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Barone V, Foschi M, Pavolucci L, Rondelli F, Rinaldi R, Nicodemo M, D’Angelo R, Favaretto E, Brusi C, Cosmi B, Degli Esposti D, D’Addato S, Bacchelli S, Giostra F, Pomata DP, Spinardi L, Faccioli L, Faggioli G, Donti A, Borghi C, Cortelli P, Guarino M. Enhancing stroke risk prediction in patients with transient ischemic attack: insights from a prospective cohort study implementing fast-track care. Front Neurol 2024; 15:1407598. [PMID: 38859972 PMCID: PMC11163114 DOI: 10.3389/fneur.2024.1407598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024] Open
Abstract
Background and aims Fast-track care have been proved to reduce the short-term risk of stroke after transient ischemic attack (TIA). We aimed to investigate stroke risk and to characterize short- and long-term stroke predictors in a large cohort of TIA patients undergoing fast-track management. Methods Prospective study, enrolling consecutive TIA patients admitted to a Northern Italy emergency department from August 2010 to December 2017. All patients underwent fast-track care within 24 h of admission. The primary outcome was defined as the first stroke recurrence at 90 days, 12 and 60 months after TIA. Stroke incidence with 95% confidence interval (CI) at each timepoint was calculated using Poisson regression. Predictors of stroke recurrence were evaluated with Cox regression analysis. The number needed to treat (NNT) of fast-track care in preventing 90-day stroke recurrence in respect to the estimates based on baseline ABCD2 score was also calculated. Results We enrolled 1,035 patients (54.2% males). Stroke incidence was low throughout the follow-up with rates of 2.2% [95% CI 1.4-3.3%] at 90 days, 2.9% [95% CI 1.9-4.2%] at 12 months and 7.1% [95% CI 5.4-9.0%] at 60 months. Multiple TIA, speech disturbances and presence of ischemic lesion at neuroimaging predicted stroke recurrence at each timepoint. Male sex and increasing age predicted 90-day and 60-month stroke risk, respectively. Hypertension was associated with higher 12-month and 60-month stroke risk. No specific TIA etiology predicted higher stroke risk throughout the follow-up. The NNT for fast-track care in preventing 90-day stroke was 14.5 [95% CI 11.3-20.4] in the overall cohort and 6.8 [95% CI 4.6-13.5] in patients with baseline ABCD2 of 6 to 7. Conclusion Our findings support the effectiveness of fast-track care in preventing both short- and long-term stroke recurrence after TIA. Particular effort should be made to identify and monitor patients with baseline predictors of higher stroke risk, which may vary according to follow-up duration.
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Affiliation(s)
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
- Department of Neuroscience, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Lucia Pavolucci
- Department of Neuroscience, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | | | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | | | | | - Elisabetta Favaretto
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carlotta Brusi
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniela Degli Esposti
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sergio D’Addato
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Bacchelli
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabrizio Giostra
- Emergency Department, Medicina d’Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniela Paola Pomata
- Emergency Department, Medicina d’Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, DIMEC – University of Bologna, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Donti
- Pediatric Cardiology and Adult Congenital Heart Disease Program, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudio Borghi
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
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Groff H, Yousfani S, Pantoja-Ruiz C, Douiri A, Bhalla A, Wolfe C, Marshall IJ. A systematic review of the incidence and outcomes of ICD-11 defined stroke. J Stroke Cerebrovasc Dis 2024; 33:107784. [PMID: 38795795 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND The World Health Organisation has expanded the definition of stroke to include people with symptoms less than 24 h if they have evidence of stroke on neuroimaging. The impact is that people previously diagnosed as having a transient ischaemic attack (TIA) would now be considered to have had a stroke. This change will impact incidence and outcomes of stroke and increase eligibility for secondary prevention. We aimed to evaluate the new ICD-11 criteria retrospectively to previous TIA studies to understand the change in incidence and outcomes of this type of stroke. METHODS We conducted a systematic review of observational studies of the incidence and outcomes of clinically defined TIA. We searched PubMed, EMBASE, and Google Scholar from inception to 23rd May 2023. Study quality was assessed using a risk of bias tool for prevalence studies. FINDINGS Our review included 25 studies. The rate of scan positivity for stroke among those with clinically defined TIA was 24 %, (95 % CI, 16-33 %) but with high heterogeneity (I2 = 100 %, p <0.001). Sensitivity analyses provided evidence that heterogeneity could be explained by methodology and recruitment method. The scan positive rate when examining only studies at low risk of bias was substantially lower, at 13 % (95 % CI, 11-15 %, I2 = 0, p = 0.77). We estimate from population-based incidence studies that ICD-11 would result in an increase stroke incidence between 4.8 and 10.5 per 100,000 persons/year. Of those with DWI-MRI evidence of stroke, 6 % (95 % CI, 3-11 %) developed a recurrent stroke in the subsequent 90 days, but with substantial heterogeneity (I2 = 67 %, p = 0.02). CONCLUSION The impact of the ICD-11 change in stroke definition on incidence and outcomes may have been overestimated by individual studies. Community-based stroke services with access to DWI MRI are likely to accurately diagnose greater numbers of people with mild ICD-11 stroke, increasing access to effective prevention.
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Affiliation(s)
- Holli Groff
- School of Life Course and Population Science, King's College London, London, UK
| | - Sariha Yousfani
- School of Life Course and Population Science, King's College London, London, UK
| | - Camila Pantoja-Ruiz
- School of Life Course and Population Science, King's College London, London, UK
| | - Abdel Douiri
- School of Life Course and Population Science, King's College London, London, UK; NIHR ARC South London, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Ajay Bhalla
- School of Life Course and Population Science, King's College London, London, UK; NIHR ARC South London, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK; Department of Ageing Health and Stroke, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Charles Wolfe
- School of Life Course and Population Science, King's College London, London, UK; NIHR ARC South London, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Iain J Marshall
- School of Life Course and Population Science, King's College London, London, UK; NIHR ARC South London, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK.
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Purroy F, Ois A, Jove M, Arque G, Sol J, Mauri-Capdevila G, Rodriguez-Campello A, Pamplona R, Portero M, Roquer J. Lipidomic signature of stroke recurrence after transient ischemic attack. Sci Rep 2023; 13:13706. [PMID: 37607967 PMCID: PMC10444771 DOI: 10.1038/s41598-023-40838-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 08/17/2023] [Indexed: 08/24/2023] Open
Abstract
While TIA patients have transient symptoms, they should not be underestimated, as they could have an underlying pathology that may lead to a subsequent stroke: stroke recurrence (SR). Previously, it has been described the involvement of lipids in different vascular diseases. The aim of the current study was to perform a lipidomic analysis to identify differences in the lipidomic profile between patients with SR and patients without. Untargeted lipidomic analysis was performed in plasma samples of 460 consecutive TIA patients recruited < 24 h after the onset of symptoms. 37 (8%) patients suffered SR at 90 days. Lipidomic profiling disclosed 7 lipid species differentially expressed between groups: 5 triacylglycerides (TG), 1 diacylglyceride (DG), and 1 alkenyl-PE (plasmalogen) [specifically, TG(56:1), TG(63:0), TG(58:2), TG(50:5), TG(53:7, DG(38:5)) and PE(P-18:0/18:2)]. 6 of these 7 lipid species belonged to the glycerolipid family and a plasmalogen, pointing to bioenergetics pathways, as well as oxidative stress response. In this context, it was proposed the PE(P-18:0/18:2) as potential biomarker of SR condition.The observed changes in lipid patterns suggest pathophysiological mechanisms associated with lipid droplets metabolism and antioxidant protection that is translated to plasma level as consequence of a more intensive or high-risk ischemic condition related to SR.
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Affiliation(s)
- F Purroy
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida, UdL, Lleida, Spain.
- Stroke Unit, Department of Neurology, Universitat de Lleida, Hospital Universitari Arnau de Vilanova, Avda Rovira Roure 80, 25198, Lleida, Spain.
| | - A Ois
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - M Jove
- Experimental Medicine Department, Lleida University-Lleida Biomedical Research Institute (UdL-IRBLleida), 25198, Lleida, Spain
| | - G Arque
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida, UdL, Lleida, Spain
| | - J Sol
- Institut Català de la Salut (ICS), Atenció Primària, Lleida, Spain
- Research Support Unit Lleida, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Lleida, Spain
| | - G Mauri-Capdevila
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida, UdL, Lleida, Spain
- Stroke Unit, Department of Neurology, Universitat de Lleida, Hospital Universitari Arnau de Vilanova, Avda Rovira Roure 80, 25198, Lleida, Spain
| | - A Rodriguez-Campello
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - R Pamplona
- Experimental Medicine Department, Lleida University-Lleida Biomedical Research Institute (UdL-IRBLleida), 25198, Lleida, Spain
| | - M Portero
- Experimental Medicine Department, Lleida University-Lleida Biomedical Research Institute (UdL-IRBLleida), 25198, Lleida, Spain
| | - J Roquer
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
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Antiplatelet treatment patterns and outcomes of secondary stroke prevention in the United States. Heliyon 2023; 9:e13579. [PMID: 36852046 PMCID: PMC9958290 DOI: 10.1016/j.heliyon.2023.e13579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 01/20/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
Objective Patients who have an ischemic stroke (IS) or transient ischemic attack (TIA) are at risk of having a secondary stroke. Single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) may be recommended for secondary stroke prevention (SSP), depending on severity and etiology. This study evaluated outpatient antiplatelet treatment patterns for SSP and outcomes after first hospitalization for IS/TIA among adults without atrial fibrillation in the United States. Materials and methods This retrospective observational study utilized data from an adjudicated administrative health claims database. Eligible patients had an imputed National Institutes of Health Stroke Scale index event score ≤7. Over-the-counter medication use (eg, aspirin) was not captured. Results Of 154,273 patients, 41,622 (27%) were prescribed antiplatelet therapy within 90 days of the event; 93.8% received SAPT, 6.1% received DAPT. The first line of antiplatelet therapy after discharge was started a mean of 17.0 days after the event; mean treatment duration was 61.9 days. The incidence rate for secondary IS was 5.53, 2.03, and 1.17 per person-year 90-days, 1-year, and 3-years following treatment initiation, respectively. Among patients matched for demographic and clinical characteristics, the risk of secondary IS was increased with DAPT versus SAPT (hazard ratio [95% CI]: 1.27 [1.20-1.34]; p < 0.0001). Conclusions Many patients were not prescribed or discontinued antiplatelet therapy within 90 days of hospitalization for IS/TIA and, in most cases, prescriptions were not compliant with SSP consensus guidelines. Patients remained at risk for IS, which was highest within 90 days. More effective strategies for SSP are needed to improve outcomes in this patient population.
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Yu S, An J, Sun R, Feng J, Yu M. LncRNA KCNQ1OT1 predicts further cerebral events in patients with transient ischemic attack. Front Pharmacol 2022; 13:961190. [PMID: 36278219 PMCID: PMC9585189 DOI: 10.3389/fphar.2022.961190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 09/15/2022] [Indexed: 12/02/2022] Open
Abstract
Transient ischemic attack (TIA) poses a great threat of cerebrovascular diseases to a large number of patients, despite its reversible neurological dysfunction. Long non-coding RNAs (lncRNAs) have been proven to play critical roles in the pathophysiological development of cerebrovascular events. Exploring the function of lncRNAs in modulating TIA prognosis would help to develop individualized therapeutics. A total of 231 participants with the first onset of TIA were recruited in the study, including 65 subsequent stroke patients. The expression of lncRNA potassium voltage-gated channel subfamily Q member 1 opposite strand 1 (KCNQ1OT1) was upregulated in patients with recurrent ischemic events after TIA. Additionally, KCNQ1OT1 could be regarded as an independent predictor for subsequent ischemic stroke. The optimal diagnostic value was determined at 1.29 with a sensitivity of 63% and a specificity of 72%. Fewer patients would survive from further ischemic stroke with their KCNQ1OT1 level over 1.29. Furthermore, the expression of KCNQ1OT1 was elevated with a growing serum high-sensitivity C-reactive protein (hs-CRP) level. KCNQ1OT1 might be involved in the regulation of early inflammatory response during recurrence of TIA.
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Affiliation(s)
- Shijia Yu
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jing An
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ran Sun
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Juan Feng
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Mingjun Yu
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Mingjun Yu,
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Shah K, McCabe B, Mathews C, Nehamkin A, Desai SM, Jadhav AP. Expedited management of low-risk transient ischemic attack patients: The “Fast-Track” TIA protocol. J Stroke Cerebrovasc Dis 2022; 31:106522. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 10/18/2022] Open
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Purroy F, Vicente-Pascual M, Arque G, Begue R, Farre J, Gallego Y, Gil-Villar MP, Mauri G, Montalà N, Pereira C, Torres-Querol C, Vazquez-Justes D. Risk of New-Diagnosed Atrial Fibrillation After Transient Ischemic Attack. Front Neurol 2022; 13:905304. [PMID: 35911925 PMCID: PMC9331650 DOI: 10.3389/fneur.2022.905304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/07/2022] [Indexed: 12/05/2022] Open
Abstract
Background Transient ischemic attack (TIA) provides a unique opportunity to optimize secondary preventive treatments to avoid subsequent ischemic stroke (SIS). Although atrial fibrillation (AF) is the leading cause of cardioembolism in IS and anticoagulation prevents stroke recurrence (SR), limited data exists about the risk of new-diagnosed AF (NDAF) after TIA and the consequences of the diagnostic delay. The aim of our study was to determine this risk in a cohort of TIA patients with long-term follow-up. Methods We carried out a prospective cohort study of 723 consecutive TIA patients from January 2006 to June 2010. Median follow-up was 6.5 (5.0–9.6) years. In a subgroup of 204 (28.2%) consecutive patients, a panel of biomarkers was assessed during the first 24 h of the onset of symptoms. Multivariate analyses were performed to find out the associated factors of NDAF. Kaplan-Meier analysis was also performed to analyzed risk of SIS. Results NDAF was indentified in 116 (16.0%) patients: 42 (36.2%) during admission, 18 (15.5%) within first year, 29 (25%) between one and five years and 27 (23.3%) beyond 5 years. NDAF was associated with sex (female) [hazard ratio (HR) 1.61 (95% CI, 1.07- 2.41)], age [[HR 1.05 (95% CI, 1.03–1.07)], previous ischemic heart disease (IHD) [HR 1.84, (95% CI 1.15–2.97)] and cortical DWI pattern [HR 2.81 (95% CI, 1.87–4.21)]. In the Kaplan-Meier analysis, NT-proBNP ≥ 218.2 pg/ml (log-rank test P < 0.001) was associated with significant risk of NDAF during the first 5 years of follow-up. Patients with NDAF after admission and before 5 years of follow-up had the highest risk of SIS (P = 0.002). Conclusion The risk of NDAF after TIA is clinically relevant. We identified clinical and neuroimaging factors of NDAF. In addition, NT-proBNP was related to NDAF. Our results can be used to evaluate the benefit of long-term cardiac monitoring in selected patients.
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Affiliation(s)
- Francisco Purroy
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Mikel Vicente-Pascual
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Gloria Arque
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Robert Begue
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Joan Farre
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Yhovany Gallego
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
| | - Maria Pilar Gil-Villar
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Gerard Mauri
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Nuria Montalà
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
- Hospital Universitari Santa Maria de Lleida, Lleida, Spain
| | - Cristina Pereira
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Coral Torres-Querol
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Daniel Vazquez-Justes
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
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Nouri-Vaskeh M, Khalili N, Sadighi A, Yazdani Y, Zand R. Biomarkers for Transient Ischemic Attack: A Brief Perspective of Current Reports and Future Horizons. J Clin Med 2022; 11:jcm11041046. [PMID: 35207321 PMCID: PMC8877275 DOI: 10.3390/jcm11041046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023] Open
Abstract
Cerebrovascular disease is the leading cause of long-term disability in the world and the third-leading cause of death in the United States. The early diagnosis of transient ischemic attack (TIA) is of great importance for reducing the mortality and morbidity of cerebrovascular diseases. Patients with TIA have a high risk of early subsequent ischemic stroke and the development of permanent nervous system lesions. The diagnosis of TIA remains a clinical diagnosis that highly relies on the patient's medical history assessment. There is a growing list of biomarkers associated with different components of the ischemic cascade in the brain. In this review, we take a closer look at the biomarkers of TIA and their validity with a focus on the more clinically important ones using recent evidence of their reliability for practical usage.
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Affiliation(s)
- Masoud Nouri-Vaskeh
- Tropical and Communicable Diseases Research Centre, Iranshahr University of Medical Sciences, Iranshahr 7618815676, Iran;
- Network of Immunity in Infection, Malignancy and Autoimmunity, Universal Scientific Education and Research Network, Tehran 1419733151, Iran
| | - Neda Khalili
- School of Medicine, Tehran University of Medical Sciences, Tehran 1449614535, Iran;
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran 1419733151, Iran
| | - Alireza Sadighi
- Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA;
| | - Yalda Yazdani
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran;
| | - Ramin Zand
- Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA;
- Neuroscience Institute, Pennsylvania State University, State College, PA 16801, USA
- Correspondence: or ; Tel.: +1-570-808-7330; Fax: +1-570-808-3209
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Zhao L, Cao S, Pei L, Fang H, Liu H, Wu J, Sun S, Gao Y, Song B, Xu Y. Validation of CSR model to predict stroke risk after transient ischemic attack. Sci Rep 2022; 12:604. [PMID: 35022460 PMCID: PMC8755815 DOI: 10.1038/s41598-021-04405-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/22/2021] [Indexed: 11/29/2022] Open
Abstract
It is essential to identify high risk transient ischemic attack (TIA) patients. The previous study reported that the CSR (comprehensive stroke recurrence) model, a neuroimaging model, had a high predictive ability of recurrent stroke. The aims of this study were to validate the predictive value of CSR model in TIA patients and compare the predictive ability with ABCD3-I score. Data were analyzed from the prospective hospital-based database of patients with TIA which defined by the World Health Organization time-based criteria. The predictive outcome was stroke occurrence at 90 days. The receiver-operating characteristic (ROC) curves were plotted and the C statistics were calculated as a measure of predictive ability. Among 1186 eligible patients, the mean age was 57.28 ± 12.17 years, and 474 (40.0%) patients had positive diffusion-weighted imaging (DWI). There were 118 (9.9%) patients who had stroke within 90 days. In 1186 TIA patients, The C statistic of CSR model (0.754; 95% confidence interval [CI] 0.729–0.778) was similar with that of ABCD3-I score (0.717; 95% CI 0.691–0.743; Z = 1.400; P = 0.1616). In 474 TIA patients with positive DWI, C statistic of CSR model (0.725; 95% CI 0.683–0.765) was statistically higher than that of ABCD3-I score (0.626; 95% CI 0.581–0.670; Z = 2.294; P = 0.0245). The CSR model had good predictive value for assessing stroke risk after TIA, and it had a higher predictive value than ABCD3-I score for assessing stroke risk for TIA patients with positive DWI.
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Affiliation(s)
- Lu Zhao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Shuang Cao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Lulu Pei
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Hui Fang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Hao Liu
- Department of Magnetic Resonance, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Jun Wu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Shilei Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yuan Gao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Bo Song
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China.
| | - Yuming Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China.
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10
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Maier IL, Herpertz GU, Bähr M, Psychogios MN, Liman J. What is the added value of CT-angiography in patients with transient ischemic attack? BMC Neurol 2022; 22:7. [PMID: 34980008 PMCID: PMC8722154 DOI: 10.1186/s12883-021-02523-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 12/13/2021] [Indexed: 12/03/2022] Open
Abstract
Background Transient ischemic attack (TIA) is an important predictor for a pending stroke. Guidelines recommend a workup for TIA-patients similar to that of stroke patients, including an assessment of the extra- and intracranial arteries for vascular pathologies with direct therapeutic implications via computed tomography angiography (CTA). Aim of our study was a systematic analysis of TIA-patients receiving early CTA-imaging and to evaluate the predictive value of TIA-scores and clinical characteristics for ipsilateral vascular pathologies and the need of an invasive treatment. Methods We analysed clinical and imaging data from TIA patients being admitted to a tertiary university hospital between September 2015 and March 2018. Following subgroups were identified: 1) no- or low-grade vascular pathology 2) ipsilateral high-risk vascular pathology and 3) high-risk findings that needed invasive, surgical or interventional treatment. We investigated established TIA-scores (ABCD2-, the ABCD3- and the SPI-II score) and various clinical characteristics as predictive factors for ipsilateral vascular pathologies and the need for invasive treatment. Results Of 812 patients, 531 (65.4%) underwent initial CTA in the emergency department. In 121 (22.8%) patients, ipsilateral vascular pathologies were identified, of which 36 (6.7%) needed invasive treatment. The ABCD2-, ABCD3- and SPI-II-scores were not predictive for ipsilateral vascular pathologies or the need for invasive treatment. We identified male sex (OR 1.579, 95%CI 1.049–2.377, p = 0.029), a short duration of symptoms (OR 0.692, 95% CI 0.542–0.884, p = 0.003), arterial hypertension (OR 1.718, 95%CI 0.951–3.104, p = 0.073) and coronary heart disease (OR 1.916, 95%CI 1.184–3.101, p = 0.008) as predictors for ipsilateral vascular pathologies. As predictors for the need of invasive treatment, a short duration of symptoms (OR 0.565, 95%CI 0.378–0.846, p = 0.006), arterial hypertension (OR 2.612, 95%OR 0.895–7.621, p = 0.079) and hyperlipidaemia (OR 5.681, 95%CI 0.766–42.117, p = 0.089) as well as the absence of atrial fibrillation (OR 0.274, OR 0.082–0.917, p = 0.036) were identified. Conclusion More than every fifth TIA-patient had relevant vascular findings revealed by acute CTA. TIA-scores were not predictive for these findings. Patients with a short duration of symptoms and a vascular risk profile including coronary heart disease, arterial hypertension and hyperlipidaemia most likely might benefit from early CTA to streamline further diagnostics and therapy. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02523-y.
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Affiliation(s)
- Ilko L Maier
- Department of Neurology, University Medicine Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - Gerrit U Herpertz
- Department of Anesthesiology, Klinikum Bremerhaven-Reinkenheide, Bremerhaven, Germany
| | - Mathias Bähr
- Department of Neurology, University Medicine Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Marios-Nikos Psychogios
- Department of diagnostic and interventional Neuroradiology, University Clinic Basel, Basel, Switzerland
| | - Jan Liman
- Department of Neurology, University Medicine Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
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11
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Chabbert P, Lamboley L, Souquet O, Haesebaert J, Termoz A, Schott AM, Lecoanet A, Douplat M, Benhamed A, Nighoghossian N, Mechtouff L. Effect of the Implementation of a Local Care Pathway on the Transient Ischemic Attack Management in Emergency Departments. Neurologist 2021; 27:46-50. [PMID: 34842566 DOI: 10.1097/nrl.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent studies have demonstrated that urgent care decreases the risk of subsequent stroke after transient ischemic attack (TIA). In response to heterogeneous TIA management observed in our area, we developed a structured pathway, in accordance with current guidelines and adapted to local resources. We aim to assess the effect of local implementation of this care pathway on TIA management in emergency departments (EDs) in the Rhône area (France). PATIENTS AND METHODS EDs of 5 centers that had a minimum of 30 TIA/year in Lyon and Bourgoin-Jallieu participated. The first 30 consecutive patients who had a TIA as main diagnosis admitted to one of these EDs from January 1 to December 31, 2013 and from January 1 to December 31, 2016, that is, before-and-after care pathway implementation, respectively, were retrospectively included in the study. The primary outcome was the adequate management of TIA defined as having had appropriate workup and antithrombotic treatment within 24 hours. RESULTS A total of 141 patients were included in 2013 and 150 in 2016. There was a significant increase of complete (intracrania and extracranial) vessel imaging from 2013 to 2016 (n=42, 29.8% in 2013 vs. n=118, 78.7% in 2016; P<0.001). Computed tomography angiography was more often performed to assess intracranial and/or extracranial vessel imaging in 2016 compared with 2013 (n=54, 34.8% in 2013 vs. n=116, 77.3% in 2016; P<0.001). Overall, the rate of patients receiving adequate management significantly increased from 2013 to 2016 (n=36, 25.5% in 2013 vs. n=101, 67.3% in 2016; P<0.001). CONCLUSIONS Implementation of a local care pathway, in accordance with current guidelines and adapted to local resources, improved TIA management in EDs, mostly by increasing the rate of vessel imaging by computed tomography angiography.
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Affiliation(s)
| | | | | | - Julie Haesebaert
- Pôle de santé publique, Service de recherche et épidémiologie clinique
- HESPER EA 7425, Université Claude Bernard Lyon 1
| | - Anne Termoz
- Pôle de santé publique, Service de recherche et épidémiologie clinique
- HESPER EA 7425, Université Claude Bernard Lyon 1
| | - Anne-Marie Schott
- Pôle de santé publique, Service de recherche et épidémiologie clinique
- HESPER EA 7425, Université Claude Bernard Lyon 1
| | | | | | | | - Norbert Nighoghossian
- Stroke Unit, Hôpital Pierre Wertheimer, Hospices Civils de Lyon
- CarMeN Laboratory, University Lyon 1, INSERM U1060, Lyon, France
| | - Laura Mechtouff
- Stroke Unit, Hôpital Pierre Wertheimer, Hospices Civils de Lyon
- CarMeN Laboratory, University Lyon 1, INSERM U1060, Lyon, France
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12
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Del Giovane C, Boncoraglio GB, Bertù L, Banzi R, Tramacere I. Antiplatelet drugs for secondary prevention in patients with ischemic stroke or transient ischemic attack: a systematic review and network meta-analysis. BMC Neurol 2021; 21:319. [PMID: 34399713 PMCID: PMC8365925 DOI: 10.1186/s12883-021-02341-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antiplatelet drugs may prevent recurrent ischemic events after ischemic stroke but their relative effectiveness and harms still need to be clarified. Within this network meta-analysis we aimed to summarize the current evidence for using antiplatelet drugs for secondary stroke prevention. METHODS We searched MEDLINE, EMBASE and CENTRAL up to September 2020. Randomized controlled trials (RCTs) assessing antiplatelet drugs for secondary stroke prevention were included. We did pairwise meta-analyses and network meta-analyses using random-effects models. Primary outcomes were all strokes (ischemic or hemorrhagic) and all-cause mortality. RESULTS The review included 57 RCTs, 50 (n = 165,533 participants) provided data for the meta-analyses. Compared to placebo/no treatment, moderate to high-confidence evidence indicated that cilostazol, clopidogrel, dipyridamole + aspirin, ticagrelor, ticlopidine, and aspirin ≤ 150 mg/day significantly reduced the risk of all strokes (odds ratios, ORs and absolute risk difference, ARD): cilostazol 0.51 (95 % confidence interval, CI, 0.37 to 0.71; 3.6 % fewer), clopidogrel 0.63 (95 % CI, 0.49 to 0.79; 2.7 % fewer), dipyridamole + aspirin 0.65 (95 % CI, 0.55 to 0.78; 2.5 % fewer), ticagrelor 0.68 (95 % CI, 0.50 to 0.93; 2.3 % fewer), ticlopidine 0.74 (95 % CI 0.59 to 0.93; 1.9 % fewer), aspirin ≤ 150 mg/day 0.79 (95 % CI, 0.66 to 0.95; 1.5 % fewer). Aspirin > 150 mg/day and the combinations clopidogrel/aspirin, ticagrelor/aspirin, also decrease all strokes but increase the risk of hemorrhagic events. Only aspirin > 150 mg/day significantly reduced all-cause mortality (OR 0.86, 95 % CI 0.76 to 0.97; ARD 0.9 %, 95 %CI 1.5-0.2 % fewer, moderate confidence). Compared to aspirin ≤ 150 mg/day, clopidogrel significantly reduced the risk of all strokes, cardiovascular events, and intracranial hemorrhage outcomes. Cilostazol also appeared to provide advantages but data are limited to the Asian population. CONCLUSIONS Considering the benefits and harms ratio, cilostazol, clopidogrel, dipyridamole + aspirin, ticagrelor, ticlopidine, and aspirin ≤ 150 mg/day appear to be the best choices as antiplatelet drugs for secondary prevention of patients with ischemic stroke or TIA. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020159896 .
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Affiliation(s)
- Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Population Health Laboratory, University of Fribourg, Fribourg, Switzerland
| | - Giorgio B Boncoraglio
- Department of Cerebrovascular Disease, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Lorenza Bertù
- Department of Research and Clinical Development, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Rita Banzi
- Center for Health Regulatory Policies, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
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13
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Kopolovets І, Berek P, Stefanic P, Lotnyk D, Mucha R, Hertelyova Z, Toth S, Boyko N, Sihotsky V. Hypothesis of "stroke-stop" formula: a tool for risk index determination in development of acute cerebrovascular disease in asymptomatic individuals with carotid stenosis. BMC Neurol 2021; 21:310. [PMID: 34380459 PMCID: PMC8356401 DOI: 10.1186/s12883-021-02337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Extracranial carotid artery disease is considered a risk factor for developing acute cerebrovascular diseases. The paper suggests the “Stroke-Stop” formula as hypothesis for the determination of the risk of developing stroke in asymptomatic individuals with carotid stenosis. The formula is based on a mathematical calculation of the major risk factors for stroke: the degree of ICA (internal carotid artery) stenosis, the morphological structure of the atherosclerotic plaque and the level of lipoprotein-associated phospholipase A2 (Lp-PLA2) concentration. Methods The cross sectional study included 70 patients with atherosclerotic ICA stenosis. Among vascular inflammatory markers, Lp-PLA2 was determined with concentration 252.7–328.6 mg/l. The obtained results were evaluated using descriptive statistics (the frequency, percentage ratio) as well as the one-way analysis of variance (ANOVA) and chi-square test. Results The risk of stroke development is eminently increasing with the progression of ICA stenosis and elevation of Lp-PLA2 levels. In patients with echolucent plaque, the risk of stroke development was significantly higher in correlation with patients with echogenic plaque. Based on calculations using “Stroke-Stop” formula, three main groups were generated: low (< 70 points), medium (70–100 points) and high (> 100 points) risk of stroke development. Conclusions Hypothesis of “Stroke-Stop” formula is proposed for better selection of patients who should be indicated for surgical treatment and will be evaluated in prospective study. In order to verify this hypothesis, we plan to do prospective study using “Stroke-Stop” formula for ipsilateral annual stroke rate in asymptomatic individuals with carotid stenosis who receive conservative therapy. Stenosis, ulceration of the atherosclerotic plaque and Lp-PLA2 concentration are calculated 3 groups of stroke risk development were set (low, medium and high) Proposed formula form personalized approach to the diagnosis and prevention of stroke
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Affiliation(s)
- Іvan Kopolovets
- Clinic of Vascular Surgery, Eastern Slovak Institute of Cardiovascular Diseases and Faculty of Medicine, Pavol Jozef Safarik University, Ondavska 8, 04011, Kosice, Slovak Republic
| | - Peter Berek
- Clinic of Vascular Surgery, Eastern Slovak Institute of Cardiovascular Diseases and Faculty of Medicine, Pavol Jozef Safarik University, Ondavska 8, 04011, Kosice, Slovak Republic.
| | - Peter Stefanic
- Clinic of Vascular Surgery, Eastern Slovak Institute of Cardiovascular Diseases and Faculty of Medicine, Pavol Jozef Safarik University, Ondavska 8, 04011, Kosice, Slovak Republic
| | - Dmytro Lotnyk
- Department of Physics Cornell University Clark Hall, New York, USA
| | - Rastislav Mucha
- Institute of Neurobiology, Biomedical Research Center of the Slovak Academy of Sciences, Kosice, Slovak Republic
| | - Zdenka Hertelyova
- Institute of Experimental Medicine, Faculty of Medicine, Pavol Jozef Safarik University, Kosice, Slovak Republic
| | - Stefan Toth
- Clinic of Cardiology, Eastern Slovak Institute of Cardiovascular Diseases and Faculty of Medicine, Pavol Jozef Safarik University, Kosice, Slovak Republic
| | - Nadiya Boyko
- Uzhhorod National University, Research Development and Educational Center of Molecular Microbiology and Mucosal Immunology, Uzhhorod, Ukraine
| | - Vladimir Sihotsky
- Clinic of Vascular Surgery, Eastern Slovak Institute of Cardiovascular Diseases and Faculty of Medicine, Pavol Jozef Safarik University, Ondavska 8, 04011, Kosice, Slovak Republic
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14
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Shahjouei S, Sadighi A, Chaudhary D, Li J, Abedi V, Holland N, Phipps M, Zand R. A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 78:77-87. [PMID: 33044505 DOI: 10.1001/jamaneurol.2020.3627] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Management of transient ischemic attack (TIA) has gained significant attention during the past 25 years after several landmark studies indicated the high incidence of a subsequent stroke. Objective To calculate the pooled event rate of subsequent ischemic stroke within 2, 7, 30, and 90 days of a TIA and compare this incidence among the population with TIA recruited before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C). Data Sources All published studies of TIA outcomes were obtained by searching PubMed from 1996, to the last update on January 31, 2020, irrespective of the study design, document type, or language. Study Selection Of 11 516 identified citations, 175 articles were relevant to this review. Both the classic time-based definition of TIA and the new tissue-based definition were accepted. Studies with a combined record of patients with TIA and ischemic stroke, without clinical evaluation for the index TIA, with diagnosis of index TIA event after ischemic stroke occurrence, with low suspicion for TIA, or duplicate reports of the same database were excluded. Data Extraction and Synthesis The study was conducted and reported according to the PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality assessment used the Quality in Prognosis Studies tool. Publication bias was visualized by funnel plots and measured by the Begg-Mazumdar rank correlation Kendall τ2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models. Main Outcomes and Measures The proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size. Results Systematic review yielded 68 unique studies with 223 866 unique patients from 1971 to 2019. The meta-analysis included 206 455 patients (58% women) during a span of 4 decades. The overall subsequent ischemic stroke incidence rates were estimated as 2.4% (95% CI, 1.8%-3.2%) within 2 days, 3.8% (95% CI, 2.5%-5.4%) within 7 days, 4.1% (95% CI, 2.4%-6.3%) within 30 days, and 4.7% (95% CI, 3.3%-6.4%) within 90 days. There was a recurrence risk of 3.4% among group A in comparison with 2.1% in group B or 2.1% in group C within 2 days; 5.5% in group A vs 2.9% in group B or 3.2% in group C within 7 days; 6.3% in group A vs 2.9% in group B or 3.4% in group C within 30 days, and 7.4% in group A vs 3.9% in group B or 3.9% in group C within 90 days. Conclusions and Relevance These findings suggest that TIA continues to be associated with a high risk of early stroke; however, the rate of post-TIA stroke might have decreased slightly during the past 2 decades.
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Affiliation(s)
- Shima Shahjouei
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Alireza Sadighi
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Durgesh Chaudhary
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania.,Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Neil Holland
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Michael Phipps
- Department of Neurology, University of Maryland, Baltimore
| | - Ramin Zand
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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15
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Fonseca AC, Merwick Á, Dennis M, Ferrari J, Ferro JM, Kelly P, Lal A, Ois A, Olivot JM, Purroy F. European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack. Eur Stroke J 2021; 6:CLXIII-CLXXXVI. [PMID: 34414299 PMCID: PMC8370080 DOI: 10.1177/2396987321992905] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 01/16/2021] [Indexed: 01/14/2023] Open
Abstract
The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.
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Affiliation(s)
- Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Áine Merwick
- Department of Neurology, Cork University Hospital & University College Cork, Cork, Ireland
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Julia Ferrari
- Department of Neurology, St. John´s of God Hospital, Vienna, Austria
| | - José M Ferro
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Peter Kelly
- Stroke Service, Mater University Hospital and HRB Stroke Clinical Trials Network Ireland, University College Dublin, Ireland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Angel Ois
- Department of Neurology, Hospital del Mar, IMIM, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Jean Marc Olivot
- Acute Stroke Unit, Clinical Investigation Center and Toulouse Neuro Imaging Center, Toulouse University Medical Center, Toulouse, France
| | - Francisco Purroy
- Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomedica de Lleida (IRBLleida), Universitat de Lleida (UdL), Lleida, Spain
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16
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Ajčević M, Furlanis G, Naccarato M, Caruso P, Polverino P, Marsich A, Accardo A, Manganotti P. e-Health solution for home patient telemonitoring in early post-acute TIA/Minor stroke during COVID-19 pandemic. Int J Med Inform 2021; 152:104442. [PMID: 34058641 PMCID: PMC9045782 DOI: 10.1016/j.ijmedinf.2021.104442] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 12/28/2022]
Abstract
Background When it comes to critical early post-acute TIA/stroke phase, there is a lack of a comprehensive multi-parametric telemonitoring system. The COVID-19 emergency, its related global mobility restrictions and fear of hospitalization further highlighted the need of a comprehensive solution. Objective We aimed to design and test a pragmatic e-Health system based on multiparametric telemonitoring to support of TIA/stroke patients in sub-acute phase during the COVID-19 pandemic. Methods We proposed a telemonitoring system and protocol for TIA/minor stroke patients during COVID-19 pandemic for patients at risk of stroke recurrence. This system involves the use of portable devices for BP/HR/SpO2/temperature sensing, panic-button, gateway, and a dedicated ICT platform. The protocol is a 14-day multiparametric telemonitoring, therapy, and emergency intervention based on vital sign alteration notifications. We conducted a proof-of-concept validation test on 8 TIA/minor stroke patients in the early post-acute phase (< 14 days from ischemic event). Results The proposed solution allowed to promptly and remotely identify vital sign alterations at home during the early post-acute phase, allowing therapy and behavioral intervention adjustments. Also, we observed a significant improvement of quality of life, as well as a significant reduction of anxiety and depression status. TUQ showed ease of use, good interface quality and high user satisfaction of the proposed solution. The 3-month follow-up showed total adherence of prescribed therapy and no stroke/TIA recurrence or other emergency department admissions. Conclusion The proposed e-Health solution and telemonitoring protocol may be highly useful for early post-acute remote patient management, thus supporting constant monitoring and patient adherence to the treatment pathway, especially during the COVID-19 emergency.
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Affiliation(s)
- Miloš Ajčević
- Department of Engineering and Architecture, University of Trieste, Via A. Valerio, 10 - 34127, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447 - 34149, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447 - 34149, Trieste, Italy
| | - Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447 - 34149, Trieste, Italy
| | - Paola Polverino
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447 - 34149, Trieste, Italy
| | | | - Agostino Accardo
- Department of Engineering and Architecture, University of Trieste, Via A. Valerio, 10 - 34127, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447 - 34149, Trieste, Italy.
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17
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Purroy F, Vicente-Pascual M, Arque G, Baraldes-Rovira M, Begue R, Gallego Y, Gil MI, Gil-Villar MP, Mauri G, Quilez A, Sanahuja J, Vazquez-Justes D. Sex-Related Differences in Clinical Features, Neuroimaging, and Long-Term Prognosis After Transient Ischemic Attack. Stroke 2021; 52:424-433. [PMID: 33493055 PMCID: PMC7834662 DOI: 10.1161/strokeaha.120.032814] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Differences in sex in the incidence, presentation, and outcome of events after ischemic stroke have been studied in depth. In contrast, only limited data are available after transient ischemic attack (TIA). We aim to assess sex-related differences in the presentation, cause, neuroimaging features, and predictors of long-term prognosis in patients with TIA.
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Affiliation(s)
- Francisco Purroy
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Mikel Vicente-Pascual
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Gloria Arque
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Mariona Baraldes-Rovira
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Robert Begue
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Yhovany Gallego
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - M Isabel Gil
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - M Pilar Gil-Villar
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Gerard Mauri
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Alejandro Quilez
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Jordi Sanahuja
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Daniel Vazquez-Justes
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
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Acute ischemic stroke versus transient ischemic attack: Differential plaque morphological features in symptomatic intracranial atherosclerotic lesions. Atherosclerosis 2021; 319:72-78. [PMID: 33486353 DOI: 10.1016/j.atherosclerosis.2021.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/18/2020] [Accepted: 01/06/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIMS Intracranial atherosclerotic disease (ICAD) is a major etiologic cause for acute ischemic stroke (AIS) and transient ischemic attack (TIA). The study was designed to investigate if differential morphological features exist in symptomatic atherosclerotic lesions between AIS and TIA patients. METHODS The culprit plaques from 45 AIS patients and 42 TIA patients were analyzed for the degree of stenosis, vessel wall irregularity, normalized wall index (NWI), remodeling index, plaque-wall contrast ratio (CR), high signal intensity on T1-weighted images, plaque enhancement ratio and enhancement grade. These plaque features along with clinical characteristics were compared between AIS and TIA groups as well as between their stenosis degree-matched subgroups. RESULTS Overall, grade 2 enhancement (OR 3.85, 95%CI 1.42-10.46, p = 0.006) and hyperlipidemia (OR 3.04, 95%CI 1.13-8.22, p = 0.025) were independent indicators for AIS, whereas high NWI (OR 1.47, 95%CI 0.76-2.86, p = 0.004) was associated with TIA. In the comparison between the subgroups with moderate (30%-69%) stenosis, high plaque-wall CR (OR 5.38, 95%CI 1.39-20.75, p = 0.008) was associated with AIS, whereas high NWI (OR 2.50, 95%CI 0.61-10.00, p = 0.006) was associated with TIA. CONCLUSIONS Our study reveals differential morphological features in symptomatic ICAD lesions between AIS and TIA patients. Probing these features with MR vessel wall imaging may provide insights into the prognosis of patients with ICAD.
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Scott IU, Campochiaro PA, Newman NJ, Biousse V. Retinal vascular occlusions. Lancet 2020; 396:1927-1940. [PMID: 33308475 PMCID: PMC9546635 DOI: 10.1016/s0140-6736(20)31559-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/29/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022]
Abstract
Acute retinal vascular occlusions are common causes of visual impairment. Although both retinal artery occlusions and retinal vein occlusions are associated with increased age and cardiovascular risk factors, their pathophysiology, systemic implications, and management differ substantially. Acute management of retinal artery occlusions involves a multidisciplinary approach including neurologists with stroke expertise, whereas treatment of retinal vein occlusions is provided by ophthalmologists. Optimisation of systemic risk factors by patients' primary care providers is an important component of the management of these two disorders.
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Affiliation(s)
- Ingrid U Scott
- Department of Ophthalmology and Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Peter A Campochiaro
- Department of Ophthalmology and Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
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20
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Jeeva-Patel T, Kabanovski A, Margolin E. Transient Monocular Visual Loss: When Is It an Emergency? J Emerg Med 2020; 60:192-196. [PMID: 33277110 DOI: 10.1016/j.jemermed.2020.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/14/2020] [Accepted: 10/04/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients who experienced transient monocular vision loss (TMVL) commonly present to the emergency department for evaluation. Although multiple etiologies can cause TMVL, it is most important to identify patients with retinal ischemia and those with vasculitis (giant cell arteritis) as the cause of TMVL. Patients with transient retinal ischemia have the same risk of cardiovascular events and death as patients who experienced transient brain ischemia. Patients with giant cell arteritis are at imminent risk of visual loss. CASE REPORT A 65-year-old man noticed three separate episodes of sudden onset of blurry vision in one eye. Ophthalmologic examination was normal but, as his symptoms were compatible with transient retinal ischemic attack, urgent investigations were initiated. He had normal inflammatory markers but computed tomography angiogram of the brain and neck demonstrated a large plaque in the ipsilateral internal carotid artery. Double anti-platelet therapy was started and stenting of the involved carotid artery was performed. The patient was symptom-free at the last follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with retinal ischemia as the etiology of TMVL are at high risk of cardiovascular events and death. Their risk of cerebrovascular accidents is highest within 48 h from the episode of TMVL, thus they should have an urgent ophthalmologic examination and, if it is unrevealing, inflammatory markers should be checked and an urgent stroke prevention protocol should be initiated. Appropriate management with medical or surgical interventions significantly reduces morbidity and mortality in these patients.
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Affiliation(s)
- Trishal Jeeva-Patel
- Department Ophthalmology and Vision Sciences, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
| | - Anna Kabanovski
- Faculty of Medicine, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
| | - Edward Margolin
- Department Ophthalmology and Vision Sciences, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
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21
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Reduction in Stroke After Transient Ischemic Attack in a Province-Wide Cohort Between 2003 and 2015. Can J Neurol Sci 2020; 48:335-343. [PMID: 32959741 DOI: 10.1017/cjn.2020.205] [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: 11/07/2022]
Abstract
BACKGROUND Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province. METHODS Using administrative data from the Canadian Institute for Health Information's (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015. RESULTS From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001). INTERPRETATION At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.
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Foschi M, Pavolucci L, Rondelli F, Spinardi L, Favaretto E, Filippini M, Degli Esposti D, Strocchi E, Faggioli G, Cortelli P, Guarino M. Prospective observational cohort study of early recurrent TIA: Features, frequency, and outcome. Neurology 2020; 95:e1733-e1744. [PMID: 32727840 DOI: 10.1212/wnl.0000000000010317] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 04/06/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To evaluate the frequency, clinical and etiologic features, and short- and long-term outcomes of early recurrent TIA. METHODS This prospective observational cohort study enrolled all consecutive patients with TIA referred to our emergency department and diagnosed by a vascular neurologist. Expedited assessment and best secondary prevention were performed within 24 hours. Primary endpoints were stroke and a composite outcome including stroke, acute coronary syndrome, and vascular death at 3, 12, and, for a subset of patients, 60 months; secondary outcomes were TIA relapse, cerebral hemorrhage, new-onset atrial fibrillation, and death resulting from other causes. Concordance between index TIA and subsequent stroke etiologies was also evaluated. RESULTS A total of 1,035 patients (822 with a single TIA, 213 with recurrent TIA = 21%) were enrolled from August 2010 to December 2017. Capsular warning syndrome and large artery atherosclerosis showed the strongest relationship with early recurrent TIA. The risk of stroke was significantly higher in the early recurrent TIA subgroup at each follow-up, and most stroke episodes occurred within 48 hours of index TIA. TIAs with lesion, dysarthria, and leukoaraiosis were the 3- and 12-month independent predictors of stroke incidence after early recurrent TIA subgroup. Index TIA and subsequent stroke etiologies showed substantial concordance. An ABCD3 score >6 predicted a higher risk of stroke recurrence over the entire follow-up. CONCLUSIONS Our study evaluated long-term outcome after early recurrent TIA. Our observations support the importance of promptly detecting and treating patients with early recurrent TIAs to reduce the high early and long-term risk of poor clinical outcomes.
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Affiliation(s)
- Matteo Foschi
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Lucia Pavolucci
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Francesca Rondelli
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Luca Spinardi
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Elisabetta Favaretto
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Massimo Filippini
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Daniela Degli Esposti
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Enrico Strocchi
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Gianluca Faggioli
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Pietro Cortelli
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy
| | - Maria Guarino
- From the Neurology Unit (M.F., L.P., F.R., M.G.), Neuroradiology Unit (L.S.), Angiology and Blood Coagulation Unit (E.F., M.F.), Internal Medicine Unit (D.D.E., E.S.), and Vascular Surgery Unit (G.F.), S. Orsola-Malpighi University Hospital; and IRCCS Istituto delle Scienze Neurologiche di Bologna (F.R., P.C., M.G.), Italy.
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e-Health vs COVID-19: home patient telemonitoring to maintain TIA continuum of care. Neurol Sci 2020; 41:2023-2024. [PMID: 32607851 PMCID: PMC7324905 DOI: 10.1007/s10072-020-04524-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/20/2020] [Indexed: 10/31/2022]
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Lodha N, Patel P, Harrell J, Casamento-Moran A, Zablocki V, Christou EA, Poisson SN. Motor impairments in transient ischemic attack increase the odds of a positive diffusion-weighted imaging: A meta-analysis. Restor Neurol Neurosci 2020; 37:509-521. [PMID: 31594263 DOI: 10.3233/rnn-190940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Unilateral motor impairment is a key symptom used in the diagnosis of transient ischemic attack (TIA). Diffusion-weighted imaging (DWI) is a promising diagnostic tool for detecting ischemic lesions. While both motor impairments and DWI abnormalities are linked to the diagnosis of TIA, the association between these prognostic factors is not well understood. OBJECTIVE To examine the association between unilateral motor impairments and the odds of a positive DWI in TIA. Further, to determine whether the time between symptom onset and neuroimaging (delay to scan) influences the odds of a positive DWI. METHODS We used PRISMA guidelines to conduct a systematic search from 1989 to 2018. We included studies that reported number of individuals with/without unilateral motor symptoms and a positive/negative DWI. RESULTS Twenty-four studies from North America, Australia, Asia, and Europe were submitted to a meta-analysis. A pooled odds ratio of 1.80 (95% CI, 1.45-2.24, p = 0.00; I2 = 57.38) suggested that the odds of a positive DWI are greater in TIA individuals who experience motor symptoms as compared with those who experience no motor symptoms. Further, increasing the time delay to scan from the symptom onset (>2 days) did not influence the odds of a positive DWI as compared with an earlier scan (≤2 days). CONCLUSIONS The current meta-analysis provides cumulative evidence from 6710 individuals with TIA that the presence of motor symptoms increases the odds of a positive DWI by two-folds. These findings transform the clinical perception into evidence-based knowledge that motor impairments elevate the risk for brain tissue damage. Unilateral motor impairments in a cerebrovascular event should increase a physician's suspicion of detecting brain infarctions. These findings may influence the clinical management of TIA by generating faster response to motor impairments in TIA and accelerating referral to specialized stroke clinic.
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Affiliation(s)
- Neha Lodha
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Prakruti Patel
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Jane Harrell
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | | | - Victoria Zablocki
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Evangelos A Christou
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Sharon N Poisson
- Department of Neurology, University of Colorado, Aurora, CO, USA
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25
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NT-pro-BNP: A novel predictor of stroke risk after transient ischemic attack. Int J Cardiol 2020; 298:93-97. [DOI: 10.1016/j.ijcard.2019.06.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/20/2019] [Accepted: 06/19/2019] [Indexed: 11/22/2022]
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Blythe R, Kularatna S, White N, Graves N, Clark K, Middleton H, Grimley R. Fits, faints, falls and funny turns: cost and capacity savings in Queensland from the accelerated transient attack pathway initiative (ATAP). Age Ageing 2019; 48:745-750. [PMID: 31297515 DOI: 10.1093/ageing/afz086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/15/2019] [Accepted: 06/19/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND falls, seizures, syncope and transient ischaemic attacks (TIA) are common presentations to emergency departments sharing overlapping clinical features and diagnostic uncertainties. These transient attacks can be markers of serious adverse outcomes and are associated with high admission rates. We evaluated the effects of an integrated suite of pathways for transient attacks designed to improve adherence to best practices and reduce costs through fewer admissions. METHODS a suite of clinician-designed pathways based on initial presenting diagnosis was developed to support ambulant care in a large hospital in Queensland, Australia. We performed a set of regression analyses to identify the differences in total cost and length of stay (LOS) before and after implementation. We conducted a Monte Carlo simulation to estimate the cost savings of the freed capacity in the patient cohort. RESULTS pathway implementation was associated with reduced admitted LOS and costs. Falls patients admitted LOS declined by 32.5%, and admission costs by 19.5%. Syncope, seizure, and TIA patients admitted LOS declined by 22% with no change in admitted costs. Despite a small increase in 90-day representations, total emergency department LOS was unchanged. Emergency department costs were similar between falls and non-falls patients. The Monte Carlo analysis showed that the most likely outcome was a cost savings in freed capacity of $71 per patient episode. CONCLUSION the ATAP suite of pathways was associated with reduction in LOS, release of capacity and reduction in costs. Further study is needed to evaluate mechanisms and clinical outcomes in this vulnerable population.
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Affiliation(s)
- Robin Blythe
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queenland University of Technology, Kelvin Grove, Queensland, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queenland University of Technology, Kelvin Grove, Queensland, Australia
| | - Nicole White
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queenland University of Technology, Kelvin Grove, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queenland University of Technology, Kelvin Grove, Queensland, Australia
| | - Kevin Clark
- Metro North Hospital and Health Service, Brisbane, Australia
| | | | - Rohan Grimley
- Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
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Rogers JM, Bechara J, Middleton S, Johnstone SJ. Acute EEG Patterns Associated With Transient Ischemic Attack. Clin EEG Neurosci 2019; 50:196-204. [PMID: 30045636 DOI: 10.1177/1550059418790708] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Transient ischemic attack (TIA) is characterized by stroke-like neurologic signs and symptoms in the absence of demonstrable structural neuropathology. There is no test for TIA, with classification often reliant on subjective, retrospective report. Functional brain measures such as the electroencephalogram (EEG) may be helpful in objectively detecting and describing the pathophysiology of TIA, but this has not been adequately examined. METHODS EEG was obtained from a single electrode over the left frontal lobe during 3-minute resting-state and auditory oddball conditions administered to consecutive patients within 72 hours of admission to the acute stroke ward of a tertiary hospital. Separately, patients were classified by their treating team as having suffered either an ischemic stroke (n = 10) or a TIA (n = 10). Relative power of delta, theta, alpha, and beta EEG frequency bands were extracted for comparison between the 2 clinical groups and an existing normative sample of 10 healthy, age-, gender-, and education-matched older adults. RESULTS Analysis of variance with post hoc testing identified pronounced delta activity in stroke patients, while alpha and beta power were elevated in TIA patients. Both patient groups exhibited attenuated theta activity compared with healthy controls. Receiver operating characteristic curve analysis identified thresholds for each EEG frequency capable of distinguishing the 3 participant groups. CONCLUSIONS TIA, ischemic stroke, and healthy aging are each associated with distinct electrophysiological profiles. These preliminary findings suggest that acute EEG may be helpful in elucidating the pathophysiology and reversibility of TIA symptoms, and further exploration of the value of this unique functional brain data is encouraged.
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Affiliation(s)
- Jeffrey M Rogers
- 1 Department of Psychology, Prince of Wales Hospital, Randwick, New South Wales, Australia.,2 Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Jacob Bechara
- 3 School of Psychology, Australian Catholic University, Sydney, New South Wales, Australia
| | - Sandy Middleton
- 4 Nursing Research Institute, St Vincent's Health Australia and Australian Catholic University, Sydney, New South Wales, Australia
| | - Stuart J Johnstone
- 5 School of Psychology and Brain & Behaviour Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
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Zonneveld TP, Richard E, Vergouwen MDI, Nederkoorn PJ, de Haan RJ, Roos YBWEM, Kruyt ND. Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack. Cochrane Database Syst Rev 2018; 7:CD007858. [PMID: 30024023 PMCID: PMC6513249 DOI: 10.1002/14651858.cd007858.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Stroke is an important cause of death and disability worldwide. Since high blood pressure is an important risk factor for stroke and stroke recurrence, drugs that lower blood pressure might play an important role in secondary stroke prevention. OBJECTIVES To investigate whether blood pressure-lowering drugs (BPLDs) started at least 48 hours after the index event are effective for the prevention of recurrent stroke, major vascular events, and dementia in people with stroke or transient ischaemic attack (TIA). Secondary objectives were to identify subgroups of people in which BPLDs are effective, and to investigate the optimum systolic blood pressure target after stroke or TIA for preventing recurrent stroke, major vascular events, and dementia. SEARCH METHODS In August 2017, we searched the Trials Registers of the Cochrane Stroke Group and the Cochrane Hypertension Group, the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), MEDLINE Ovid (1946 to August 2017), Embase Ovid (1974 to August 2017), ClinicalTrials.gov, the ISRCTN Registry, Stroke Trials Registry, Trials Central, and the World Health Organization (WHO) International Clinical Trials Registry Platform Portal. SELECTION CRITERIA Randomised controlled trials (RCTs) of BPLDs started at least 48 hours after stroke or TIA. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts, selected eligible trials, extracted the data, assessed risk of bias, and used GRADE to assess the quality of the evidence. If necessary, we contacted the principal investigators or corresponding authors for additional data. MAIN RESULTS We included 11 studies involving a total of 38,742 participants: eight studies compared BPLDs versus placebo or no treatment (35,110 participants), and three studies compared different systolic blood pressure targets (3632 participants). The risk of bias varied greatly between included studies. The pooled risk ratios (RRs) of BPLDs were 0.81 (95% confidence interval (CI) 0.70 to 0.93; 8 RCTs; 35,110 participants; moderate-quality evidence), 0.90 (95% CI 0.78 to 1.04; 4 RCTs; 28,630 participants; high-quality evidence) for major vascular event, and 0.88 (95% CI 0.73 to 1.06; 2 RCTs; 6671 participants; high-quality evidence) for dementia. We mainly observed a reduced risk of recurrent stroke in the subgroup of participants using an angiotensin-converting enzyme (ACE) inhibitor or a diuretic (I2 statistic for subgroup differences 72.1%; P = 0.006). The pooled RRs of intensive blood pressure-lowering were 0.80 (95% CI 0.63 to 1.00) for recurrent stroke and 0.58 (95% CI 0.23 to 1.46) for major vascular event. AUTHORS' CONCLUSIONS Our results support the use of BPLDs in people with stroke or TIA for reducing the risk of recurrent stroke. Current evidence is primarily derived from trials studying an ACE inhibitor or a diuretic. No definite conclusions can be drawn from current evidence regarding an optimal systolic blood pressure target after stroke or TIA.
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Affiliation(s)
- Thomas P Zonneveld
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Edo Richard
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
- Radboud University Nijmegen Medical CenterDepartment of Neurology, Donders Institute for Brain, Behaviour and CognitionNijmegenNetherlands
| | - Mervyn DI Vergouwen
- University Medical Center UtrechtBrain Center Rudolf Magnus, Department of Neurology and NeurosurgeryUtrechtNetherlands
| | - Paul J Nederkoorn
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Rob J de Haan
- Amsterdam UMC, University of AmsterdamClinical Research UnitAmsterdamNetherlands
| | - Yvo BWEM Roos
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Nyika D Kruyt
- Leiden University Medical CenterDepartment of NeurologyLeidenNetherlands
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Biousse V, Nahab F, Newman NJ. Management of Acute Retinal Ischemia: Follow the Guidelines! Ophthalmology 2018; 125:1597-1607. [PMID: 29716787 DOI: 10.1016/j.ophtha.2018.03.054] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/25/2018] [Accepted: 03/27/2018] [Indexed: 11/24/2022] Open
Abstract
Acute retinal arterial ischemia, including vascular transient monocular vision loss (TMVL) and branch (BRAO) and central retinal arterial occlusions (CRAO), are ocular and systemic emergencies requiring immediate diagnosis and treatment. Guidelines recommend the combination of urgent brain magnetic resonance imaging with diffusion-weighted imaging, vascular imaging, and clinical assessment to identify TMVL, BRAO, and CRAO patients at highest risk for recurrent stroke, facilitating early preventive treatments to reduce the risk of subsequent stroke and cardiovascular events. Because the risk of stroke is maximum within the first few days after the onset of visual loss, prompt diagnosis and triage are mandatory. Eye care professionals must make a rapid and accurate diagnosis and recognize the need for timely expert intervention by immediately referring patients with acute retinal arterial ischemia to specialized stroke centers without attempting to perform any further testing themselves. The development of local networks prompting collaboration among optometrists, ophthalmologists, and stroke neurologists should facilitate such evaluations, whether in a rapid-access transient ischemic attack clinic, in an emergency department-observation unit, or with hospitalization, depending on local resources.
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Affiliation(s)
- Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
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Mugge L, Mansour TR, Krafcik B, Mazur T, Floyd-Bradstock T, Medhkour A. Immunological, vascular, metabolic, and autonomic changes seen with aging possible implications for poor outcomes in the elderly following decompressive hemicraniectomy for malignant MCA stroke: a critical review. J Neurosurg Sci 2018. [PMID: 29527887 DOI: 10.23736/s0390-5616.18.04207-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Stroke is one of the leading causes of mortality and morbidity worldwide and requires rapid and intensive treatment to prevent adverse outcomes. Decompressive hemicraniectomy stands as the gold standard for surgical resolution of the intracranial swelling which accompanies cerebral infarction; however, the benefits of this procedure are not as well achieved in the elderly (age >65 years) compared to the younger population. EVIDENCE ACQUISITION This is a critical review performed on all available literature relating to middle cerebral artery (MCA) stroke in the elderly with emphasis on articles examining causality of adverse outcomes in this group over younger populations. Utilizing PRISMA guidelines, we initially identified 1462 articles. EVIDENCE SYNTHESIS After screening, four clear areas of physiological change associated with aging were identified and expounded upon as they relate to MCA stroke. These four areas include: immunological, autonomic, mitochondrial, and vascular changes. Elderly patients have a decreased and declining capacity to regulate the inflammation that develops postinfarction and this contributes to adverse outcomes from a neurological stand point. Additionally, aging decreases the ability of elderly patients to regulate their autonomic system resulting in aberrant blood pressures systemically post infarction. With age, the mitochondrial response to ischemia is exaggerated and causes greater local damage in elderly patients compared to younger populations. Finally, there are numerous vascular changes that occur with age including accumulation of homocysteine and atherosclerosis which together contributed to decreased structural integrity of the vasculature in the elderly and render decreased support to the recovery process post infarction. CONCLUSIONS We conclude that physiological changes inherent in the aging process serve to intensify adverse outcomes that are commonly associated with strokes in the elderly. Identification and subsequent minimization of these risk factors could allow for more effective management of elderly patients, post stroke, and promote better clinical outcomes.
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Affiliation(s)
- Luke Mugge
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Tarek R Mansour
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Brianna Krafcik
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Travis Mazur
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Tonya Floyd-Bradstock
- Interprofessional Immersive Simulation Center, University of Toledo Medical Center, Toledo, OH, USA
| | - Azedine Medhkour
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA -
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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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Lodha N, Harrell J, Eisenschenk S, Christou EA. Motor Impairments in Transient Ischemic Attack Increase the Odds of a Subsequent Stroke: A Meta-Analysis. Front Neurol 2017. [PMID: 28638365 PMCID: PMC5461338 DOI: 10.3389/fneur.2017.00243] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background and purpose Transient ischemic attack (TIA) increases the risk for a subsequent stroke. Typical symptoms include motor weakness, gait disturbance, and loss of coordination. The association between the presence of motor impairments during a TIA and the chances of a subsequent stroke has not been examined. In the current meta-analysis, we examine whether the odds of a stroke are greater in TIA individuals who experience motor impairments as compared with those who do not experience motor impairments. Methods We conducted a systematic search of electronic databases as well as manual searches of the reference lists of retrieved articles. The meta-analysis included studies that reported an odds ratio relating motor impairments to a subsequent stroke, or the number of individuals with or without motor impairments who experienced a subsequent stroke. We examined these studies using rigorous meta-analysis techniques including random effects model, forest and funnel plots, I2, publication bias, and fail-safe analysis. Results Twenty-four studies with 15,129 participants from North America, Australia, Asia, and Europe qualified for inclusion. An odds ratio of 2.11 (95% CI, 1.67–2.65, p = 0.000) suggested that the chances of a subsequent stroke are increased by twofolds in individuals who experience motor impairments during a TIA compared with those individuals who have no motor impairments. Conclusion The presence of motor impairments during TIA is a significantly high-risk clinical characteristic for a subsequent stroke. The current evidence for motor impairments following TIA relies exclusively on the clinical reports of unilateral motor weakness. A comprehensive examination of motor impairments in TIA will enhance TIA prognosis and restoration of residual motor impairments.
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Affiliation(s)
- Neha Lodha
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, United States
| | - Jane Harrell
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, United States
| | - Stephan Eisenschenk
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Evangelos A Christou
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, United States
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