1
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Fischer G. [EC-IC bypass for occlusion of the internal carotid artery]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00117-024-01343-8. [PMID: 39009759 DOI: 10.1007/s00117-024-01343-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND There are barely any alternative treatment options to the drug treatment of hemodynamically caused cerebral ischemia, as in occlusion of the internal carotid artery. OBJECTIVE For secondary prevention of an ischemic stroke due to carotid occlusion and hemodynamic instability, extracranial-intracranial (EC-IC) bypass surgery can be an important option in selected patients. MATERIAL AND METHODS The development, study situation, indications and surgical technique for placement of an EC-IC bypass in cases of occlusion of the internal carotid artery are presented. RESULTS With appropriate expertise and strict selection of patients, the placement of an EC-IC bypass enables stabilization of cerebral perfusion with a low rate of complications. CONCLUSION The study situation is controversially discussed; nevertheless, surgical treatment in a specialized neurovascular center should at least be considered.
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Affiliation(s)
- G Fischer
- Neurochirurgische Klinik, Universitätsklinikum des Saarlandes, Kirrberger Str. 90.5, 66421, Homburg/Saar, Deutschland.
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2
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Marinheiro G, Araújo B, Monteiro GDA, Leite M, Mutarelli A, Almeida AMD, Cavalcante-Neto JF, Rivera A, Pinheiro AC, Telles JPM. Ticagrelor versus clopidogrel in dual antiplatelet therapy after minor stroke or transient ischemic attack: an updated network meta-analysis. J Neurol 2024; 271:3030-3038. [PMID: 38580815 DOI: 10.1007/s00415-024-12330-3] [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: 02/23/2024] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin is a well-established practice after a minor stroke or transient ischemic attack (TIA). However, ticagrelor plus aspirin may be an alternative. AIMS We systematically searched PubMed, Embase, and Cochrane Central from inception to January 2024. We included randomized controlled trials (RCTs) enrolling adults with acute minor stroke or TIA within 72 hours of the onset of the symptoms. RESULTS A total of 8 RCTs were included in our meta-analysis. Ticagrelor plus aspirin (RR, 0.70; 95% CrI 0.52, 0.91) and clopidogrel plus aspirin (RR, 0.79; 95% CrI 0.64, 0.98) were superior to aspirin in preventing stroke recurrence in overall analysis. Excluding studies with dual antiplatelet up to 90 days, ticagrelor plus aspirin was the only strategy that maintained superiority compared with aspirin regarding stroke recurrence (RR, 0.70; 95% CrI 0.51, 0.95) and ischemic stroke (RR, 0.68; 95% CrI 0.47, 0.94). There was no significant difference between treatment groups regarding hemorrhagic stroke, functional disability, and mortality. CONCLUSIONS DAPTs were superior to aspirin in preventing recurrence or ischemic stroke. Although no significant difference was observed between DAPTs, ticagrelor plus aspirin may be related to worse major bleeding results, including intracranial bleeding. Ticagrelor plus aspirin is a considerable option for patients after a minor stroke or TIA.
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Affiliation(s)
| | - Beatriz Araújo
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | | | - Marianna Leite
- School of Medicine, Santa Marcelina College, São Paulo, Brazil
| | - Antonio Mutarelli
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | - André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | - Agostinho C Pinheiro
- Department of Neurology, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, USA
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3
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A. Gawad EA, El Madani M, Mostafa H, Abdel halim RM. Precision medicine as a predictive factor for risk of hospitalization of recurrent ischemic stroke patients treated with low dose aspirin. A pilot study. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2174833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Affiliation(s)
| | | | - Hanan Mostafa
- Department of Anesthesia, surgical intensive care medicine and pain, Cairo University, Egypt
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4
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Kalyuzhnaya Y, Khaitin A, Demyanenko S. Modeling transient ischemic attack via photothrombosis. Biophys Rev 2023; 15:1279-1286. [PMID: 37974996 PMCID: PMC10643708 DOI: 10.1007/s12551-023-01121-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 11/19/2023] Open
Abstract
The health significance of transient ischemic attacks (TIAs) is largely underestimated. Often, TIAs are not given significant importance, and in vain, because TIAs are a predictor of the development of serious cardiovascular diseases and even death. Because of this, and because of the difficulty in diagnosing the disease, TIAs and related microinfarcts are poorly investigated. Photothrombotic models of stroke and TIA allow reproducing the occlusion of small brain vessels, even single ones. When dosing the concentration of photosensitizer, intensity and irradiation time, it is possible to achieve occlusion of well-defined small vessels with high reproducibility, and with the help of modern methods of blood flow assessment it is possible to achieve spontaneous restoration of blood flow without vessel rupture. In this review, we discuss the features of microinfarcts and the contemporary experimental approaches used to model TIA and microinfarcts, with an emphasis on models using the principle of photothrombosis of brain vessels. We review modern techniques for in vivo detection of blood flow in small brain vessels, as well as biomarkers of microinfarcts.
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Affiliation(s)
- Y.N. Kalyuzhnaya
- Southern Federal University, Academy of Biology and Biotechnology, Rostov-on-Don, Russia
| | - A.M. Khaitin
- Southern Federal University, Academy of Biology and Biotechnology, Rostov-on-Don, Russia
| | - S.V. Demyanenko
- Southern Federal University, Academy of Biology and Biotechnology, Rostov-on-Don, Russia
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5
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Kim JT, Lee JS, Kim BJ, Kang J, Lee KJ, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Park TH, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Choi JC, Kwon JH, Kim WJ, Shin DI, Yum KS, Sohn SI, Hong JH, Lee SH, Park MS, Choi KH, Ryu WS, Lee J, Saver JL, Bae HJ. Admission hyperglycemia, stroke subtypes, outcomes in acute ischemic stroke. Diabetes Res Clin Pract 2023; 196:110257. [PMID: 36642337 DOI: 10.1016/j.diabres.2023.110257] [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: 12/09/2022] [Revised: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023]
Abstract
AIMS Whether admission hyperglycemia is differentially associated with early vascular outcomes in acute ischemic stroke (AIS) depending on stroke subtype has been incompletely delineated. METHODS In a multicenter, prospective stroke registry, patients with AIS were categorized based on admission glucose levels into normoglycemia, moderate hyperglycemia, and severe hyperglycemia (<140mg/dl, 140-179mg/dl, and ≥180mg/dl, respectively) groups. Multivariate analysis assessed the interaction between the hyperglycemia and ischemic stroke subtypes of large artery atherothrombosis (LAA), cardioembolism (CE), and small vessel occlusion (SVO) and early vascular outcomes (3-month stroke, all-cause mortality, and composite of stroke, MI, and all-cause mortality). RESULTS Among the 32,772 patients (age:69.0±12.6yrs, male:58.4%) meeting eligibility criteria, 61.9% were in the normoglycemia group, 19.5% were in the moderate hyperglycemia group, and 18.7% were in the severe hyperglycemia group. Substantial interactions between hyperglycemia groups and stroke subtypes were observed for 3-month stroke (Pinteraction = 0.003) and composite of stroke, MI, and all-cause mortality (Pinteraction = 0.001), with differential recurrence strongest among CE, intermediate among LAA, and least among SVO. CONCLUSIONS Hyperglycemia was differently associated with the risk of 3-month stroke by ischemic stroke subtype. The associations of hyperglycemia with 3-month stroke were greatest in CE subtype but not in SVO subtype. These results suggest that the effect of glucose-lowering treatment after AIS may differ according to stroke subtype.
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Affiliation(s)
- Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea.
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Keon-Joo Lee
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si, Republic of Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Republic of Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Republic of Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Hong-Kyun Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Republic of Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University College of Medicine, Ulsan, Republic of Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University College of Medicine, Ulsan, Republic of Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sang-Hwa Lee
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea; Artificial Intelligence Research Center, JLK Inc., Seoul, Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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6
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Krishnan K, Law ZK, Minhas JS, Bath PM, Robinson TG, Sprigg N, Mavilakandy A, England TJ, Eveson D, Mistri A, Dawson J, Appleton JP. Antiplatelet treatment for acute secondary prevention of non-cardioembolic minor stroke / transient ischaemic attack: an update for the acute physician. Clin Med (Lond) 2022; 22:449-454. [PMID: 38589066 PMCID: PMC9595021 DOI: 10.7861/clinmed.2021-0597] [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: 12/15/2022]
Abstract
Acute stroke is the leading cause of disability in the UK and a leading cause of mortality worldwide. The majority of patients with ischaemic stroke present with minor deficits or transient ischaemic attack (TIA), and are often first seen by patient-facing clinicians. Urgent evaluation and treatment are important as many patients are at high risk of major vascular events and death within hours to days after the index event. This narrative review summarises the evidence on four antiplatelet treatments for non-cardioembolic stroke prevention: aspirin, clopidogrel, dipyridamole and ticagrelor. Each of these drugs has a unique mechanism and has been tested as a single agent or in combination. Aspirin, when given early is beneficial and short-term treatment with aspirin and clopidogrel has been shown to be more effective in high-risk TIA / minor stroke. This review concludes by highlighting gaps in evidence, including scope for future trials that could potentially change clinical practice.
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Affiliation(s)
| | - Zhe Kang Law
- National University of Malaysia, Kuala Lumpur, Malaysia
| | - Jatinder S Minhas
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | - Thompson G Robinson
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | | | - Timothy J England
- Queen's Medical Centre, Nottingham, UK and Royal Derby Hospital, Derby, UK
| | | | | | - Jesse Dawson
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK and Queen Elizabeth University Hospital, Glasgow, UK
| | - Jason P Appleton
- Queen Elizabeth Hospital, Birmingham, UK and University of Birmingham College of Dental and Medical Sciences, Birmingham, UK
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7
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Marilyn ML, Gordon G, Stephen P, Nicholas G, Wanda F, Kara T, Chris T, Howard W, Sharon S, David M, Gail E, Fiona P, Chris B, Judy D. Program of Rehabilitative Exercise and Education to Avert Vascular Events After Non-Disabling Stroke or Transient Ischemic Attack (PREVENT Trial): A Randomized Controlled Trial. Neurorehabil Neural Repair 2021; 36:119-130. [PMID: 34788569 PMCID: PMC9066689 DOI: 10.1177/15459683211060345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Non-disabling stroke (NDS) and transient ischemic attack (TIA) herald the possibility of future, more debilitating vascular events. Evidence is conflicting about potency of exercise and education in reducing risk factors for second stroke. Methods Three-site, single-blinded, randomized controlled trial with 184 participants <3 months of NDS or TIA (mean age, 65 years; 66% male) randomized to usual care (UC) or UC + 12-week program of exercise and education (PREVENT). Primary (resting systolic blood pressure) and secondary outcomes (diastolic blood pressure [DBPrest], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], total cholesterol [TC], TC/HDL, triglycerides, fasting glucose, and body mass index) were assessed at baseline, post-intervention, and 6- and 12-month follow-up. Peak oxygen consumption (VO2peak) was measured at baseline, post-intervention, 12-month assessments. Results Significant between-group differences at post-intervention favored PREVENT group over UC: DBPrest (mean difference [MD]: −3.2 mmHg, 95% confidence interval [CI]: −6.3, −.2, P = .04) and LDL-C (MD: −.31 mmol/L, 95% CI: −.42, −.20, P = .02). Trends of improvement in PREVENT group were noted in several variables between baseline and 6-month follow-up but not sustained at 12-month follow-up. Of note, VO2 peak did not change over time in either group. Conclusion Impact of PREVENT on vascular risk factor reduction was more modest than anticipated, possibly because several outcome variables approximated normative values at baseline and training intensity may have been sub-optimal. Further investigation is warranted to determine when exercise and education programs are viable adjuncts to pharmaceutical management for reduction of risk factors for second stroke. Clinical Trial Registration-URL:http://www.clinicaltrials.gov. Unique identifier: #NCT00885456
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Affiliation(s)
- MacKay-Lyons Marilyn
- School of Physiotherapy, 3688Dalhousie University, Halifax, NS, Canada.,Physical Medicine, Nova Scotia Health Authority, 3688Dalhousie University, Halifax, NS, Canada
| | - Gubitz Gordon
- Neurology, 3688Dalhousie University, Halifax, NS, Canada
| | | | - Giacomantonio Nicholas
- QEII Health Sciences Centre, Halifax, NS, Canada.,Cardiac Rehabilitation, QEII Community Cardiovascular Hearts-in-Motion, Halifax, NS, Canada
| | - Firth Wanda
- Cardiac Rehabilitation, QEII Community Cardiovascular Hearts-in-Motion, Halifax, NS, Canada
| | - Thompson Kara
- Nova Scotia Health, Research Methods Unit, Halifax, NS, Canada
| | - Theriault Chris
- Nova Scotia Health, Research Methods Unit, Halifax, NS, Canada
| | - Wightman Howard
- Cardiology Associates, Valley Regional Hospital, Kentville, NS, Canada
| | - Slipp Sharon
- Cardiac Rehabilitation, Valley Regional Hospital, Kentville, NS, Canada
| | - Marsters David
- Internal Medicine, Valley Regional Hospital, Kentville, NS, Canada
| | - Eskes Gail
- Physical Medicine, Nova Scotia Health Authority, Halifax, NS, Canada.,Psychiatry, 3688Dalhousie University, Halifax, NS, Canada.,Medicine, Nova Scotia Health, Halifax, NS, Canada
| | - Peacock Fiona
- Cardiac Specialty Clinic, Valley Regional Hospital, Kentville, Canada
| | | | - Dewolfe Judy
- Cardiac Specialty Clinic, Valley Regional Hospital, Kentville, Canada
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8
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Luengo-Fernandez R, Li L, Silver L, Gutnikov S, Beddows NC, Rothwell PM. Long-Term Impact of Urgent Secondary Prevention After Transient Ischemic Attack and Minor Stroke: Ten-Year Follow-Up of the EXPRESS Study. Stroke 2021; 53:488-496. [PMID: 34706563 PMCID: PMC8785519 DOI: 10.1161/strokeaha.121.034279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Urgent assessment aimed at reducing stroke risk after transient ischemic attack or minor stroke is cost-effective over the short-term. However, it is unclear if the short-term impact is lost on long-term follow-up, with recurrent events being delayed rather than prevented. By 10-year follow-up of the EXPRESS study (Early Use of Existing Preventive Strategies for Stroke), previously showing urgent assessment reduced 90-day stroke risk by 80%, we determined whether that early benefit was still evident long-term for stroke risk, disability, and costs. METHODS EXPRESS was a prospective population-based before (phase 1: April 2002-September 2004; n=310) versus after (phase 2: October 2004-March 2007; n=281) study of the effect of early assessment and treatment of transient ischemic attack/minor stroke on early recurrent stroke risk, with an external control. This report assesses the effect on 10-year recurrent stroke risk, functional outcomes, quality-of-life, and costs. RESULTS A reduction in stroke risk in phase 2 was still evident at 10 years (55/23.3% versus 82/31.6%; hazard ratio=0.68 [95% CI, 0.48-0.95]; P=0.024), as was the impact on risk of disabling or fatal stroke (17/7.7% versus 32/13.1%; hazard ratio=0.54 [0.30-0.97]; P=0.036). These effects were due to maintenance of the early reduction in stroke risk, with neither additional benefit nor rebound catch-up after 90 days (post-90 days hazard ratio=0.88 [0.65-1.44], P=0.88; and hazard ratio=0.83 [0.42-1.65], P=0.59, respectively). Disability-free life expectancy was 0.59 (0.03-1.15; P=0.043) years higher in patients in phase 2, as was quality-adjusted life expectancy (0.49 [0.03-0.95]; P=0.036). Overall, 10-year costs were nonsignificantly higher in patients attending the phase 2 clinic ($1022 [-3865-5907]; P=0.66). The additional cost per quality-adjusted life year gained in phase 2 versus phase 1 was $2103, well below current cost-effectiveness thresholds. CONCLUSIONS Urgent assessment and treatment of patients with transient ischemic attack or minor stroke resulted in a long-term reduction in recurrent strokes and improved outcomes, with little atrophy of the early benefit over time, representing good value for money even with a 10-year time horizon. Our results suggest that other effective acute treatments in transient ischemic attack/minor stroke in the short-term will also have the potential to have long-term benefit.
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Affiliation(s)
- Ramon Luengo-Fernandez
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Linxin Li
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Louise Silver
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Sergei Gutnikov
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Nicola C Beddows
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Peter M Rothwell
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
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9
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Chang TP, Bery AK, Wang Z, Sebestyen K, Ko YH, Liberman AL, Newman-Toker DE. Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. ACTA ACUST UNITED AC 2021; 9:96-106. [PMID: 34147048 DOI: 10.1515/dx-2020-0124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/22/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Isolated dizziness is a challenging stroke presentation in the emergency department, but little is known about this problem in other clinical settings. We sought to compare stroke hospitalizations after treat-and-release clinic visits for purportedly "benign dizziness" between general and specialty care settings. METHODS This was a population-based retrospective cohort study from a national database. We included clinic patients with a first incident treat-and-release visit diagnosis of non-specific dizziness/vertigo or a peripheral vestibular disorder (ICD-9-CM 780.4 or 386.x [not 386.2]). We compared general care (internal medicine, family medicine) vs. specialty care (neurology, otolaryngology) providers. We used propensity scores to control for baseline stroke risk differences unrelated to dizziness diagnosis. We measured excess (observed>expected) stroke hospitalizations in the first 30 d (i.e., missed strokes associated with an adverse event). RESULTS We analyzed 144,355 patients discharged with "benign dizziness" (n=117,117 diagnosed in general care; n=27,238 in specialty care). After propensity score matching, patients in both groups were at higher risk of stroke in the first 30 d (rate difference per 10,000 treat-and-release visits for "benign dizziness" 24.9 [95% CI 18.6-31.2] in general care and 10.6 [95% CI 6.3-14.9] in specialty care). Short-term stroke risk was higher in general care than specialty care (relative risk, RR 2.2, 95% CI 1.5-3.2) while the long-term risk was not significantly different (RR 1.3, 95% CI 0.9-1.9), indicating higher misdiagnosis-related harms among dizzy patients who initially presented to generalists after adequate propensity matching. CONCLUSIONS Missed stroke-related harms in general care were roughly twice that in specialty care. Solutions are needed to address this care gap.
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Affiliation(s)
- Tzu-Pu Chang
- Department of Neurology/Neuro-Medical Scientific Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Neurology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Anand K Bery
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krisztian Sebestyen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yu-Hung Ko
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Ava L Liberman
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins Hospital, Pathology Building 2-221, 600 North Wolfe Street, Baltimore, MD 21287-6921, USA
- Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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10
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Ran J, Cui Y, Wang Y, Gu P. Relationship between fasting blood glucose and subsequent vascular events in Chinese patients with mild ischaemic stroke: a cohort study. J Int Med Res 2021; 49:3000605211019645. [PMID: 34044643 PMCID: PMC8165852 DOI: 10.1177/03000605211019645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To characterise the relationship between fasting blood glucose (FBG) and the
incidence of subsequent vascular events (SVE) during the 6 months following
a mild ischaemic stroke (MIS) in Chinese patients. Methods Data from patients with MIS were retrospectively analysed. The primary
endpoint was an SVE during the 6-month follow-up period. The participants
were allocated to three groups (tertiles), according to their FBG
concentration. Results Of the 260 participants, 51 (19.6%) reported an SVE during the follow-up
period. The incidence of SVE significantly differed among the tertiles of
FBG. The odds ratio (OR) was 2.361 (95% confidence interval [CI]:
1.551–3.594) for FBG as a continuous variable and that for FBG categorised
according to tertile was 13.30 (95% CI: 3.519–50.322) in the fully adjusted
model. Curve fitting showed that the incidence of SVE gradually increased
with increasing FBG, with the highest tertile showing the highest mean
incidence (46.7%; 95% CI: 16.2%–79.9%). In addition, participants with or
without diabetes mellitus, hypertension, headache, dizziness, mild cognitive
impairment or anterior circulation artery lesion showed similar associations
between FBG and the incidence of SVE. Conclusion FBG is an independent predictor of 6-month SVE risk in Chinese patients with
MIS.
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Affiliation(s)
- Juanjuan Ran
- Department of Neurology, Wuxi No.5 People's Hospital, Wuxi, China
| | - Yu Cui
- Department of Neurology, Wuxi No.5 People's Hospital, Wuxi, China
| | - Yi Wang
- Department of Neurology, Wuxi No.5 People's Hospital, Wuxi, China
| | - Ping Gu
- Department of Neurology, Wuxi No.5 People's Hospital, Wuxi, China
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11
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Meng X, Wang A, Zhang G, Niu S, Li W, Han S, Fang F, Zhao X, Dong K, Jin Z, Zheng H, Chen K, Li H, Yang C, Wang Y. Analytical validation of GMEX rapid point-of-care CYP2C19 genotyping system for the CHANCE-2 trial. Stroke Vasc Neurol 2021; 6:274-279. [PMID: 33952669 PMCID: PMC8258065 DOI: 10.1136/svn-2021-000874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 04/08/2021] [Indexed: 12/20/2022] Open
Abstract
Background and purpose Rapid genotyping is useful for guiding early antiplatelet therapy in patients with high-risk nondisabling ischaemic cerebrovascular events (HR-NICE). Conventional genetic testing methods used in CYP2C19 genotype-guided antiplatelet therapy for patients with HR-NICE did not satisfy the needs of the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE)-2 trial. Therefore, we developed the rapid-genotyping GMEX (point-of-care) system to meet the needs of the CHANCE-2 trial. Methods Healthy individuals and patients with history of cardiovascular diseases (n=408) were enrolled from six centres of the CHANCE-2 trial. We compared the laboratory-based genomic test results with Sanger sequencing test results for accuracy verification. Next, we demonstrated the accuracy, timeliness and clinical operability of the GMEX system compared with laboratory-based technology (YZY Kit) to verify whether the GMEX system satisfies the needs of the CHANCE-2 trial. Results Genotypes reported by the GMEX system showed 100% agreement with those determined by using the YZY Kit and Sanger sequencing for all three CYP2C19 alleles (*2, *3 and *17) tested. The average result’s turnaround times for the GMEX and YZY Kit methods were 85.0 (IQR: 85.0–86.0) and 1630.0 (IQR: 354.0–7594.0) min (p<0.001), respectively. Conclusions Our data suggest that the GMEX system is a reliable and feasible point-of-care system for rapid CYP2C19 genotyping for the CHANCE-2 trial or related clinical and research applications.
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Affiliation(s)
- Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guojun Zhang
- Department of Clinical Diagnosis Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Siying Niu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sifei Han
- Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Fang Fang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kehui Dong
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zening Jin
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huaguang Zheng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kelin Chen
- Department of Clinical Diagnosis Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengyuan Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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12
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Platelet function/reactivity testing and prediction of risk of recurrent vascular events and outcomes after TIA or ischaemic stroke: systematic review and meta-analysis. J Neurol 2020; 267:3021-3037. [DOI: 10.1007/s00415-020-09932-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/21/2022]
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13
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[Diagnostic criteria for Menière's disease according to the Classification Committee of the Bárány Society]. HNO 2019; 65:887-893. [PMID: 28770282 DOI: 10.1007/s00106-017-0387-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This paper presents diagnostic criteria for Menière's disease jointly formulated by the Classification Committee of the Bárány Society, The Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology (EAONO), the Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Korean Balance Society. The classification includes two categories: definite Menière's disease and probable Menière's disease. The diagnosis of definite Menière's disease is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low- to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing, tinnitus and/or fullness) in the affected ear. Duration of vertigo episodes is limited to a period between 20 min and 12 h. Probable Menière's disease is a broader concept defined by episodic vestibular symptoms (vertigo or dizziness) associated with fluctuating aural symptoms occurring in a period from 20 min to 24 h.
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14
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Dunås T, Wåhlin A, Zarrinkoob L, Malm J, Eklund A. 4D flow MRI—Automatic assessment of blood flow in cerebral arteries. Biomed Phys Eng Express 2018. [DOI: 10.1088/2057-1976/aae8d1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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15
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Omron R, Kotwal S, Garibaldi BT, Newman‐Toker DE. The Diagnostic Performance Feedback "Calibration Gap": Why Clinical Experience Alone Is Not Enough to Prevent Serious Diagnostic Errors. AEM EDUCATION AND TRAINING 2018; 2:339-342. [PMID: 30386846 PMCID: PMC6194049 DOI: 10.1002/aet2.10119] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/28/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Rodney Omron
- Johns Hopkins University School of MedicineBaltimoreMD
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16
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Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. BMJ Qual Saf 2018; 27:557-566. [PMID: 29358313 DOI: 10.1136/bmjqs-2017-007032] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 12/04/2017] [Accepted: 12/14/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND The public health burden associated with diagnostic errors is likely enormous, with some estimates suggesting millions of individuals are harmed each year in the USA, and presumably many more worldwide. According to the US National Academy of Medicine, improving diagnosis in healthcare is now considered 'a moral, professional, and public health imperative.' Unfortunately, well-established, valid and readily available operational measures of diagnostic performance and misdiagnosis-related harms are lacking, hampering progress. Existing methods often rely on judging errors through labour-intensive human reviews of medical records that are constrained by poor clinical documentation, low reliability and hindsight bias. METHODS Key gaps in operational measurement might be filled via thoughtful statistical analysis of existing large clinical, billing, administrative claims or similar data sets. In this manuscript, we describe a method to quantify and monitor diagnostic errors using an approach we call 'Symptom-Disease Pair Analysis of Diagnostic Error' (SPADE). RESULTS We first offer a conceptual framework for establishing valid symptom-disease pairs illustrated using the well-known diagnostic error dyad of dizziness-stroke. We then describe analytical methods for both look-back (case-control) and look-forward (cohort) measures of diagnostic error and misdiagnosis-related harms using 'big data'. After discussing the strengths and limitations of the SPADE approach by comparing it to other strategies for detecting diagnostic errors, we identify the sources of validity and reliability that undergird our approach. CONCLUSION SPADE-derived metrics could eventually be used for operational diagnostic performance dashboards and national benchmarking. This approach has the potential to transform diagnostic quality and safety across a broad range of clinical problems and settings.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Departments of Epidemiology and Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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17
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Chang TP, Wang Z, Winnick AA, Chuang HY, Urrutia VC, Carey JP, Newman-Toker DE. Sudden Hearing Loss with Vertigo Portends Greater Stroke Risk Than Sudden Hearing Loss or Vertigo Alone. J Stroke Cerebrovasc Dis 2017; 27:472-478. [PMID: 29102540 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/20/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Because it is unknown whether sudden hearing loss (SHL) in acute vertigo is a "benign" sign (reflecting ear disease) or a "dangerous" sign (reflecting stroke), we sought to compare long-term stroke risk among patients with (1) "SHL with vertigo," (2) "SHL alone," and (3) "vertigo alone" using a large national health-care database. METHODS Patients with first-incident SHL (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] 388.2) or vertigo (ICD-9-CM 386.x, 780.4) were identified from the National Health Insurance Research Database of Taiwan (2002-2009). We defined SHL with vertigo as a vertigo-related diagnosis ±30 days from the index SHL event. SHL without a temporally proximate vertigo diagnosis was considered SHL alone. The vertigo-alone group had no SHL diagnosis. All the patients were followed up until stroke, death, withdrawal from the database, or current end of the database (December 31, 2012) for a minimum period of 3 years. The hazards of stroke were compared across groups. RESULTS We studied 218,656 patients (678 SHL with vertigo, 1998 with SHL alone, and 215,980 with vertigo alone). Stroke rates at study end were 5.5% (SHL with vertigo), 3.0% (SHL alone), and 3.9% (vertigo alone). Stroke hazards were higher in SHL with vertigo than in SHL alone (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.28-2.91) and in vertigo alone (HR, 1.63; 95% CI, 1.18-2.25). Defining a narrower window between SHL and vertigo (±3 days) increased the hazards. CONCLUSIONS The combination of SHL plus vertigo in close temporal proximity is associated with increased subsequent stroke risk over SHL alone and vertigo alone. This suggests that SHL in patients with vertigo is not necessarily a benign peripheral vestibular sign.
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Affiliation(s)
- Tzu-Pu Chang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurology/Neuro-medical Scientific Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; Department of Medicine, Tzu Chi University, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Zheyu Wang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Biostatistics, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Ariel A Winnick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hsun-Yang Chuang
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John P Carey
- Department of Otolaryngology- Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Otolaryngology- Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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18
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Ferris JK, Edwards JD, Ma JA, Boyd LA. Changes to white matter microstructure in transient ischemic attack: A longitudinal diffusion tensor imaging study. Hum Brain Mapp 2017; 38:5795-5803. [PMID: 28815853 DOI: 10.1002/hbm.23768] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/13/2017] [Accepted: 08/07/2017] [Indexed: 12/20/2022] Open
Abstract
Transient ischemic attack (TIA) is associated with localized ischemic changes, identifiable by diffusion-weighted imaging. Past research has not considered whether TIA is also associated with diffuse changes to white matter microstructure; further past work has not tracked changes longitudinally. Here we examine whole-brain changes in fractional anisotropy (FA) in individuals with TIA presenting with sensorimotor symptoms. Twenty individuals with a recent (within 30 days) TIA and 12 healthy older adults were recruited. Participants underwent 3.0 T diffusion MRI at baseline; scans were repeated for the TIA group 90 days post-TIA. Track-based spatial statistics (TBSS) was used to conduct a voxel-wise analysis of FA between groups. FA was significantly lower in the TIA group relative to healthy controls, primarily in anterior white matter tracts including: forceps minor, anterior thalamic radiations, cingulum, inferior fronto-occipital fasciculus, and corticospinal tract. TBSS results informed an ROI-based longitudinal examination of FA in the TIA group. There were no changes to TBSS-identified clusters, forceps minor, or the corticospinal tract over time. There was lower FA in the anterior thalamic radiations in the TIA-affected hemisphere at baseline, but no difference between hemispheres at 90 days. In summary, individuals with TIA presenting with sensorimotor symptoms have decreased FA in tracts that are also implicated in sensorimotor function, which outlast the clinical symptoms associated with TIA. This suggests a more profound type of brain damage associated with TIA than has been typically described in past work. Diffusion tensor imaging may have utility as a marker of TIA-associated changes to white matter pathways. Hum Brain Mapp 38:5795-5803, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Jennifer K Ferris
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jodi D Edwards
- L.C. Campbell Cognitive Neurology Research Unit, Toronto, Ontario, Canada.,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jennifer A Ma
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lara A Boyd
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, British Columbia, Canada
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19
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Intravenous Thrombolysis in Chinese Patients with Different Subtype of Mild Stroke: Thrombolysis in Patients with Mild Stroke. Sci Rep 2017; 7:2299. [PMID: 28536425 PMCID: PMC5442116 DOI: 10.1038/s41598-017-02579-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/13/2017] [Indexed: 12/04/2022] Open
Abstract
Thrombolysis treatment for patients with mild stroke is controversial. The aim of our study was to investigate whether patients with mild stroke or its specific etiologic subtype might benefit from rt-PA therapy. Data were derived from two cohorts of patients with and without rt-PA treatment: (1) the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) and (2) the China National Stroke Registry (CNSR) database. Patients with mild stroke (defined as National Institutes of Health Stroke Scale ≤5) receiving the rt-PA therapy and without rt-PA therapy were matched in 1:2 for age, sex, stroke severity and etiologic subtype. A total of 134 rt-PA-treated patients were matched to 249 non-rt-PA-treated patients in the study. Among them, 104 (76%) rt-PA-treated patients with mild stroke had good outcome after 3 months compared with 173 (69.5%) non-rt-PA-treated matching cases (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.91–2.43; P = 0.12). Compared with non-rt-PA-treated group, rt-PA-treated patients had good outcome after 3 months in those with stroke subtype of large-artery atherosclerosis (LAA) (80.5% vs 65.1%; OR, 2.19; 95%CI, 1.14–4.21; P = 0.02). For patients with mild stroke, intravenous rt-PA treatment may be effective. Patients with stroke subtype of LAA might benefit more from rt-PA treatment.
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20
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Abel AS, Suresh S, Hussein HM, Carpenter AF, Montezuma SR, Lee MS. Practice Patterns After Acute Embolic Retinal Artery Occlusion. Asia Pac J Ophthalmol (Phila) 2017; 6:37-39. [PMID: 28161924 DOI: 10.22608/apo.201690] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/11/2016] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To compare stroke evaluations recommended by retina special-ists and neurologists for retinal artery occlusion (RAO). DESIGN A cross-sectional survey. METHODS An anonymous survey was emailed to members of the American Academy of Neurology Stroke Section listserv and vitreoretinal specialists registered with the American Academy of Ophthalmology. The survey was divided based on duration of symptoms before encounter: less than 12 hours, 24-48 hours, and more than 1 week. Institutional review board approval was obtained before data collection. RESULTS Four hundred forty-eight surveys were completed (281 retinologists and 167 neurologists). Within 12 hours of RAO, most neurologists (75%) pursue a hospital-based evaluation, whereas the majority of retinologists (82%) pursue outpatient workup (P < 0.0001). Most neurologists (92%) and retinologists (98%) pursue outpatient stroke workup if symptoms have been present for more than 7 days. CONCLUSIONS Neurologists pursue higher acuity care after RAO, whereas most retinologists order outpatient evaluations. Retina specialists should consider urgent stroke evaluation to mitigate stroke risk factors.
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Affiliation(s)
- Anne S Abel
- Department of Ophthalmology, University of Minnesota
| | - Sandip Suresh
- Department of Ophthalmology, University of Minnesota
| | - Haitham M Hussein
- Department of Neurosciences, HealthPartners Clinics and Services, Minneapolis, MN
| | | | | | - Michael S Lee
- Department of Ophthalmology, University of Minnesota
- Department of Neurology, University of Minnesota
- Department of Neurosurgery, University of Minnesota
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21
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Akijian L, Ní Chróinín D, Callaly E, Hannon N, Marnane M, Merwick Á, Sheehan Ó, Hayden D, Horgan G, Duggan J, Kyne L, O’Rourke K, Murphy S, Dolan E, Williams D, Kelly PJ. Why do transient ischemic attack patients have higher early stroke recurrence risk than those with ischemic stroke? Influence of patient behavior and other risk factors in the North Dublin Population Stroke Study. Int J Stroke 2016; 12:96-104. [DOI: 10.1177/1747493016669851] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Few studies have directly compared stroke recurrence rates after stroke and transient ischemic attack, and the risk factors underlying early recurrence are poorly understood. We aimed to investigate risk factors for recurrent stroke after first stroke and transient ischemic attack in a population-based study. Methods The North Dublin Population Stroke Study applied multiple overlapping hot and cold pursuit methods, to ascertain hospital- and community-treated stroke and transient ischemic attack patients over a 12-month period. Inclusion criteria were: (1) Stroke-physician confirmed transient ischemic attack/ischemic stroke; (2) first-stroke/transient ischemic attack event within the ascertainment period. Patients were prospectively followed at 72 h, 7, 28 and 90 days. Results A total of 584 patients met eligibility criteria (172 transient ischemic attack, 412 stroke). More transient ischemic attack than stroke patients presented to medical attention with recurrent stroke (8.24% vs. 0.24%, p = 0.0002). Recurrent stroke was more common after transient ischemic attack than index stroke at each time-interval (at 72 h, 4.07% vs. 1.23%, p = 0.03; at 90 days, 13.45% vs. 5.72%, p = 0.002). Stroke recurrence at 90 days was also associated with delay seeking medical attention after the index event (OR 3.2, p = 0.001), delayed anti-platelet (OR 2.8, p = 0.001) and statin (OR 2.4, p = 0.009) treatment, carotid stenosis/occlusion (OR 2.4, p = 0.008). On multivariable analysis, transient ischemic attack as index event (adjusted OR 2.3, p = 0.02), delayed statin treatment (OR 2.5, p = 0.02), and carotid stenosis/occlusion (OR 2.4, p = 0.02) were independent predictors of 90-day recurrent stroke. Conclusion A combination of pathophysiological and behavioral factors was associated with early stroke recurrence risk. Improved public awareness to reduce delays to self-referral for transient ischemic attack symptoms is needed.
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Affiliation(s)
- Layan Akijian
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Danielle Ní Chróinín
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Elizabeth Callaly
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Niamh Hannon
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Michael Marnane
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Áine Merwick
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Órla Sheehan
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Derek Hayden
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Gillian Horgan
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Joseph Duggan
- Department of Geriatric and Stroke Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Lorraine Kyne
- Department of Geriatric and Stroke Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Killian O’Rourke
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eamon Dolan
- Department of Geriatric and Stroke Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - David Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland
| | - Peter J Kelly
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin, Dublin, Ireland
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Acute neurovascular events in cancer patients receiving anti-vascular endothelial growth factor agents: Clinical experience in Paris University Hospitals. Eur J Cancer 2016; 66:75-82. [PMID: 27529757 DOI: 10.1016/j.ejca.2016.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 07/11/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite the increasing and broadening use of agents targeting the vascular endothelial growth factor (VEGF) pathway, little is known on their acute neurovascular toxicities. METHODS This retrospective, multi-centre study examined the characteristics of patients with solid tumours who experienced an ischaemic or haemorrhagic stroke, a transient ischaemic accident (TIA) or a posterior reversible encephalopathy syndrome (PRES) while under anti-VEGF and until 8 weeks after termination of treatment and evaluated their management in our institutions from 2004 to 2014. Patients with newly diagnosed or progressive cerebral metastases at the time of the acute neurovascular event were excluded. RESULTS Thirty-four patients (55.9% men) were identified, and experienced either ischaemic stroke (n = 18), PRES (n = 9), TIA (n = 6) or haemorrhagic stroke (n = 1). At initiation of anti-VEGF agents, 64.7% of patients had previous cardiovascular risk factors, and 52.9% had hypertension. Eight patients (23.5%) had received cerebral radiotherapy, five of which concomitantly to anti-VEGF treatment. Six (17%) patients died in the 8 weeks following the acute neurovascular event, and only 55.9% recovered their initial neurological status. Overall, 1-year and 2-year survival rates after the acute neurovascular event were 67.9% and 50%, respectively. When anti-VEGF agents were reintroduced (n = 6), severe vascular toxicity recurred in two patients. CONCLUSIONS Neurovascular events under VEGF treatments are potentially severe, and the management of comorbid conditions has to be improved. A prospective collection of data and standardised management of such events is therefore being structured in our institutions.
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Abstract
Carotid bifurcation stenosis is an important cause of ischaemic stroke, particularly in patients with recent transient ischaemic attack or minor stroke. Large randomized trials of endarterectomy have shown that surgery reduces the risk of stroke in patients with ≥ 50% recently symptomatic carotid stenosis, and more recent research has gone some way to wards identifying which patients benefit the most. Individual risk modelling has been shown to be useful in selecting patients with the most to gain from endarterectomy for symptomatic stenosis, although timely surgery and optimal medical treatment are of equal importance.
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24
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U-King-Im JM, Tang T, Moustafa RR, Baron JC, Warburton EA, Gillard JH. Imaging the Cellular Biology of the Carotid Plaque. Int J Stroke 2016; 2:85-96. [DOI: 10.1111/j.1747-4949.2007.00123.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Carotid atherosclerotic disease is a significant preventable cause of stroke. Clinical decision-making in current practice is based primarily on detection of the severity of luminal stenosis, as determined by ultrasound or conventional angiographic imaging modalities. New insights in the biology of atherosclerosis now suggests that the morphological characteristics of the carotid plaque as well as the molecular and cellular processes occurring within it may be more important markers of plaque vulnerability and stroke risk. This review summarizes emerging applications in the molecular imaging of atherosclerosis and detection of the vulnerable carotid plaque. We discuss how advances in imaging platforms and biochemical technology (e.g. targeted contrast agents) have driven some exciting and promising novel diagnostic imaging approaches from bench to bedside.
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Affiliation(s)
- Jean Marie U-King-Im
- Department of Radiology, Addenbrooke's Hospital and the University of Cambridge, Cambridge CB22QQ, UK
| | - Tjun Tang
- Department of Radiology, Addenbrooke's Hospital and the University of Cambridge, Cambridge CB22QQ, UK
| | - Ramez R. Moustafa
- Department of Stroke Medicine, Addenbrooke's Hospital and the University of Cambridge, Cambridge CB22QQ, UK
| | - Jean Claude Baron
- Department of Stroke Medicine, Addenbrooke's Hospital and the University of Cambridge, Cambridge CB22QQ, UK
| | - Elizabeth A. Warburton
- Department of Stroke Medicine, Addenbrooke's Hospital and the University of Cambridge, Cambridge CB22QQ, UK
| | - Jonathan H. Gillard
- Department of Radiology, Addenbrooke's Hospital and the University of Cambridge, Cambridge CB22QQ, UK
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Abbott AL, Bladin CF, Levi CR, Chambers BR. What Should We Do with Asymptomatic Carotid Stenosis? Int J Stroke 2016; 2:27-39. [DOI: 10.1111/j.1747-4949.2007.00096.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.
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Affiliation(s)
- Anne L. Abbott
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
| | - Christopher F. Bladin
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
| | - Christopher R. Levi
- Department of Neuroscience, John Hunter Hospital, Lookout Road, Lambton Heights, Newcastle, NSW, 2035, Australia
| | - Brian R. Chambers
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
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Deng QQ, Tang J, Chen C, Markus H, Huang YN, Zhao H, Ratanakorn D, Wong KSL, Fu JH. The curative effect comparison of two kinds of therapeutic regimens on decreasing the relative intensity of microembolic signal in CLAIR trial. J Neurol Sci 2016; 367:18-21. [PMID: 27423556 DOI: 10.1016/j.jns.2016.05.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/26/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Microembolic signals (MESs) are direct markers of unstable large artery atherosclerotic plaques. In a previous study, we found that the number of MESs is associated with stroke recurrence and that clopidogrel plus aspirin more effectively reduce the number of MESs than does aspirin alone. Stroke recurrence is associated with not only the number of MESs but also the size of the MES, which can theoretically be estimated by monitoring the MES intensity via transcranial doppler (TCD). Thus, we compared the effects of clopidogrel and aspirin with aspirin alone on MES intensity using TCD. METHODS We recruited 100 patients who experienced acute ischemic stroke or transient ischemic attack (TIA) within 7days of symptom onset. All patients also had large artery stenosis in the cerebral or carotid arteries and the presence of MES as revealed by TCD. The patients were randomized to receive either aspirin or clopidogrel and aspirin for 7days. MES monitoring was performed on days 2 and 7. RESULTS Intent-to-treat (ITT) analysis (46 patients in the dual therapy group, 52 patients in the monotherapy group) and per-protocol (PP) analysis (25 patients in the dual therapy group, 31 patients in the monotherapy group) were performed on 98 patients. The primary finding was that the MES intensity was dramatically reduced in the dual therapy group. ITT analysis of the dual therapy group revealed that the MES intensity was 8.04 (0-16) dB before treatment, 0.00 (0-17) dB on day 2, and 0.00 (0-12) dB on day 7 (P=0.000). In the monotherapy group, the MES intensity was 9.00 (0-20) dB before treatment, 8.25 (0-17) dB on day 2, and 7.0 (0-18) dB on day 7 (P=0.577). PP analysis revealed similar results. No severe hemorrhagic complications were detected. The two patients in this study who experienced stroke recurrence were in the monotherapy group. CONCLUSIONS Clopidogrel and aspirin more effectively decrease the MES intensity than aspirin alone in patients with large artery stenotic minor stroke or TIA.
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Affiliation(s)
- Q Q Deng
- Department of Neurology, Jing'an District Central Hospital of Shanghai, Shanghai, China.
| | - J Tang
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai, China.
| | - C Chen
- Department of Pharmacology, National University of Singapore, Singapore.
| | - H Markus
- Department of Clinical Neuroscience, St George's, University of London, London, UK.
| | - Y N Huang
- Department of Neurology, Peking University First Hospital, Beijing, China.
| | - H Zhao
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, China.
| | | | - K S L Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
| | - J H Fu
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai, China; Department of Neurology, Pudong hospital, Shanghai, China.
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Sutton J, Jannes J, Karnon J, Sutton DA, Milton A, Kramer S, Hamilton-Bruce MA, Koblar S. Advanced management services for transient ischaemic attacks and minor stroke. Hippokratia 2016. [DOI: 10.1002/14651858.cd012180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Jinlian Sutton
- The University of Adelaide; School of Medicine; North Terrace Adelaide Australia
- MSP Group of Companies; Windsor Gardens SA Australia 5086
| | - Jim Jannes
- The University of Adelaide; School of Medicine; North Terrace Adelaide Australia
- The Queen Elizabeth Hospital; Basil Hetzel Institute; 28 Woodville Road Woodville South Australia
| | - Jonathan Karnon
- The University of Adelaide; Discipline of Public Health, School of Population Health and Clinical Practice; Adelaide Australia
| | - Daniel Alexander Sutton
- ClinPsych; 162 Payneham Road Evandale South Austraila Australia 5069
- Bingston Pty Ltd; Suit 511 Horizon 104 North Terrace Adelaide South Australia Australia 5000
| | - Austin Milton
- The Queen Elizabeth Hospital; Basil Hetzel Institute; 28 Woodville Road Woodville South Australia
| | - Sharon Kramer
- The Florey Institute of Neuroscience and Mental Health; Stroke Division; 245 Burgundy Street Heidelberg Victoria Australia 3084
| | - Monica Anne Hamilton-Bruce
- The University of Adelaide; School of Medicine; North Terrace Adelaide Australia
- The Queen Elizabeth Hospital; Basil Hetzel Institute; 28 Woodville Road Woodville South Australia
| | - Simon Koblar
- The University of Adelaide; Stroke Research Programme, School of Medicine; Adelaide Australia
- The Queen Elizabeth Hospital; Department of Neurology; 28 Woodville Road Woodville South South Australia Australia
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Lopez-Escamez JA, Carey J, Chung WH, Goebel JA, Magnusson M, Mandalà M, Newman-Toker DE, Strupp M, Suzuki M, Trabalzini F, Bisdorff A. Criterios diagnósticos de enfermedad de Menière. Documento de consenso de la Bárány Society, la Japan Society for Equilibrium Research, la European Academy of Otology and Neurotology (EAONO), la American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) y la Korean Balance Society. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2016; 67:1-7. [DOI: 10.1016/j.otorri.2015.05.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 05/24/2015] [Indexed: 11/25/2022]
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Newman-Toker DE, Della Santina CC, Blitz AM. Vertigo and hearing loss. HANDBOOK OF CLINICAL NEUROLOGY 2016; 136:905-21. [PMID: 27430449 DOI: 10.1016/b978-0-444-53486-6.00046-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Symptoms referable to disorders affecting the inner ear and vestibulocochlear nerve (eighth cranial nerve) include dizziness, vertigo, tinnitus, and hearing loss, in various combinations. Similar symptoms may occur with involvement of the central nervous system, principally the brainstem and cerebellum, to which the vestibular and auditory systems are connected. Imaging choices should be tailored to patient symptoms and the clinical context. Computed tomography (CT) should be used primarily to assess bony structures. Magnetic resonance imaging (MRI) should be used primarily to assess soft-tissue structures. Vascular imaging by angiography or venography should be obtained when vascular lesions are suspected. No imaging should be obtained in patients with typical presentations of common peripheral vestibular or auditory disorders. In current clinical practice, neuroimaging is often overused, especially CT in the assessment of acute dizziness and vertigo in the emergency department. Despite low sensitivity for ischemic strokes, CT is often used to rule out neurologic causes. When ischemic stroke is the principal concern in acute vestibular presentations, imaging should almost always be by MRI with diffusion-weighted images, rather than CT. In this chapter, we describe recommended strategies for audiovestibular imaging based on patient symptoms and signs.
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Affiliation(s)
- David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Charles C Della Santina
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ari M Blitz
- Neuro-radiology Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Newman-Toker DE. Missed stroke in acute vertigo and dizziness: It is time for action, not debate. Ann Neurol 2015; 79:27-31. [PMID: 26418192 DOI: 10.1002/ana.24532] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Atzema CL, Grewal K, Lu H, Kapral MK, Kulkarni G, Austin PC. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol 2015; 79:32-41. [DOI: 10.1002/ana.24521] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 09/08/2015] [Accepted: 09/10/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Clare L. Atzema
- Division of Emergency Medicine, Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- the Institute of Health Policy; Management and Evaluation at the University of Toronto; Toronto Ontario Canada
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Keerat Grewal
- Division of Emergency Medicine, Department of Medicine; University of Toronto; Toronto Ontario Canada
| | - Hong Lu
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Moira K. Kapral
- University Health Network; Toronto Ontario Canada
- the Institute of Health Policy; Management and Evaluation at the University of Toronto; Toronto Ontario Canada
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Girish Kulkarni
- University Health Network; Toronto Ontario Canada
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Peter C. Austin
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- the Institute of Health Policy; Management and Evaluation at the University of Toronto; Toronto Ontario Canada
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
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Yang F, Jiang W, Bai Y, Han J, Liu X, Zhang G, Zhao G. Treatment of Rivaroxaban versus Aspirin for Non-disabling Cerebrovascular Events (TRACE): study protocol for a randomized controlled trial. BMC Neurol 2015; 15:195. [PMID: 26458895 PMCID: PMC4603584 DOI: 10.1186/s12883-015-0453-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 10/01/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transient ischemic attack (TIA) or minor ischemic stroke represents the largest group of cerebrovascular disease, and those patients have a high risk of early recurrent stroke. Over decades, anticoagulation therapy has been used prudently in them for likely increasing the risk of intra-/extra-cranial hemorrhagic complications. However, recently rivaroxaban, a new oral anticoagulant, is proved to be as effective as traditional anticoagulants, while carrying significantly less risk of intracranial hemorrhage. Therefore, we assumed that patients may benefit from rivaroxaban if treated soon after TIA or minor stroke, and designed this adequately powered randomized study, TRACE. METHODS AND DESIGN The Treatment of Rivaroxaban versus Aspirin in Non-disabling Cerebrovascular Events (TRACE) study is a randomized, double-blind clinical trial with a target enrollment of 4400 patients. A 14-days regimen of rivaroxaban 10 mg daily or a 14-days regimen of aspirin 100 mg daily will be administrated to randomized participants with acute TIA or minor stroke, defined as National Institute of Health Stroke Scale scores ≤ 3. The primary efficacy end point is percentage of patients with any stroke (ischemic or hemorrhage) at 14 days. Study visits will be performed at the day of randomization, day 14 and day 90. DISCUSSION Even though the new oral anticoagulants seem to be both safe and effective, few clinical trials have been carried out to test their effect on non-disabling cerebrovascular events. Treatment with rivaroxaban may prevent more cerebrovascular events with an acceptable risk profile after TIA or minor stroke, compared with aspirin, thus helping to improve the outcome of the disease. TRIAL REGISTRATION No. NCT01923818.
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Affiliation(s)
- Fang Yang
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Wenrui Jiang
- Emergency Department, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Ya Bai
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Junliang Han
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Xuedong Liu
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Guangyun Zhang
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
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Lawlor M, Perry R, Hunt BJ, Plant GT. Strokes and vision: The management of ischemic arterial disease affecting the retina and occipital lobe. Surv Ophthalmol 2015; 60:296-309. [DOI: 10.1016/j.survophthal.2014.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 12/10/2014] [Accepted: 12/16/2014] [Indexed: 11/16/2022]
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Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P, Dennis M. An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation. Health Technol Assess 2014; 18:1-368, v-vi. [PMID: 24791949 DOI: 10.3310/hta18270] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment. OBJECTIVES Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention? DATA SOURCES Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. REVIEW METHODS Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios. RESULTS The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective. LIMITATIONS Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity. CONCLUSIONS Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Miriam Brazzelli
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hector Miranda
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zahid Quayyum
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Duncan Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Grewal K, Austin PC, Kapral MK, Lu H, Atzema CL. Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study. Stroke 2014; 46:108-13. [PMID: 25477217 DOI: 10.1161/strokeaha.114.007087] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to determine the proportion of emergency department (ED) patients with a diagnosis of peripheral vertigo who received computed tomography (CT) head imaging in the ED and to examine whether strokes were missed using CT imaging. METHODS This population-based retrospective cohort study assessed patients who were discharged from an ED in Ontario, Canada, with a diagnosis of peripheral vertigo, April 2006 to March 2011. Patients who received CT imaging (exposed) were matched by propensity score methods to patients who did not (unexposed). If performed, CT imaging was presumed to be negative for stroke because brain stem/cerebellar stroke would result in hospitalization. We compared the incidence of stroke within 30, 90, and 365 days subsequent to ED discharge between groups, to determine whether the exposed group had a higher frequency of early strokes than the matched unexposed group. RESULTS Among 41 794 qualifying patients, 8596 (20.6%) received ED head CT imaging, and 99.8% of these patients were able to be matched to a control. Among exposed patients, 25 (0.29%) were hospitalized for stroke within 30 days when compared with 11 (0.13%) among matched nonexposed patients. The relative risk of a 30- and 90-day stroke among exposed versus unexposed patients was 2.27 (95% confidence interval, 1.12-4.62) and 1.94 (95% confidence interval, 1.10-3.43), respectively. There was no difference between groups at 1 year. Strokes occurred at a median of 32.0 days (interquartile range, 4.0-33.0 days) in exposed patients, compared with 105 days (interquartile range, 11.5-204.5) in unexposed patients. CONCLUSIONS One fifth of patients diagnosed with peripheral vertigo in Ontario received imaging that is not recommended in guidelines, and that imaging was associated with missed strokes.
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Affiliation(s)
- Keerat Grewal
- From the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.G., C.L.A.); Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (P.C.A., C.L.A.); University Health Network, Toronto, Ontario, Canada (M.K.K.); and the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (P.C.A., M.K.K., H.L., C.L.A.)
| | - Peter C Austin
- From the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.G., C.L.A.); Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (P.C.A., C.L.A.); University Health Network, Toronto, Ontario, Canada (M.K.K.); and the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (P.C.A., M.K.K., H.L., C.L.A.)
| | - Moira K Kapral
- From the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.G., C.L.A.); Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (P.C.A., C.L.A.); University Health Network, Toronto, Ontario, Canada (M.K.K.); and the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (P.C.A., M.K.K., H.L., C.L.A.)
| | - Hong Lu
- From the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.G., C.L.A.); Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (P.C.A., C.L.A.); University Health Network, Toronto, Ontario, Canada (M.K.K.); and the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (P.C.A., M.K.K., H.L., C.L.A.)
| | - Clare L Atzema
- From the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.G., C.L.A.); Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (P.C.A., C.L.A.); University Health Network, Toronto, Ontario, Canada (M.K.K.); and the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (P.C.A., M.K.K., H.L., C.L.A.).
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Yang F, Lei H, Jiang W, Jiang W, Han J, Zhao G. Initial 3-weeks' Apixaban Versus Dual-antiplatelet Therapy (Clopidogrel and Aspirin) followed by Clopidogrel alone in high-risk patients with Acute Non-Disabling Cerebrovascular Events (ADANCE): study protocol for a randomized controlled trial. Clin Drug Investig 2014; 34:755-61. [PMID: 25200142 PMCID: PMC4210645 DOI: 10.1007/s40261-014-0228-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background
Nondisabling cerebrovascular events represent the largest group of cerebrovascular disease with a high risk of recurrent stroke. A recent trial demonstrated that dual-antiplatelet therapy (clopidogrel and aspirin), compared with aspirin monotherapy, reduced the risk of recurrent stroke and was not associated with increased risk of hemorrhagic events. Apixaban, a new oral anticoagulant, has been proven to be as safe and effective as traditional anticoagulants while carrying significantly less risk of intracranial hemorrhage. Patients with transient ischemic attack (TIA)/minor stroke might benefit from apixaban treatment; therefore, an adequately powered randomized study is needed. Methods and Results The ADANCE [Apixaban Versus Dual-antiplatelet Therapy (Clopidogrel and Aspirin) in Acute Non-disabling Cerebrovascular Events] study is a randomized, double-blind clinical trial with a target enrollment of 5,500 patients. A 21-day regimen of apixaban or of clopidogrel with aspirin followed by clopidogrel on days 22 through 90 will be administered to randomized participants with acute TIA or minor ischemic stroke. The primary efficacy endpoint is the percentage of patients with any new stroke (ischemic or hemorrhage), including fatal stroke, at day 21. Study visits will be performed on the day of randomization, and at days 7, 22, and 90. Discussion The novel oral anticoagulant apixaban has been widely used with fewer adverse effects than traditional anticoagulants. We designed the ADANCE trial to observe the effects of apixaban on recurrent stroke after TIA or minor stroke. The results should better guide the selection of anticoagulant or dual-antiplatelet therapy for patients with acute TIA or minor ischemic stroke.
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Affiliation(s)
- Fang Yang
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China,
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Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. ACTA ACUST UNITED AC 2014; 1:155-166. [PMID: 28344918 PMCID: PMC5361750 DOI: 10.1515/dx-2013-0038] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Some cerebrovascular events are not diagnosed promptly, potentially resulting in death or disability from missed treatments. We sought to estimate the frequency of missed stroke and examine associations with patient, emergency department (ED), and hospital characteristics. Methods Cross-sectional analysis using linked inpatient discharge and ED visit records from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases and 2008–2009 State ED Databases across nine US states. We identified adult patients admitted for stroke with a treat-and-release ED visit in the prior 30 days, considering those given a non-cerebrovascular diagnosis as probable (benign headache or dizziness diagnosis) or potential (any other diagnosis) missed strokes. Results There were 23,809 potential and 2243 probable missed strokes representing 12.7% and 1.2% of stroke admissions, respectively. Missed hemorrhages (n = 406) were linked to headache while missed ischemic strokes (n = 1435) and transient ischemic attacks (n = 402) were linked to headache or dizziness. Odds of a probable misdiagnosis were lower among men (OR 0.75), older individuals (18–44 years [base]; 45–64:OR 0.43; 65–74:OR 0.28; ≥ 75:OR 0.19), and Medicare (OR 0.66) or Medicaid (OR 0.70) recipients compared to privately insured patients. Odds were higher among Blacks (OR 1.18), Asian/Pacific Islanders (OR 1.29), and Hispanics (OR 1.30). Odds were higher in non-teaching hospitals (OR 1.45) and low-volume hospitals (OR 1.57). Conclusions We estimate 15,000–165,000 misdiagnosed cerebrovascular events annually in US EDs, disproportionately presenting with headache or dizziness. Physicians evaluating these symptoms should be particularly attuned to the possibility of stroke in younger, female, and non-White patients.
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Affiliation(s)
- David E Newman-Toker
- 1Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernest Moy
- 2Agency for Healthcare Research and Quality, Rockville, MD, USA
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Faulkner J, Stoner L, Lambrick D. Physical Activity and Exercise Engagement in Patients Diagnosed with Transient Ischemic Attack and Mild/Non-disabling Stroke: A Commentary on Current Perspectives. Rehabil Process Outcome 2014. [DOI: 10.4137/rpo.s12338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Individuals diagnosed with a transient ischemic attack (TIA) or mild/non-disabling stroke are at high risk of cardiovascular or recurrent cerebrovascular (stroke, TIA) events. Pharmacological intervention (ie anti-platelet and anti-coagulant medication) is considered the cornerstone of secondary prevention care for this population group. However, recent research has explored the utility of non-pharmacological interventions (eg exercise, diet, education) in improving health outcomes and reducing the risk of secondary events in patients with TIA or mild/non-disabling stroke. This commentary discusses the efficacy of implementing exercise interventions as a part of the secondary care program for acute and non-acute TIA and stroke patients. Current perspectives and future research initiatives are also discussed.
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Affiliation(s)
- James Faulkner
- School of Sport and Exercise, Massey University, Wellington, New Zealand
| | - Lee Stoner
- School of Sport and Exercise, Massey University, Wellington, New Zealand
| | - Danielle Lambrick
- Institute of Food, Nutrition and Human Health, Massey University, Wellington, New Zealand
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Chiu LHS, Yau WH, Leung LP, Pang P, Tsui CT, Wan KA, Au TTS, Fong WC, Chung SHJ. Short-Term Prognosis of Transient Ischemic Attack and Predictive Value of the ABCD(2) Score in Hong Kong Chinese. Cerebrovasc Dis Extra 2014; 4:40-51. [PMID: 24715897 PMCID: PMC3975175 DOI: 10.1159/000360074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 01/27/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Literature on prognosis of transient ischemic attack (TIA) in Chinese is scarce. The short-term prognosis of TIA and the predictive value of the ABCD(2) score in Hong Kong Chinese patients attending the emergency department (ED) were studied to provide reference for TIA patient management in our ED. METHODS A cohort of TIA patients admitted through the ED to 13 acute public hospitals in 2006 was recruited through the centralized electronic database by the Hong Kong Hospital Authority (HA). All inpatients were e-coded by the HA according to the International Classification of Diseases, Ninth Revision (ICD9). Electronic records and hard copies were studied up to 90 days after a TIA. The stroke risk of a separate TIA cohort diagnosed by the ED was compared. RESULTS In the 1,000 recruited patients, the stroke risk after a TIA at days 2, 7, 30, and 90 was 0.2, 1.4, 2.9, and 4.4%, respectively. Antiplatelet agents were prescribed in 89%, warfarin in 6.9%, statin in 28.6%, antihypertensives in 39.3%, and antidiabetics in 11.9% of patients after hospitalization. Before the index TIA, the prescribed medications were 27.6, 3.7, 11.3, 27.1, and 9.7%, respectively. The accuracy of the ABCD(2) score in predicting stroke risk was 0.607 at 7 days, 0.607 at 30 days, and 0.574 at 90 days. At 30 days, the p for trend across ABCD(2) score levels was 0.038 (OR for every score point = 1.36, p = 0.040). Diabetes mellitus, previous stroke and carotid bruit were associated with stroke within 90 days (p = 0.038, 0.045, 0.030, respectively). A total of 45.4% of CTs of the brain showed lacunar infarcts or small vessel disease. There was an increased stroke risk at 90 days in patients with old or new infarcts on CT or MRI. Patients with carotid stenosis ≥70% had an increased stroke risk within 30 (OR = 6.335, p = 0.013) and 90 days (OR = 3.623, p = 0.050). Stroke risks at days 2, 7, 30, and 90 in the 289 TIA patients diagnosed by the ED were 0.35, 2.4, 5.2, and 6.2%, respectively. CONCLUSION The short-term stroke risk in Hong Kong Chinese TIA patients is low. The administered nonurgent treatment cannot solely explain the favorable outcome, the lower risk can be due to the different pathophysiological mechanisms of stroke between Caucasians and Chinese. The predictive value of the ABCD(2) score is low in our population.
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Affiliation(s)
- Lai Hong Simon Chiu
- Accident and Emergency Department at Princess Margret Hospital, Hong Kong, SAR, PR China
| | - Wah Hon Yau
- Accident and Emergency Department at Queen Elizabeth Hospital, Hong Kong, SAR, PR China
| | - Ling Pong Leung
- Accident and Emergency Department at Queen Mary Hospital, Hong Kong, SAR, PR China
| | - Peter Pang
- Accident and Emergency Department at Yan Chai Hospital, Hong Kong, SAR, PR China
| | - Chee Tat Tsui
- Accident and Emergency Department at Princess Margret Hospital, Hong Kong, SAR, PR China
| | - Kuang An Wan
- Accident and Emergency Department at Ruttongie and Tang Siu Kin Hospital, Hong Kong, SAR, PR China
| | - Thomas Tak-Shun Au
- Accident and Emergency Department at Pamela Youde Nethersole Eastern Hospital, Hong Kong, SAR, PR China
| | - Wing Chi Fong
- Department of Medicine and Geriatrics, Queen Elizabeth Hospital, Hong Kong, SAR, PR China
| | - Shun Hang Joseph Chung
- Accident and Emergency Department at Tuen Mun Hospital, Queen Elizabeth Hospital, Hong Kong, SAR, PR China
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Clopidogrel High-on-Treatment Platelet Reactivity in Acute Ischemic Stroke Patients. Thromb Res 2014; 133:396-401. [DOI: 10.1016/j.thromres.2013.12.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 11/27/2013] [Accepted: 12/02/2013] [Indexed: 11/18/2022]
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Faggioli G, Pini R, Mauro R, Gargiulo M, Freyrie A, Stella A. Perioperative Outcome of Carotid Endarterectomy According to Type and Timing of Neurologic Symptoms and Computed Tomography Findings. Ann Vasc Surg 2013; 27:874-82. [DOI: 10.1016/j.avsg.2012.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 11/11/2012] [Accepted: 12/28/2012] [Indexed: 11/16/2022]
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Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, Mantokoudis G, Hanley DF, Zee DS, Kattah JC. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013; 20:986-96. [PMID: 24127701 DOI: 10.1111/acem.12223] [Citation(s) in RCA: 226] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 04/23/2013] [Accepted: 04/28/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Dizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]). METHODS This was a cross-sectional study of high-risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow-up. ABCD2 risk scores (0-7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three-component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR-) were assessed for stroke and other central causes, and the results were stratified by age. False-negative initial neuroimaging was also assessed. RESULTS A total of 190 adult AVS patients were assessed (1999-2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR- of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR- was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR- was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR- was 0.01 for HINTS "plus" (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI. CONCLUSIONS HINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.
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Affiliation(s)
| | | | | | - John H. Pula
- University of Illinois College of Medicine at Peoria; Illinois Neurological Institute; Peoria IL
| | - Rodney Omron
- Johns Hopkins University School of Medicine; Baltimore MD
| | | | | | | | - David S. Zee
- Johns Hopkins University School of Medicine; Baltimore MD
| | - Jorge C. Kattah
- University of Illinois College of Medicine at Peoria; Illinois Neurological Institute; Peoria IL
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Lee SB, Huh PW, Kim DS, Yoo DS, Lee TG, Cho KS. Early superficial temporal artery to middle cerebral artery bypass in acute ischemic stroke. Clin Neurol Neurosurg 2013; 115:1238-44. [DOI: 10.1016/j.clineuro.2012.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 11/20/2012] [Accepted: 11/24/2012] [Indexed: 01/20/2023]
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Bruls S, Desfontaines P, Defraigne JO, Sakalihasan N. Urgent Carotid Endarterectomy in Patients with Acute Neurological Symptoms: The Results of a Single Center Prospective Nonrandomized Study. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2013; 1:110-6. [PMID: 26798682 DOI: 10.12945/j.aorta.2013.13-008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 05/10/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND To evaluate the feasibility and the safety of performing urgent (within 24 hours) carotid endarterectomy in patients with carotid stenosis presenting with repetitive transient ischemic attacks or progressing stroke. METHODS Thirty consecutive patients underwent urgent carotid endarterectomy for repetitive transient ischemic attacks (N = 12) or progressing stroke (N = 18) according to the following criteria: two or more transient ischemic attacks or a fluctuating neurological deficit over a period of less than 24 hours (progressing stroke), no impairment of consciousness, no cerebral infarct larger than 1.5 cm in diameter on computed tomography and a carotid artery stenosis of 70% or more on the appropriate side, diagnosed by echodoppler ultrasonography and/or arteriography. Patients with cerebral hemorrhage were excluded. All patients were examined pre- and postoperatively by the same neurologist and surgery was performed by the same vascular surgeon. All the patients underwent a cerebral CT scan within 5 days after surgery. RESULTS There were 19 men and 11 women. The mean age was 71 ± 7.6 years. The time delay of surgery after the onset of transient ischemic attacks or progressing stroke averaged 19.4 ± 11.5 hours. For patients suffering progressive stroke, one developed a fatal ischemic stroke 24 hours after surgery, five showed no improvement of their neurological status after surgery, but none worsened. Twelve patients experienced significant improvement of their neurological status with an European Stroke Scale of 77.9 ± 25.2 at admission and 95.8 ± 4.6 at discharge, and all but one of those patients had a Barthel's index value over 85/100 at discharge. The 12 patients with repetitive transient ischemic attacks had an uneventful postoperative outcome. The mean duration of follow-up was 3.4 ± 1.2 years. No patient developed another transient ischemic attack or ischemic stroke during the follow-up period. CONCLUSIONS The results of our series documented the feasibility and the safety of performing urgent (within 24 hours) carotid endarterectomy in patients presenting with repetitive transient ischemic attacks or progressing stroke. This procedure seems to us to be justified by the fact that waiting for surgery may lead to the development of a more profound deficit or another stroke in these neurologically unstable patients whose only chance for neurological recovery is in the early phase.
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Affiliation(s)
- Samuel Bruls
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Liege, Liege, Belgium
| | | | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Liege, Liege, Belgium
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Lau AY, Zhao Y, Chen C, Leung TW, Fu J, Huang Y, Suwanwela NC, Han Z, Tan KS, Ratanakorn D, Markus HS, Wong KS. Dual antiplatelets reduce microembolic signals in patients with transient ischemic attack and minor stroke: subgroup analysis of CLAIR study. Int J Stroke 2013; 9 Suppl A100:127-32. [PMID: 23489888 DOI: 10.1111/ijs.12003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 08/02/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Short course of dual antiplatelet therapy for early secondary prevention is a promising treatment for patients with minor stroke or transient ischemic attack at high risk of recurrence. METHODS We examined the efficacy and safety of dual antiplatelets in patients with transient ischemic attack or minor stroke, defined as National Institute of Health Stroke Scale scores 0-3, in a subgroup analysis of Clopidogrel plus aspirin versus Aspirin alone for Reducing embolization in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR) study. Microembolic signals on transcranial Doppler monitoring was used as surrogate marker for recurrent stroke risk. Patients with ≥1 microembolic signals at baseline were randomized to receive dual therapy (aspirin 75-160 mg daily and clopidogrel 300 mg day 1 then 75 mg daily) or monotherapy (aspirin 75-160 mg daily) for seven-days. RESULTS Sixty-five of 100 patients recruited had transient ischemic attack or minor stroke: 30 received dual therapy and 35 received monotherapy. Mean onset-to-randomization was 2·3 days in dual therapy group and 3·2 days in monotherapy group (P = 0·03). At day 7, the proportion of patients with ≥1 microembolic signals was 9 of 29 patients in dual therapy group and 18 of 34 patients in monotherapy group (adjusted relative risk reduction 41·4%, 95% CI 29·8-51·1, P < 0·001). The median number of microembolic signals on day 7 was 0 in dual therapy group and 1·0 in monotherapy group (P = 0·046). No patients had intracranial or severe systemic hemorrhage. CONCLUSIONS Early dual therapy with clopidogrel and aspirin reduces microembolic signals in patients with minor ischemic stroke or transient ischemic attack, without causing significant bleeding complications.
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Affiliation(s)
- Alexander Y Lau
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
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Paul NLM, Koton S, Simoni M, Geraghty OC, Luengo-Fernandez R, Rothwell PM. Feasibility, safety and cost of outpatient management of acute minor ischaemic stroke: a population-based study. J Neurol Neurosurg Psychiatry 2013; 84:356-61. [PMID: 23172867 PMCID: PMC5321491 DOI: 10.1136/jnnp-2012-303585] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Outpatient management safely and effectively prevents early recurrent stroke after transient ischaemic attack (TIA), but this approach may not be safe in patients with acute minor stroke. OBJECTIVE To study outcomes of clinic and hospital-referred patients with TIA or minor stroke (National Institute of Health Stroke Scale score ≤3) in a prospective, population-based study (Oxford Vascular Study). RESULTS Of 845 patients with TIA/stroke, 587 (69%) were referred directly to outpatient clinics and 258 (31%) directly to inpatient services. Of the 250 clinic-referred minor strokes (mean age 72.7 years), 237 (95%) were investigated, treated and discharged on the same day, of whom 16 (6.8%) were subsequently admitted to hospital within 30 days for recurrent stroke (n=6), sepsis (n=3), falls (n=3), bleeding (n=2), angina (n=1) and nursing care (n=1). The 150 patients (mean age 74.8 years) with minor stroke referred directly to hospital (median length-of-stay 9 days) had a similar 30-day readmission rate (9/150; 6.3%; p=0.83) after initial discharge and a similar 30-day risk of recurrent stroke (9/237 in clinic patients vs 8/150, OR=0.70, 0.27-1.80, p=0.61). Rates of prescription of secondary prevention medication after initial clinic/hospital discharge were higher in clinic-referred than in hospital-referred patients for antiplatelets/anticoagulants (p<0.05) and lipid-lowering agents (p<0.001) and were maintained at 1-year follow-up. The mean (SD) secondary care cost was £8323 (13 133) for hospital-referred minor stroke versus £743 (1794) for clinic-referred cases. CONCLUSION Outpatient management of clinic-referred minor stroke is feasible and may be as safe as inpatient care. Rates of early hospital admission and recurrent stroke were low and uptake and maintenance of secondary prevention was high.
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Affiliation(s)
- Nicola L M Paul
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK, OX3 9DU
| | - Silvia Koton
- Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Michela Simoni
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK, OX3 9DU
| | - Olivia C Geraghty
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK, OX3 9DU
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK, OX3 9DU
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Faggioli G, Pini R, Rapezzi C, Mauro R, Freyrie A, Gargiulo M, Bacchi Reggiani L, Stella A. Carotid revascularization in patients with ongoing oral anticoagulant therapy: the advantages of stent placement. J Vasc Interv Radiol 2013; 24:370-7. [PMID: 23433413 DOI: 10.1016/j.jvir.2012.11.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 11/29/2012] [Accepted: 11/30/2012] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To assess the influence of oral anticoagulant therapy conversion to heparin (OAT-CH) on carotid endarterectomy (CEA) outcomes and the influence of unmodified oral anticoagulant therapy (OAT) on carotid artery stenting (CAS) and to compare the outcomes of CEA in OAT-CH with CAS in ongoing OAT. MATERIALS AND METHODS The 30-day results from all patients who underwent CEA and CAS in a 6-year period were analyzed for stroke, death, myocardial infarction (MI), and hematoma of the access site requiring surgical evacuation. We evaluated the influence of OAT-CH in CEA and the influence of OAT in CAS and compared CEA and CAS outcomes in patients receiving OAT-CH and OAT. RESULTS Among 1,222 carotid revascularizations, there were 711 CEAs (58.1%) and 511 CAS procedures (41.9%). In the CEA group, 31 (4.4%) patients were treated with OAT-CH, and these patients had a significantly higher complication rate compared with patients not receiving OAT, including death (1 [3.2%] vs 4 [0.6%]; P = .04), stroke (4 [12.9%] vs 10 [1.4%]; P = .001), and hematoma (3 [9.6%] vs 11 [1.6%]; P = .02). In CAS, the results were similar in patients receiving OAT (30 [5.8%]) and patients not receiving OAT. Patients receiving OAT who underwent CAS had better outcomes than patients receiving OAT-CH who underwent CEA, including stroke, death, MI, and hematoma combined (0 [0.0%] vs 7 [22.5%]; P =.01). CONCLUSIONS OAT management significantly influences the results of carotid revascularization. Because CAS with unmodified OAT had a significantly better outcome than CEA with OAT-CH, carotid revascularization strategies should favor CAS rather than CEA in this setting.
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Affiliation(s)
- Gianluca Faggioli
- Department of Vascular Surgery, University of Bologna, Via Massarenti 11, Bologna 40138, Italy
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Charidimou A, Baron JC, Werring DJ. Transient Focal Neurological Episodes, Cerebral Amyloid Angiopathy, and Intracerebral Hemorrhage Risk: Looking beyond TIAs. Int J Stroke 2013; 8:105-8. [DOI: 10.1111/ijs.12035] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
When most doctors encounter older patients with transient focal neurological symptoms, they usually suspect a diagnosis of transient ischemic attacks or some of their known mimics (including migraine auras or focal seizures). This article emphasizes new observations on transient focal neurological episodes in the context of cerebral amyloid angiopathy, a common but under-recognized small vessel disease most often encountered as a cause of symptomatic lobar intracerebral hemorrhage. Transient focal neurological episodes in cerebral amyloid angiopathy are of clinical and pathophysiological interest because they can mimic transient ischemic attacks, but are probably more often related to bleeding (especially superficial cortical siderosis or focal convexity sub-arachnoid hemorrhage) rather than ischemia. Importantly, such episodes may also herald a very high future risk of symptomatic intracerebral hemorrhage. The article highlights scenarios encountered in clinical practice and discusses implications for patient care including: (a) the value of blood-sensitive magnetic resonance imaging sequences in investigating transient focal neurological episodes; and (b) treatment implications, as giving antiplatelet or anticoagulant drugs for these episodes could increase the risk of serious intracerebral hemorrhage.
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Affiliation(s)
- Andreas Charidimou
- Stroke Research Group, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Jean-Claude Baron
- Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- INSERM-Université Paris 5, Sorbonne Paris Cité, UMR 894, Paris, France
| | - David J. Werring
- Stroke Research Group, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Abstract
BACKGROUND Recurrent stroke is one of severe outcomes of transient ischemic attack (TIA) and minor ischemic stroke (MIS), which are collectively termed as nondisabling stroke. However, the association between multiple risk factors and nondisabling stroke has not been fully studied. Here, we aimed to identify predicative risk factors in TIA and MIS in order to prevent recurrent nondisabling stroke. METHODS We used logistic regression methods to analysis risk factors in 620 patients with TIA or MIS between August 2006 and january 2009 and followed up to 90 days. We selected 20 factors, including age, gender, body mass index (BMI), smoking and alcohol history, blood pressure, limb weakness, speech impairment, diabetes, ischemic brain lesions, previous history of stroke (> 24 hours), coronary atherosclerotic heart disease, cardiac function insufficiency, duration of symptoms of at least 1 hour, blood lipids, lysophosphatidic acid, C-reactive protein, atrial fibrillation, and carotid artery plaque in ultrasound examination. RESULTS We found that limb weakness, history of cerebrovascular events, and carotid artery plaque in ultrasound examination were risk factors of recurrent stroke within 14 days, whereas the factors for the recurrence within 90 days were duration of symptoms of at least 1 hour, speech impairment, limb weakness, BMI of at least 25 kg/m2, history of cerebrovascular events, and carotid artery plaque in ultrasound examination. CONCLUSION Six risk factors are associated with recurrent nondisabling stroke, including symptom duration of at least 1 hour, speech impairment, limb weakness, BMI of at least 25 kg/m2, history of cerebrovascular events, and carotid artery plaque in ultrasound examination. Thus, identification and prevention of these risk factors may reduce recurrent stroke.
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Sanders LM, Srikanth VK, Jolley DJ, Sundararajan V, Psihogios H, Wong K, Ramsay D, Phan TG. Monash Transient Ischemic Attack Triaging Treatment. Stroke 2012; 43:2936-41. [DOI: 10.1161/strokeaha.112.664060] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lauren M. Sanders
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Velandai K. Srikanth
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Damien J. Jolley
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Vijaya Sundararajan
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Helen Psihogios
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Kitty Wong
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - David Ramsay
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
| | - Thanh G. Phan
- From the Stroke and Aging Research Centre, Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (L.M.S., V.K.S., K.W., T.G.P.); Stroke Unit, Monash Medical Centre, Southern Health, Victoria, Australia (L.M.S., V.K.S., D.R., T.G.P.); School of Public Health and Preventative Medicine, Monash University, Victoria, Australia (D.J.J.); Department of Medicine, Southern Clinical School, Monash University, Victoria, Australia (V.S.); Department Emergency Medicine, Monash
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