriAGe+ score) rely on vascular risk factors, clinical symptoms, and focal neurologic findings. While these other scores are easier for frontline providers to use, their diagnostic accuracy is far lower than HINTS+ or STANDING. Therefore, a focus on providing dedicated training in HINTS+ or STANDING techniques to frontline clinicians will be key to improving diagnostic accuracy and avoiding unnecessary brain imaging.
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Affiliation(s)
- Alexander A. Tarnutzer
- Department of Neurology, Cantonal Hospital of Baden, 5404 Baden, Switzerland
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Jonathan A. Edlow
- Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
- Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA
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Cao S, Zhao L, Pei L, Gao Y, Fang H, Liu K, Liu H, Yang S, Sun S, Wu J, Song B, Xu Y. ABCD2 score has equivalent stroke risk prediction for anterior circulation TIA and posterior circulation TIA. Sci Rep 2023; 13:13993. [PMID: 37634045 PMCID: PMC10460395 DOI: 10.1038/s41598-023-41260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023] Open
Abstract
Transient ischemic attack (TIA) was clinically divided into anterior circulation (AC) or posterior circulation (PC). Previous study reported that ABCD2 score could predict the stroke risk after AC-TIA but might have limitation for PC-TIA. We aimed to classify TIA depending on neuroimaging and assess the value of ABCD2 score for predicting stroke risk in different territories. Research data was from TIA database of the First Affiliated Hospital of Zhengzhou University. TIA patients with acute infarction on diffuse weighted imaging [that is, transient symptoms with infarction (TSI)] were divided into anterior and posterior circulation groups according to the location of infarction. The outcome was recurrent stroke within 7 and 90 days. The predictive power of ABCD2 score was determined using area under receiver operator characteristic curve (AUC) analyses. Overall, 382 AC-TSI and 112 PC-TSI patients were included. There were 38 (9.9%) AC-TSI patients and 11(9.8%) PC-TSI patients who had recurrent stroke at 7 days, and 66 (17.3%) AC-TSI patients and 19 (17.0%) PC-TSI patients who had recurrent stroke within 90 days. At 7 days, the AUC for ABCD2 score was 0.637 (95% confidence interval CI 0.554-0.720) in anterior circulation and 0.683 (95% CI 0.522-0.845) in posterior circulation. The C statistics for ABCD2 score in the two groups were not statistically significant (Z = - 0.499; P = 0.62). Similar result was found when the outcome time-point was set at 90 days. ABCD2 score could predict the short-term risk of recurrent stroke after AC-TSI and PC-TSI, and had similar predictive abilities for AC-TSI and PC-TSI.
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Affiliation(s)
- Shuang Cao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Lu Zhao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Lulu Pei
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Yuan Gao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Hui Fang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Kai Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Hao Liu
- Department of Magnetic Resonance, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shuxiang Yang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Shilei Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Jun Wu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Bo Song
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China.
| | - Yuming Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China.
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Chu T, Lee S, Jung IY, Song Y, Kim HA, Shin JW, Tak S. Task-residual effective connectivity of motor network in transient ischemic attack. Commun Biol 2023; 6:843. [PMID: 37580508 PMCID: PMC10425379 DOI: 10.1038/s42003-023-05212-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/03/2023] [Indexed: 08/16/2023] Open
Abstract
Transient ischemic attack (TIA) is a temporary episode of neurological dysfunction that results from focal brain ischemia. Although TIA symptoms are quickly resolved, patients with TIA have a high risk of stroke and persistent impairments in multiple domains of cognitive and motor functions. In this study, using spectral dynamic causal modeling, we investigate the changes in task-residual effective connectivity of patients with TIA during fist-closing movements. 28 healthy participants and 15 age-matched patients with TIA undergo functional magnetic resonance imaging at 7T. Here we show that during visually cued motor movement, patients with TIA have significantly higher effective connectivity toward the ipsilateral primary motor cortex and lower connectivity to the supplementary motor area than healthy controls. Our results imply that TIA patients have aberrant connections among motor regions, and these changes may reflect the decreased efficiency of primary motor function and disrupted control of voluntary movement in patients with TIA.
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Affiliation(s)
- Truc Chu
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju, 28119, Republic of Korea
- Graduate School of Analytical Science and Technology, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Seonjin Lee
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju, 28119, Republic of Korea
- Graduate School of Analytical Science and Technology, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Il-Young Jung
- Department of Rehabilitation Medicine, Chungnam National University Sejong Hospital, Sejong, 30099, Republic of Korea
| | - Youngkyu Song
- Bio-Chemical Analysis Team, Korea Basic Science Institute, Cheongju, 28119, Republic of Korea
| | - Hyun-Ah Kim
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
| | - Jong Wook Shin
- Department of Neurology, Chungnam National University Sejong Hospital, Sejong, 30099, Republic of Korea.
| | - Sungho Tak
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju, 28119, Republic of Korea.
- Graduate School of Analytical Science and Technology, Chungnam National University, Daejeon, 34134, Republic of Korea.
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Woodhouse LJ, Appleton JP, Christensen H, Dineen RA, England TJ, James M, Krishnan K, Montgomery AA, Ranta A, Robinson TG, Sprigg N, Bath PM. Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia. Sci Rep 2023; 13:11717. [PMID: 37474599 PMCID: PMC10359249 DOI: 10.1038/s41598-023-38474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24-3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8-35 day period but not in the 0-7 or 36-90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains.Trial registration ISRCTN47823388 .
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Rob A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Derby Stroke Centre, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
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Shao K, Zhang F, Li Y, Cai H, Paul Maswikiti E, Li M, Shen X, Wang L, Ge Z. A Nomogram for Predicting the Recurrence of Acute Non-Cardioembolic Ischemic Stroke: A Retrospective Hospital-Based Cohort Analysis. Brain Sci 2023; 13:1051. [PMID: 37508983 PMCID: PMC10377670 DOI: 10.3390/brainsci13071051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/26/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Non-cardioembolic ischemic stroke (IS) is the predominant subtype of IS. This study aimed to construct a nomogram for recurrence risks in patients with non-cardioembolic IS in order to maximize clinical benefits. From April 2015 to December 2019, data from consecutive patients who were diagnosed with non-cardioembolic IS were collected from Lanzhou University Second Hospital. The least absolute shrinkage and selection operator (LASSO) regression analysis was used to optimize variable selection. Multivariable Cox regression analyses were used to identify the independent risk factors. A nomogram model was constructed using the "rms" package in R software via multifactor Cox regression. The accuracy of the model was evaluated using the receiver operating characteristic (ROC), calibration curve, and decision curve analyses (DCA). A total of 729 non-cardioembolic IS patients were enrolled, including 498 (68.3%) male patients and 231 (31.7%) female patients. Among them, there were 137 patients (18.8%) with recurrence. The patients were randomly divided into training and testing sets. The Kaplan-Meier survival analysis of the training and testing sets consistently revealed that the recurrence rates in the high-risk group were significantly higher than those in the low-risk group (p < 0.01). Moreover, the receiver operating characteristic curve analysis of the risk score demonstrated that the area under the curve was 0.778 and 0.760 in the training and testing sets, respectively. The nomogram comprised independent risk factors, including age, diabetes, platelet-lymphocyte ratio, leukoencephalopathy, neutrophil, monocytes, total protein, platelet, albumin, indirect bilirubin, and high-density lipoprotein. The C-index of the nomogram was 0.752 (95% CI: 0.705~0.799) in the training set and 0.749 (95% CI: 0.663~0.835) in the testing set. The nomogram model can be used as an effective tool for carrying out individualized recurrence predictions for non-cardioembolic IS.
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Affiliation(s)
- Kangmei Shao
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Fan Zhang
- Department of Oncology Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Hongbin Cai
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Ewetse Paul Maswikiti
- Department of Oncology Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Mingming Li
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Xueyang Shen
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Longde Wang
- Expert Workstation of Academician Wang Longde, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Zhaoming Ge
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
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Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
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Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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Mbizvo GK, Schnier C, Simpson CR, Duncan SE, Chin RFM. Case-control study developing Scottish Epilepsy Deaths Study Score to predict epilepsy-related death. Brain 2023; 146:2418-2430. [PMID: 36477471 PMCID: PMC10232261 DOI: 10.1093/brain/awac463] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 09/29/2022] [Accepted: 11/26/2022] [Indexed: 02/17/2024] Open
Abstract
This study aimed to develop a risk prediction model for epilepsy-related death in adults. In this age- and sex-matched case-control study, we compared adults (aged ≥16 years) who had epilepsy-related death between 2009 and 2016 to living adults with epilepsy in Scotland. Cases were identified from validated administrative national datasets linked to mortality records. ICD-10 cause-of-death coding was used to define epilepsy-related death. Controls were recruited from a research database and epilepsy clinics. Clinical data from medical records were abstracted and used to undertake univariable and multivariable conditional logistic regression to develop a risk prediction model consisting of four variables chosen a priori. A weighted sum of the factors present was taken to create a risk index-the Scottish Epilepsy Deaths Study Score. Odds ratios were estimated with 95% confidence intervals (CIs). Here, 224 deceased cases (mean age 48 years, 114 male) and 224 matched living controls were compared. In univariable analysis, predictors of epilepsy-related death were recent epilepsy-related accident and emergency attendance (odds ratio 5.1, 95% CI 3.2-8.3), living in deprived areas (odds ratio 2.5, 95% CI 1.6-4.0), developmental epilepsy (odds ratio 3.1, 95% CI 1.7-5.7), raised Charlson Comorbidity Index score (odds ratio 2.5, 95% CI 1.2-5.2), alcohol abuse (odds ratio 4.4, 95% CI 2.2-9.2), absent recent neurology review (odds ratio 3.8, 95% CI 2.4-6.1) and generalized epilepsy (odds ratio 1.9, 95% CI 1.2-3.0). Scottish Epilepsy Deaths Study Score model variables were derived from the first four listed before, with Charlson Comorbidity Index ≥2 given 1 point, living in the two most deprived areas given 2 points, having an inherited or congenital aetiology or risk factor for developing epilepsy given 2 points and recent epilepsy-related accident and emergency attendance given 3 points. Compared to having a Scottish Epilepsy Deaths Study Score of 0, those with a Scottish Epilepsy Deaths Study Score of 1 remained low risk, with odds ratio 1.6 (95% CI 0.5-4.8). Those with a Scottish Epilepsy Deaths Study Score of 2-3 had moderate risk, with odds ratio 2.8 (95% CI 1.3-6.2). Those with a Scottish Epilepsy Deaths Study Score of 4-5 and 6-8 were high risk, with odds ratio 14.4 (95% CI 5.9-35.2) and 24.0 (95% CI 8.1-71.2), respectively. The Scottish Epilepsy Deaths Study Score may be a helpful tool for identifying adults at high risk of epilepsy-related death and requires external validation.
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Affiliation(s)
- Gashirai K Mbizvo
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH16 4TJ, UK
- Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L69 7BE, UK
| | | | - Colin R Simpson
- Usher Institute, University of Edinburgh, Edinburgh EH16 4UX, UK
- School of Health, Wellington Faculty of Health, Victoria University of Wellington, Wellington 6140, New Zealand
| | - Susan E Duncan
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH16 4TJ, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh EH16 4SA, UK
| | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH16 4TJ, UK
- Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Amin HP, Madsen TE, Bravata DM, Wira CR, Johnston SC, Ashcraft S, Burrus TM, Panagos PD, Wintermark M, Esenwa C. Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association. Stroke 2023; 54:e109-e121. [PMID: 36655570 DOI: 10.1161/str.0000000000000418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
At least 240 000 individuals experience a transient ischemic attack each year in the United States. Transient ischemic attack is a strong predictor of subsequent stroke. The 90-day stroke risk after transient ischemic attack can be as high as 17.8%, with almost half occurring within 2 days of the index event. Diagnosing transient ischemic attack can also be challenging given the transitory nature of symptoms, often reassuring neurological examination at the time of evaluation, and lack of confirmatory testing. Limited resources, such as imaging availability and access to specialists, can further exacerbate this challenge. This scientific statement focuses on the correct clinical diagnosis, risk assessment, and management decisions of patients with suspected transient ischemic attack. Identification of high-risk patients can be achieved through use of comprehensive protocols incorporating acute phase imaging of both the brain and cerebral vasculature, thoughtful use of risk stratification scales, and ancillary testing with the ultimate goal of determining who can be safely discharged home from the emergency department versus admitted to the hospital. We discuss various methods for rapid yet comprehensive evaluations, keeping resource-limited sites in mind. In addition, we discuss strategies for secondary prevention of future cerebrovascular events using maximal medical therapy and patient education.
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Yurtsever G, Karaali R, Bora ES. Evaluation of ABCD2 score during the development of stroke in COVID-19 patients diagnosed with transient ischemic attack in the emergency department. J Stroke Cerebrovasc Dis 2023; 32:106918. [PMID: 36621122 PMCID: PMC9715486 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The aim of the present study is to reveal the association between the risk of stroke using ABCD2 score and COVID-19 in patients who presented to our emergency department during the pandemic and were diagnosed with TIA. METHODS According to the recommendations of the European Stroke Association, patients with an ABCD2 score of <4 were classified as low-risk, and patients with an ABCD2 score of ≥4 were classified as high-risk. Within 90 days of the patient's admission to the emergency room, the development of stroke was tracked and recorded on the system. RESULTS Stroke occurred in 35.78% of the patients. Regarding COVID-19, 75.34% of stroke patients were positive for COVID-19 and 65.75% had COVID-19 compatible pneumonia on 'thoracic CT'. Regarding mortality, 16.4% of the patients who were positive for COVID-19 and developed a stroke died. The presence of COVID-19 compatible pneumonia on thorax CT, PCR test result and ABCD2 score were determined as independent risk factors for the development of stroke. According to the PCR test results, the probability of having a stroke decreases 0.283 times in patients who are negative for COVID-19. According to the PCR test results, the probability of having a stroke increased 2.7 times in COVID-19 positive patients. CONCLUSIONS Adding the presence of COVID-19 and the presence of COVID-19 pneumonia to the ABCD2 score, based on the information about the increased risk of stroke in TIA patients, improves the predictive power of the score. More studies are needed in this regard.
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Affiliation(s)
- Güner Yurtsever
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey.
| | - Rezan Karaali
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey
| | - Ejder Saylav Bora
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey
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Derivation and validation of a machine learning-based risk prediction model in patients with acute heart failure. J Cardiol 2023; 81:531-536. [PMID: 36858175 DOI: 10.1016/j.jjcc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/18/2023] [Accepted: 02/07/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Risk stratification is important in patients with acute heart failure (AHF), and a simple risk score that accurately predicts mortality is needed. The aim of this study is to develop a user-friendly risk-prediction model using a machine-learning method. METHODS A machine-learning-based risk model using least absolute shrinkage and selection operator (LASSO) regression was developed by identifying predictors of in-hospital mortality in the derivation cohort (REALITY-AHF), and its performance was externally validated in the validation cohort (NARA-HF) and compared with two pre-existing risk models: the Get With The Guidelines risk score incorporating brain natriuretic peptide and hypochloremia (GWTG-BNP-Cl-RS) and the acute decompensated heart failure national registry risk (ADHERE). RESULTS In-hospital deaths in the derivation and validation cohorts were 76 (5.1 %) and 61 (4.9 %), respectively. The risk score comprised four variables (systolic blood pressure, blood urea nitrogen, serum chloride, and C-reactive protein) and was developed according to the results of the LASSO regression weighting the coefficient for selected variables using a logistic regression model (4 V-RS). Even though 4 V-RS comprised fewer variables, in the validation cohort, it showed a higher area under the receiver operating characteristic curve (AUC) than the ADHERE risk model (AUC, 0.783 vs. 0.740; p = 0.059) and a significant improvement in net reclassification (0.359; 95 % CI, 0.10-0.67; p = 0.006). 4 V-RS performed similarly to GWTG-BNP-Cl-RS in terms of discrimination (AUC, 0.783 vs. 0.759; p = 0.426) and net reclassification (0.176; 95 % CI, -0.08-0.43; p = 0.178). CONCLUSIONS The 4 V-RS model comprising only four readily available data points at the time of admission performed similarly to the more complex pre-existing risk model in patients with AHF.
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Tian Y, Pan Y, Wang M, Meng X, Zhao X, Liu L, Wang Y, Wang Y. The combination of heart rate variability and ABCD 2 score portends adverse outcomes after minor stroke or transient ischemic attack. J Neurol Sci 2023; 445:120522. [PMID: 36634579 DOI: 10.1016/j.jns.2022.120522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/06/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The residual recurrent risk of stroke, which cannot be entirely explained by the traditional ABCD2 score, still existed. Heart rate variability (HRV), a method for reflecting the function of automatic nervous system (ANS), was a novel predictor of secondary stroke events. We aimed to investigate the relationships of combined HRV and ABCD2 score with adverse outcomes after acute minor stroke (MS) or transient ischemic attack (TIA), and further investigate the independent associations between HRV and adverse outcomes after MS/TIA stratified by ABCD2 score. METHODS Data were obtained from the Third China National Stroke Registry (CNSR-III) study. We assessed the activity of ANS using standard deviation of NN intervals (SDNN), a time domain index of HRV. Trained investigators collected clinical characteristics and estimated ABCD2 score for each participant. All enrolled patients were categorized into different risk groups based on SDNN level and ABCD2 score. The clinial outcomes included recurrent stroke, recurrent ischemic stroke, and disability within 1-year follow-up. We evaluated whether combined SDNN and ABCD2 score were associated with recurrent events using multivariable Cox regression models, and those with disability using multivariable logistic regression models. The independent associations between SDNN and diverse outcomes stratified by ABCD2 score were explored using multivariable Cox and logistic regression analyses. RESULTS A total of 5,743 participants [3,316 (70.02) males, 62.0 (54.0-69.0) years] were included. Patients with low SDNN and ABCD2 ≥ 4 were associated with higher risk of recurrent stroke within 1 year (10.8% versus 4.9%; [HR] 1.31, 95% [CI] 0.92-1.88, P = 0.14) compared to patients with high SDNN with ABCD2 < 4. Lower SDNN was associated with higher recurrent stroke in patients with ABCD2 0-3 score ([HR] 0.73, 95% [CI] 0.57-0.947, P = 0.01) and ABCD2 4-5 score ([HR] 0.85, 95% [CI] 0.74-0.97, P = 0.02), but not in patients with ABCD2 6-7 score. CONCLUSION The combination of HRV and ABCD2 score might efficiently stratify the risk of 1-year recurrent stroke after MS/TIA. Moreover, lower SDNN was independently related to recurrent stroke in patients with MS/TIA, especially for those with low-to-moderate traditional vascular risk factors.
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Affiliation(s)
- Yu Tian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Chinese Institute for Brain Research, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Chinese Institute for Brain Research, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Mengxing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Chinese Institute for Brain Research, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Chinese Institute for Brain Research, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Chinese Institute for Brain Research, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Chinese Institute for Brain Research, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Chinese Institute for Brain Research, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Chinese Institute for Brain Research, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Aftyka J, Staszewski J, Dębiec A, Pogoda-Wesołowska A, Żebrowski J. Heart rate variability as a predictor of stroke course, functional outcome, and medical complications: A systematic review. Front Physiol 2023; 14:1115164. [PMID: 36846317 PMCID: PMC9947292 DOI: 10.3389/fphys.2023.1115164] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Background: Heart rate variability (HRV) is a non-invasive marker of autonomic nervous system function that is based on the analysis of length differences between subsequent RR intervals of the electrocardiogram. The aim of this systematic review was to assess the current knowledge gap in the utility of HRV parameters and their value as predictors of the acute stroke course. Methods: A systematic review was performed in accordance with the PRISMA guidelines. Relevant articles published between 1 January 2016 and 1 November 2022 available in the PubMed, Web of Science, Scopus, and Cochrane Library databases were obtained using a systematic search strategy. The following keywords were used to screen the publications: "heart rate variability" AND/OR "HRV" AND "stroke." The eligibility criteria that clearly identified and described outcomes and outlined restrictions on HRV measurement were pre-established by the authors. Articles assessing the relationship between HRV measured in the acute phase of stroke and at least one stroke outcome were considered. The observation period did not exceed 12 months. Studies that included patients with medical conditions influencing HRV with no established stroke etiology and non-human subjects were excluded from the analysis. To minimize the risk of bias, disagreements throughout the search and analysis were resolved by two independent supervisors. Results: Of the 1,305 records obtained from the systematic search based on keywords, 36 were included in the final review. These publications provided insight into the usability of linear and non-linear HRV analysis in predicting the course, complications, and mortality of stroke. Furthermore, some modern techniques, such as HRV biofeedback, for the improvement of cognition performance after a stroke are discussed. Discussion: The present study showed that HRV could be considered a promising biomarker of a stroke outcome and its complications. However, further research is needed to establish a methodology for appropriate quantification and interpretation of HRV-derived parameters.
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Affiliation(s)
- Joanna Aftyka
- Faculty of Physics, Warsaw University of Technology, Warsaw, Poland,*Correspondence: Joanna Aftyka,
| | - Jacek Staszewski
- Clinic of Neurology, Military Institute of Medicine, Warsaw, Poland
| | | | | | - Jan Żebrowski
- Faculty of Physics, Warsaw University of Technology, Warsaw, Poland
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46
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Tian X, Fang H, Lan L, Ip HL, Abrigo J, Liu H, Zheng L, Fan FSY, Ma SH, Ip B, Song B, Xu Y, Li J, Zhang B, Xu Y, Soo YOY, Mok V, Wong KS, Leung TW, Leng X. Risk stratification in symptomatic intracranial atherosclerotic disease with conventional vascular risk factors and cerebral haemodynamics. Stroke Vasc Neurol 2023; 8:77-85. [PMID: 36104090 PMCID: PMC9985805 DOI: 10.1136/svn-2022-001606] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 09/02/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND AND PURPOSE Symptomatic intracranial atherosclerotic stenosis (sICAS) is associated with a considerable risk of recurrent stroke despite contemporarily optimal medical treatment. Severity of luminal stenosis in sICAS and its haemodynamic significance quantified with computational fluid dynamics (CFD) models were associated with the risk of stroke recurrence. We aimed to develop and compare stroke risk prediction nomograms in sICAS, based on vascular risk factors and these metrics. METHODS Patients with 50%-99% sICAS confirmed in CT angiography (CTA) were enrolled. Conventional vascular risk factors were collected. Severity of luminal stenosis in sICAS was dichotomised as moderate (50%-69%) and severe (70%-99%). Translesional pressure ratio (PR) and wall shear stress ratio (WSSR) were quantified via CTA-based CFD modelling; the haemodynamic status of sICAS was classified as normal (normal PR&WSSR), intermediate (otherwise) and abnormal (abnormal PR&WSSR). All patients received guideline-recommended medical treatment. We developed and compared performance of nomograms composed of these variables and independent predictors identified in multivariate logistic regression, in predicting the primary outcome, recurrent ischaemic stroke in the same territory (SIT) within 1 year. RESULTS Among 245 sICAS patients, 20 (8.2%) had SIT. The D2H2A nomogram, incorporating diabetes, dyslipidaemia, haemodynamic status of sICAS, hypertension and age ≥50 years, showed good calibration (P for Hosmer-Lemeshow test=0.560) and discrimination (C-statistic 0.73, 95% CI 0.60 to 0.85). It also had better performance in risk reclassification and provided larger net benefits in decision curve analysis, compared with nomograms composed of conventional vascular risk factors only, and plus the severity of luminal stenosis in sICAS. Sensitivity analysis in patients with anterior-circulation sICAS showed similar results. CONCLUSIONS The D2H2A nomogram, incorporating conventional vascular risk factors and the haemodynamic significance of sICAS as assessed in CFD models, could be a useful tool to stratify sICAS patients for the risk of recurrent stroke under contemporarily optimal medical treatment.
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Affiliation(s)
- Xuan Tian
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Hui Fang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Linfang Lan
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China.,Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hing Lung Ip
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Jill Abrigo
- Department of Imaging and Interventional, The Chinese University, Hong Kong, China
| | - Haipeng Liu
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China.,Research Centre of Intelligent Healthcare, Faculty of Health and Life Science, Coventry University, Coventry, UK
| | - Lina Zheng
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Florence S Y Fan
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Sze Ho Ma
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Bonaventure Ip
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Bo Song
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yuming Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jingwei Li
- Department of Neurology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Bing Zhang
- Department of Radiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Yun Xu
- Department of Neurology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Yannie O Y Soo
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Vincent Mok
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Ka Sing Wong
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University, Hong Kong, China
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Chiu YC, Tang SC, Tsai LK, Hsieh MJ, Chiang WC, Jeng JS, Ma MHM. Development and Validation of a Risk Score for Predicting Ischemic Stroke After Transient Ischemic Attack. J Emerg Med 2023; 64:167-174. [PMID: 36813643 DOI: 10.1016/j.jemermed.2022.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND A risk stratification scale is essential to identify high-risk patients who had transient ischemic attack (TIA) to prevent subsequent permanent disability caused by ischemic stroke. OBJECTIVE This study aimed to develop and validate a scoring system to predict acute ischemic stroke within 90 days after TIA in an emergency department (ED). METHODS We retrospectively analyzed the data of patients with TIA in a stroke registry between January 2011 and September 2018. Characteristics, medication history, electrocardiogram (ECG), and imaging findings were collected. Univariable and multivariable stepwise logistic regression analyses were performed to create an integer point system. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration. Youden's Index was also used to determine the best cutoff value. RESULTS A total of 557 patients were included, and the occurrence rate of acute ischemic stroke within 90 days after TIA was 5.03%. After multivariable analysis, a new integer point system was created-MESH (Medication Electrocardiogram Stenosis Hypodense) score-which contained medication history (antiplatelet medication taken before admission, 1 point), right bundle branch block on electrocardiogram (1 point), intracranial stenosis ≥ 50% (1 point), and size of the hypodense area on computed tomography (diameter ≥ 4 cm, 2 points). The MESH score showed adequate discrimination (AUC = 0.78) and calibration (HL test = 0.78). The best cutoff value was 2 points, with a sensitivity of 60.71% and specificity of 81.66%. CONCLUSIONS The MESH score indicated improved accuracy for TIA risk stratification in the ED setting.
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Affiliation(s)
- Yu-Chen Chiu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
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48
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Yao K, Zu HB. Isolated transient vertigo due to TIA: challenge for diagnosis and therapy. J Neurol 2023; 270:769-779. [PMID: 36371598 DOI: 10.1007/s00415-022-11443-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
As a prevalent vertigo disease in the clinic, isolated transient vertigo can present as a vertigo episode without focal signs and always free of symptoms on presentation. Previous studies showed a part of isolated transient vertigo events had a high risk of stroke during follow-up. However, how to discern posterior circulation ischemia become a great challenge for clinicians, especially in emergency, neurology, and ENT departments. Routine besides, hematological, and imaging examinations are often difficult provide a clear etiological diagnosis. Hence, this article reviews current knowledge about the epidemiology, risk factors, offending lesions, and clinical manifestation of transient ischemic attack (TIA) presenting as isolated transient vertigo. In addition, we summarize several advances in besides examinations, serum biomarkers, and imaging technologies to better identify stroke events. Finally, the current situation of therapy was briefly retrospected. Here we present a critical clinical puzzle that needs to be solved in the future. Of note, there is a still lack of high-quality studies in this field. The article reviews the keys to the diagnosis of isolated transient vertigo due to TIA and provides us with more methods to screen for high-risk stroke populations.
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Affiliation(s)
- Kai Yao
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China
| | - Heng-Bing Zu
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China.
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Vera A, Cecconi A, Ximénez-Carrillo Á, Ramos C, Martínez-Vives P, Lopez-Melgar B, Sanz-García A, Ortega G, Aguirre C, Montes Á, Vivancos J, Jiménez-Borreguero LJ, Alfonso F. Risk of recurrent stroke and mortality after cryptogenic stroke in diabetic patients. Heart Vessels 2023; 38:817-824. [PMID: 36695856 DOI: 10.1007/s00380-023-02235-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Diabetes mellitus is a highly prevalent and growing chronic disease that is associated with increased risk of recurrence among several stroke subtypes. However, evidence on the prognostic role of diabetes in the setting of cryptogenic stroke (CS) remains scarce. METHODS From April 2019 to November 2021, we recruited prospectively 78 consecutive patients with CS. Patients were classified according to the presence of diabetes. Main outcome was the composite of stroke recurrence and death. Secondary outcome was stroke recurrence. RESULTS Mean age of the cohort was 78 ± 7.7 years and 18 patients (23%) had diabetes. After a median clinical follow-up of 23 months the incidence of stroke recurrence and mortality [HR 5.8 (95% CI 1.9-19), p = 0.002] and the incidence of stroke recurrence [HR 16.6 (95% CI 1.8-149), p = 0.012], were higher in patients with diabetes. After adjusting for potential confounders diabetes was identified as an independent predictor of stroke recurrence and death in patients with CS [HR 33.8 (95% CI 2.1-551), p = 0.013]. Other independent predictors of stroke recurrence and mortality were hypertension [HR 31.4 (95% CI 1.8-550), p = 0.018], NTproBNP [HR 1.002 (95% CI 1.001-1.004), p = 0.013] and chronic kidney disease (CKD) [HR 27.4 (95% CI 1.4-549) p = 0.03]. Furthermore, diabetes was an independent predictor of stroke recurrence [HR 103 (95% CI 1.3-8261), p = 0.038]. CONCLUSION Diabetic patients with CS are at higher risk of stroke recurrence and death. Hypertension CKD and NTproBNP are also independent predictors of stroke recurrence and death after CS.
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Affiliation(s)
- Alberto Vera
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Alberto Cecconi
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain.
| | - Álvaro Ximénez-Carrillo
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carmen Ramos
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Pablo Martínez-Vives
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Beatriz Lopez-Melgar
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, Madrid, Spain
| | - Guillermo Ortega
- Data Analysis Unit, Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, Madrid, Spain
| | - Clara Aguirre
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Álvaro Montes
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - José Vivancos
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Luis Jesús Jiménez-Borreguero
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain.
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
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50
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Joundi RA, Yu AYX, Smith EE, Zerna C, Penn AM, Balshaw RF, Votova K, Bibok MB, Penn M, Saly V, Hegedus J, Coutts SB, Yu AYX, Penn AM, Trivedi A, Cook J, Morrison J, Blackwood K, Richards K, Votova K, Nealis M, Bibok MB, Penn M, Beattyova P, Rosenberg P, Frost S, Grant C, Hedgedus J, Grant S, Watson T, Saly V, Sedgwick C, Lesperance ML, Croteau NS, Appireddy R, Balshaw RF, Field TS, Dubuc V, Demchuk AM, Jambula A, Le A, Menon BK, Calvert C, Kenney C, Zerna C, Nikneshan D, Smith EE, Klourfeld E, Wagner G, Klein G, Aram H, Desai J, Ryckborst K, Bilston L, Hill MD, Almekhlafi M, Godfrey N, Imoukheude O, Stys P, Barber PA, Couillard P, Eswaradas P, Rhandawa P, Coutts SB, Bal S, Peters S, Save S, Subramaniam S, Musuka T, Stewart T, Hong ZM. Association Between Duration of Transient Neurological Events and Diffusion-Weighted Brain Lesions. J Am Heart Assoc 2023; 12:e027861. [PMID: 36695298 PMCID: PMC9973650 DOI: 10.1161/jaha.122.027861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background The relationship between duration of transient neurological events and presence of diffusion-weighted lesions by symptom type is unclear. Methods and Results This was a substudy of SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment), a multicenter prospective cohort of patients with minor ischemic cerebrovascular events or stroke mimics at academic emergency departments in Canada. For this study we included patients with resolved symptoms and determined the presence of diffusion-weighted imaging (DWI) lesion on magnetic resonance imaging within 7 days. Using logistic regression, we evaluated the association between symptom duration and DWI lesion, assessing for interaction with symptom type (focal only versus nonfocal/mixed), and adjusting for age, sex, education, comorbidities, and systolic blood pressure. Of 658 patients included, a DWI lesion was present in 232 (35.1%). There was a significant interaction between symptom duration and symptom type. For those with focal-only symptoms, there was a continuous increase in DWI probability up to 24 hours in duration (ranging from ≈40% to 80% probability). In stratified analyses, the increase in probability of DWI lesion with increased duration of focal symptoms was seen in women but not men. For those with nonfocal or mixed symptoms, predicted probability of DWI lesion was ≈35% and was greater in men, but did not increase with longer duration. Conclusions Increased duration of neurological deficits is associated with greater probability of DWI lesion in those with focal symptoms only. For individuals with nonfocal or mixed symptoms, about one-third had DWI lesions, but the probability did not increase with duration. These results may be important to improve risk stratification of transient neurological events.
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Affiliation(s)
- Raed A. Joundi
- Division of Neurology, Hamilton Health SciencesMcMaster University & Population Health Research InstituteHamiltonOntarioCanada
| | - Amy Y. X. Yu
- Division of Neurology, Department of MedicineUniversity of Toronto, Sunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Eric E. Smith
- Departments of Clinical Neurosciences and Community Health SciencesUniversity of CalgaryAlbertaCanada
| | - Charlotte Zerna
- Department of Clinical Neurosciences and Diagnostic ImagingUniversity of Calgary Cumming School of MedicineCalgaryAlbertaCanada
| | - Andrew M. Penn
- Stroke Rapid Assessment Unit, Island HealthVictoriaBritish ColumbiaCanada
| | - Robert F. Balshaw
- George & Fay Yee Centre for Healthcare InnovationUniversity of ManitobaWinnipegManitobaCanada
| | - Kristine Votova
- Island Health Regional Health Authority, Division of Medical SciencesUniversity of VictoriaVictoriaBritish ColumbiaCanada
| | - Maximilian B. Bibok
- Department of Research and Capacity Building, Island HealthVictoriaBritish ColumbiaCanada
| | - Melanie Penn
- Stroke Rapid Assessment Unit, Island HealthVictoriaBritish ColumbiaCanada
| | - Viera Saly
- Stroke Rapid Assessment Unit, Island HealthVictoriaBritish ColumbiaCanada
| | - Janka Hegedus
- Stroke Rapid Assessment Unit, Island HealthVictoriaBritish ColumbiaCanada
| | - Shelagh B. Coutts
- Departments of Clinical Neurosciences and Community Health SciencesUniversity of CalgaryAlbertaCanada
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