Transient ischaemic attacks in young patients: a thromboembolic or migrainous manifestation? A 10 year follow up study of 46 patients

Headache and transient focal neurological symptoms during pregnancy, a prospective cohort

OBJECTIVE

The main purpose of the present prospective study was to evaluate the course of migraine and non-migrainous headache during pregnancy and to estimate the occurrence of self-reported transient focal neurological symptoms.

MATERIAL AND METHODS

In total 1631 (77%) pregnant women completed the study and were followed-up during pregnancy. The first questionnaire (Q1) was sent together with the appointment letter and delivered at the time of ultrasound screening. The second questionnaire (Q2), to be filled in during pregnancy, was delivered at the time of birth. Q1 and Q2 covered questions about headache, transient neurological symptoms, and other background and demographic data. Subjects reporting transient sensory, motor or visual disturbances were also interviewed by phone in order to achieve a more precise description of the symptoms.

RESULTS

A total of 58% subjects with migraine reported not having migraine or no headache at all during pregnancy. Among individuals with non-migrainous headache 25% reported not having any headaches, while 1.9% of the subjects without headache experienced headache attacks during pregnancy that fulfilled the criteria for migraine. Individuals without headache or with non-migrainous headache reported significantly less sensory, motor and visual disturbances during pregnancy compared with migraine subjects. More than 60% of those with possible aura phenomenon were migraine patients, while symptoms of peripheral or non-neurological origin were more common among headache free or those with non-migrainous headache.

CONCLUSION

Transient neurological symptoms were less common among individuals without or with non-migrainous headache compared with migraine. This may indicate that there is an increased susceptibility of unknown cause for these symptoms among migraine patients during pregnancy.

[Ischemic strokes in young adults]

PURPOSE

The incidence of cerebral ischemia occurring between 15 and 45 years of age is of 60 to 200 new cases per year per million inhabitants. The causes of cerebral ischemia consist of complications of atherosclerosis, cardio embolism, small-vessel occlusion, other determined causes and unknown causes. The breakdown of the causes differ from that of elderly subjects with a prominence of "unknown causes" and "other determined causes".

KEY MESSAGE

The association of a patent foramen ovale and an interatrioseptal aneurysm is a marker of an increased risk of recurrence. Cervical-artery dissections are the leading cause of cerebral ischemia in young adults and are usually associated with a good outcome in patients who survive the acute stage. Depending on the exhaustivity of the diagnostic work-up, 30 to 50% of cases have no clear cause. Mortality rate and recurrence rates in cerebral ischemia occurring in young adults are low. A negative diagnostic work-up is associated with a low risk of recurrence. Epilepsy is frequent. The incidence of cerebral ischemia occurring during pregnancies is 4,3 for 100,000 deliveries. Specific causes are led by eclampsia, and reversible angiopathies of the post partum period.

FUTURE

If the outcome is good, the causes are multiple and research should focus on the identification of new causes and the natural history in many of them.

Long term risks of stroke, myocardial infarction, and vascular death in "low risk" patients with a non-recent transient ischaemic attack

BACKGROUND

Previous studies of prognosis after a transient ischaemic attack (TIA) have recruited patients soon after the event, when the risk of stroke is very high. However, the majority of patients survive for many years after a TIA, and the need for continued preventive treatment to lower vascular risk will need to be reassessed at a later date.

OBJECTIVE

To determine the long term risks of stroke and other vascular events in patients with TIA who survive the initial high risk period.

METHODS

290 patients were studied who had initially been followed up after a TIA in the Oxford community stroke project and in a contemporaneous hospital based cohort study, and who were alive and stroke-free at the end of planned follow up in 1988. All patients were followed for a further 10 years, and the risks of major vascular events (stroke, myocardial infarction, vascular death) were determined. Standardised mortality ratios (SMR) were calculated from the observed numbers of fatal events and the number expected on the basis of age and sex in the general population.

RESULTS

Median time since last TIA was 3.8 years (interquartile range, 2.2 to 5.8 years). The risk of major vascular events was constant through time. The 10 year risk of first stroke was 18.8% (95% confidence interval (CI), 13.6 to 23.7; 45 events). The 10 year risk of myocardial infarction or death from coronary heart disease was 27.8% (95% CI, 21.8 to 33.3; 67 events) and there was a significant excess of fatal coronary events compared with that expected in the general population (SMR = 1.47; 95% CI, 1.10 to 1.93; p = 0.009). A total of 114 patients had at least one major vascular event, with a 10 year risk of any first stroke, myocardial infarction, or vascular death of 42.8% (95% CI, 36.4 to 48.5).

CONCLUSIONS

The overall risk of major vascular events remains high for 10 to 15 years after a TIA. It is important therefore that preventive treatments are continued in the long term, even in apparently "low risk" patients who have already survived free of stroke for several years.

Occlusive vascular diseases in oral contraceptive users. Epidemiology, pathology and mechanisms

Despite being an unprecedented departure from normal physiology, the combined oral contraceptive is not only highly effective, but it also has a remarkably good safety record. Concerns over safety persist, though, particularly with regard to venous thromboembolism (VTE), stroke and myocardial infarction (MI). Epidemiological studies consistently show an increase in risk of VTE, but the results are more contentious with regard to arterial diseases. Despite 40 years of research, the mechanisms behind these adverse effects are not understood. In this review, we integrate information from published studies of the epidemiology and pathology of the occlusive vascular diseases and their risk factors to identify likely explanations for pathogenesis in oral contraceptive users. Oral contraceptives induce both prothrombotic and fibrinolytic changes in haemostatic factors and an imbalance in haemostasis is likely to be important in oral contraceptive-induced VTE. The complexity of the changes involved and the difficulty of ascribing clinical significance has meant that uncertainty persists. A seriously under-researched area concerns vascular changes in oral contraceptive users. Histologically, endothelial and intimal proliferation have been identified in women exposed to high plasma estrogen concentrations and these lesions are associated with thrombotic occlusion. Other structural changes may result in increased vascular permeability, loss of vascular tone and venous stasis. With regard to arterial disease risk, epidemiological information relating to dose effects and joint effects with other risk factors, and studies of pathology and changes in risk factors, suggests that oral contraceptive use per se does not cause arterial disease. It can, nevertheless, synergise very powerfully with subclinical endothelial damage to promote arterial occlusion. Accordingly, the prothrombotic effects of the oral contraceptive estrogen intervene in a cycle of endothelial damage and repair which would otherwise remain clinically silent or would ultimately progress - in, for example, the presence of cigarette smoking or hypertension - to atherosclerosis. Future work in this area should focus on modification of the effects of established risk factors by oral contraceptive use rather than modification of the supposed risk of oral contraceptive use by established risk factors. Attempts to understand vascular occlusion in oral contraceptive users in terms of the general features of VTE or with reference to atherosclerosis may be limiting, and future work needs to acknowledge that such occlusions may have unique features. Unequivocal identification of the mechanisms involved would contribute considerably to the alleviation of fears over vascular disease and to the development of even safer formulations.

Long-term prognosis of cerebral ischemia in young adults. National Research Council Study Group on Stroke in the Young

BACKGROUND AND PURPOSE

Prognosis of ischemic stroke in young adults is reported as favorable, and transient ischemic attack (TIA) is commonly considered a benign event. We investigated long-term outcome and prognostic predictors of cerebral ischemia in patients under 45 years of age.

METHODS

Three hundred thirty-three patients aged 15 to 44 years who suffered from a first-ever TIA or ischemic stroke were prospectively followed up with annual clinical evaluation or complete phone interview. End points were the composite outcome event of stroke, myocardial infarction, and vascular or nonvascular death and death from all causes. The probability of event-free survival was estimated by the Kaplan-Meier method. Univariate and multivariate estimates of hazard ratios were calculated according to the Cox proportional hazards analysis.

RESULTS

An average follow-up of 96 months was available in 330 patients (99.1%). Survival was worse in patients with stroke at entry (86.5%) than in those with TIA (97.1%). Mortality in both groups was significantly higher than in the general population (standardized mortality ratio [SMR] 14.5, P<0.0001, Poisson distribution test, and SMR 7.9, P=0.002). The average annual mortality rate was higher during the first (3.94%, 95% CI 1.84 to 6. 04) than in the subsequent years. The average annual incidence rate of new stroke was higher in patients with stroke than in those with TIA at entry, and it declined from 1.56% (95% CI 0.21 to 2.91) during the first year to 0.06% (95% CI 0.04 to 0.08) at the end of the follow-up. Myocardial infarction occurred later, after the first year, with similar rates in patients with stroke and TIA at entry. The average annual rates of new stroke (2.36%), myocardial infarction (1.68%), and death (3.05%) were higher in patients with the mixed atherothrombotic and cardioembolic etiology than in the remaining patients. Male gender, age >35 years, stroke at entry, and cardiac diseases were independent predictors of the composite outcome event at the Cox regression analysis, whereas only stroke at entry and cardiac diseases predicted death from all causes.

CONCLUSIONS

Stroke and TIA in young adults have severe prognostic implications, because the mortality risk was highly increased with respect to the general population. Preventive measures are strongly recommended in the presence of any unfavorable prognostic profile.

Characteristics and prevalence of transient visual disturbances indicative of migraine visual aura

The objective of this study was to estimate the prevalence of and to compare the characteristics of transient visual disturbances (TVDs) of possible migraine origin in a clinical and a general population. Data were obtained in interviews from 100 consecutive female migraine patients (17-69 years) and 245 women (40-75 years) from the general population. The lifetime prevalences were 37% and 13%, respectively. We did not detect any differences in characteristics of TVDs between patients and women in the general population. A gradual onset of five or more minutes was stated by as few as 45% and 46%, respectively. The typical headache phase in conjunction with a TVD had more migrainous features in patients. We conclude from our data that the TVDs in this study, which do not fulfill the IHS criteria for migraine with aura, more likely represent poorly described or abortive migraine phenomena, rather than phenomena of other origin.

Transient ischemic attacks in younger and older patients. A comparative study of 798 patients in South Africa

BACKGROUND AND PURPOSE

The literature concerning transient ischemic attacks in young adults compared with strokes in young adults is scanty. This study evaluates the profile of transient ischemic attacks in young patients (aged 45 years or younger) compared with older patients (aged older than 45 years).

METHODS

Between 1981 and 1991, 75 young patients (aged 45 years or younger) and 723 older patients (aged older than 45 years) were diagnosed as having a transient ischemic attack and included in the study. History of presenting transient ischemic attack, risk factors, clinical features, investigations, and etiology were compared on the basis of the above age groups.

RESULTS

In younger patients the presenting transient ischemic attack occurred less frequently in the vertebrobasilar territory (9% versus 21%, P = .03). Risk factor analysis revealed significant differences between the groups, with hypertension, previous smoking history, ischemic heart disease, and peripheral vascular disease being more common in the older group. Migraine and valvular heart disease were more common in the younger group. Approximately 60% of the patients in each group had multiple etiologies. The most common etiology was atheromatous cerebrovascular disease in both groups (74% versus 37% [P < .0001] in the older and younger groups, respectively). Other significant etiologic differences included fibromuscular dysplasia, mitral valve prolapse, and use of oral contraceptives occurring more frequently in the younger group, and ischemic heart disease occurring more frequently in the older group.

CONCLUSIONS

This study reveals the clinical and etiologic differences between younger and older patients with transient ischemic attack. The importance of multiple etiologies in both groups of patients has diagnostic and management implications.