Etiopathogenesis of transient ischemic attacks and minor ischemic strokes: a community-based study in Segovia, Spain

Spontaneous calcific cerebral embolization revealing a calcified rheumatic mitral stenosis: a case report

BACKGROUND

Cerebral cardiac embolism accounts for an increasing proportion of ischemic strokes and transient ischemic attacks. Calcified cerebral emboli are rare and mostly iatrogenic secondary to heart or aorta catheterization. However, spontaneous cerebral calcified embolism in the case of calcified aortic valve is very rare and there are less than 10 case reports in the literature. And a more interesting fact is that such an event, in the context of calcified mitral valve disease, has never been reported, at least to our knowledge. We are reporting a case of spontaneous calcified cerebral embolism revealing a calcified rheumatic mitral valve stenosis.

CASE PRESENTATION

We report a case of a 59 year-old Moroccan patient, with a history of rheumatic fever at the age of 14 and no history of recent cardiac intervention or aortic/carotid manipulation, who was admitted to the emergency department after a transient ischemic attack. Physical examination at admission found normal blood pressure of 124/79 mmHg and heart rate of 90 bpm. A 12-lead electrocardiogram showed an atrial fibrillation, no other anomalies. Unenhanced cerebral computed tomography imaging was performed, revealing calcified material inside both middle cerebral arteries. Transthoracic echocardiography was performed, showing severe mitral leaflets calcification with a severe mitral stenosis, probably due to rheumatic heart disease. Cervical arteries Duplex was normal. A vitamin K antagonist (acenocoumarol) was prescribed, targeting an international normalized ratio of 2-3 and mitral valve replacement surgery was performed using mechanical prosthesis. Short- and long-term health, with a 1-year follow-up, were good and the patient did not experience any stroke.

CONCLUSION

Spontaneous calcified cerebral emboli secondary to mitral valve leaflet calcifications is an extremely rare condition. Replacement of the valve is the only option to prevent recurrent emboli and outcomes are still to be determined.

Usefulness of multiphase computed tomography angiography in a patient with transient ischemic attack in the hyperacute phase: A case report

RATIONALE

Patients with transient ischemic attack (TIA) have the possibility of developing stroke in the future. To prevent recurrent TIA or future stroke, identifying the cause of TIA is important. However, about two-third of patients with TIA have negative findings on diffusion-weighted imaging (DWI).We present a case of TIA, the cause of which was identified using multiphase computed tomography angiography (MCTA) in the hyperacute phase of the disease.

PATIENT CONCERNS

The patient was a 57-year-old man who was admitted to the emergency department for right-side weakness persisting for 1 hour.

DIAGNOSES

Occlusion of the proximal M3 segment of the left middle cerebral artery territory was found on the initial MCTA.

OUTCOMES

The weakness completely resolved at 2 hours after symptom onset, and there was no acute infarction on the initial diffusion-weighted magnetic resonance imaging (MRI) on the same day. Follow-up MCTA on the next day showed recanalization of the left M3 segment. Follow-up diffusion-weighted MRI showed focal acute infarction in the left middle cerebral artery territory.

LESSONS

MCTA could identify distal occlusion of the anterior circulation in patients with cardioembolic TIA in the hyperacute phase with negative DWI findings.

Clinical characteristics of cardioembolic transient ischemic attack: comparison with noncardioembolic transient ischemic attack

BACKGROUND

Previous studies show that 6%-31% of transient ischemic attacks (TIA) were caused by cardiogenic cerebral embolism (cardioembolic TIA). As prompt initiation of therapy is essential in TIA to prevent subsequent strokes, determining their cause is important. In this study, we aim to determine the features of cardioembolic TIA and to compare them with those of noncardioembolic etiology.

METHODS

We retrospectively reviewed patients with a tissue-defined TIA who were admitted to our hospital from April 2007 to August 2013. The etiology was categorized according to Trial of Org 10172 in Acute Stroke Treatment, and TIA of cardioembolic origin and cervicocerebrovascular etiology (noncardioembolic TIA) were included in this study. Those with 2 or more possible causes or undetermined etiologies were excluded. Age, sex, comorbidities, ABCD2 score, and CHADS2 score were assessed and compared between the 2 groups.

RESULTS

There were no significant differences in the neurologic symptoms and their duration, morbidities of hypertension, diabetes, and dyslipidemia between the 2 groups. Coronary and peripheral artery diseases were more common in the cardioembolic TIA group (18.4% vs. 6.9%). Incidences of prior stroke and cerebral infarction determined by MRI were similar between the 2 groups. The ABCD2 score showed a similar distribution, but the CHADS2 score was significantly different; the cardioembolic TIA group showed a higher score (P = .005).

CONCLUSIONS

Clinical features are similar in tissue-defined TIA of cardioembolic and noncardioembolic etiologies. The CHADS2 score can be useful in assessing the probability of cardioembolic TIA.

[Classification of etiologic subtypes for transient ischemic attacks: clinical significance of lacunar transient ischemic attack]

BACKGROUND

Lacunar transient ischemic attack (lacunar TIA) may have been underestimated because of diagnostic difficulties. The aim of our study was to classify TIAs by etiologic subtypes, especially using defined criteria for diagnosis of lacunar TIA and clarify clinical characteristics of lacunar TIA.

METHOD

105 TIA patients out of consecutive 1,244 patients with acute ischemic stroke admitted to our hospital between January 2007 and June 2010 were enrolled in the present study. TIA was defined as an acute focal neurological deficit lasting less than 24 hours, suspected to be of cerebrovascular origin regardless of ischemic lesions on MRI. TIAs were classified to 5 etiologic subtypes; (1) cardioembolic TIA, (2) atherothrombotic TIA, (3) lacunar TIA, (4) other etiologies, and (5) undetermined etiology and clinical characteristics in each subtype and the incidence of recurrent stroke after TIA were investigated. Lacunar TIA was diagnosed if the following criteria were fulfilled; (1) presence of lacunar infarct on MRI and/or the presence of unilateral dysfunction of at least two of three body parts (face, arm, leg) in the absence of cortical dysfunction presumed due to subcortical ischemia. (2) absence of cardiac sources of embolism and large artery atherosclerosis.

RESULTS

In 105 patients with TIA, lacunar TIA was the most frequent etiology (31%) followed by cardioembolic TIA (27%), atherothrombotic TIA (19%), undetermined etiology (18%), and other etiologies (6%). In patients with lacunar TIA, history of repeated TIA was more frequent and systolic blood pressure on admission was higher significantly than in cardioembolic TIA. Six of 105 patients had experienced recurrent stroke after TIA during admission. Among these 6 patients, 3 patients were diagnosed as lacunar infarctions.

CONCLUSIONS

Lacunar TIA was most common TIA subtype in the present study. It is critical to identify lacunar TIA on admission because some patients with lacunar TIAs experience early recurrent stroke.

Joint effects of risk factors for stroke and transient ischemic attack in a German population

BACKGROUND

Single, modifiable risk factors for stroke have extensively been studied. In contrast, differences of their combined effects among stroke and transitoy ischemic attack (TIA) have been rarely investigated. The aim of the present study was to assess single and joint effects of risk factors on the incidence of stroke and TIA and to compare their magnitudes in a large population-based German cohort.

METHODS

Incident cases of stroke and TIA were identified among 25,538 participants (aged 35-65 at baseline) of the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study. Relative risks for stroke and TIA related to modifiable risk factors were estimated using Cox proportional hazard models.

RESULTS

During 4.3 years of follow-up 100 stroke cases and 112 TIA cases occurred. Incidences of stroke and TIA were 91.7 and 102.7 per 100,000 person-years, respectively. Relative risks for ischemic stroke (RR 5.12, 95% CI 1.49-17.6, p for trend<0.0001) and for TIA (RR 3.08, 95% CI 1.00-9.44, p for trend<0.024) were highest among participants having 4 or 5 modifiable risk factors. 58.5% of ischemic strokes and 26.2% of TIA cases were attributable to the 5 risk factors hypertension, diabetes mellitus, high alcohol consumption, hyperlipidemia, and smoking.

CONCLUSION

Our data indicate that classical risk factors may explain almost 60% of ischemic stroke but only one in four TIA cases. Analysing potential differences of known risk factors between ischemic stroke and TIAs and the identification of other determinants of ischemic attacks are important steps to better explain the burden of stroke.

Differential risks of subsequent vascular events for transient ischaemic attack and minor ischaemic stroke

Using a prospective hospital-based registry, 146 patients with transient ischaemic attack (TIA) were compared with 376 patients with minor first-ever ischaemic stroke with respect to the 3-month risk of subsequent vascular events, in order to clarify the distinctions between the disease entities. All patients were enrolled within 48 h of onset. The risk factor distribution for the two groups was comparable, except that the TIA patients had more previous TIAs. Large artery atherosclerosis (34%) and small vessel occlusion (32%) were the main aetiologies in the TIA group, whereas small vessel occlusion (49%) was the major cause in the stroke group. The 3-month risk of combined endpoints of stroke, myocardial infarction, and vascular death for TIA patients was higher than that for the minor stroke group (15.1% vs. 3.2%; hazard ratio 4.6, 95% confidence interval 2.3-9.3 in multivariate analysis). Large artery atherosclerosis and male sex were the other significant predictors. TIA may demand more urgent management than minor stroke. The fact that aetiology is a predictor, highlights the need for rapid diagnostic tests to establish pathogenesis.

Imaging findings and referral outcomes of rapid assessment stroke clinics

AIM

A rapid assessment stroke clinic (RASC) was established to provide a rapid diagnostic service to individuals with suspected transient cerebral or ocular ischaemia or recovered non-hospitalized strokes. In this report we review imaging findings and clinical outcomes of patients proceeding to the carotid surgery programme.

METHODS

Between October 2000 and December 2002, 1339 people attended the RASC. The findings of head CT and carotid Doppler ultrasound of the 1320 patients who underwent brain and carotid imaging were reviewed, and the number subsequently proceeding to carotid angiography and intervention was reported.

RESULTS

CT head scans were normal in 57% of cases; 38% demonstrated ischaemia or infarction; and 3% yielded incidental or other significant findings not related to ischaemia. On screening with carotid Doppler ultrasound, 7.5% showed greater than 50% stenosis on the symptomatic side. A total of 83 patients (6.2%) proceeded to cerebral angiography and 65 (4.8%) underwent carotid endarterectomy or endovascular repair.

CONCLUSION

Rapid-access neurovascular clinics are efficient in selecting patients for carotid intervention, but this is at a cost and the number of potential strokes prevented is small. Alternative management pathways based on immediate medical treatment need to be evaluated.

Symptome, Risikofaktoren und Ätiologie von transitorisch ischämischer Attacke und Schlaganfall

BACKGROUND

It is unclear whether clinical signs and symptoms differ in the presentation of transient ischemic attack (TIA) and stroke, apart from temporal dynamics.

METHODS

Signs and symptoms of patients diagnosed with TIA or stroke were prospectively collected and compared by means of an age-adjusted logistic regression analysis. Risk factors, prehospital medication, and diagnostic workup were obtained from the charts.

RESULTS

Four hundred five patients diagnosed with stroke (68+/-12 years old, 45% female) and 143 diagnosed with TIA (64+/-14 years old, 48% female) were included. Signs and symptoms of patients with TIA were less often "classic" such as paresis (48% vs 71%, P<0.001) or sensory loss (38% vs 48%, P=0.03). The etiology of TIA was more often classified as "undetermined" (57% vs 46%, P<0.05).

CONCLUSIONS

Transient ischemic attack needs special attention and intensive diagnostic workup, because it bears a considerable risk of death and disability but presents less often with classic signs and symptoms and its etiology often remains undetermined.

Endothelin and erectile dysfunction: a target for pharmacological intervention?

Although erectile dysfunction (ED) is not life threatening, this common problem can significantly affect the quality of life and psychological and social well-being. The Massachusetts male ageing study (1,290 men aged 40 - 70 years) showed that 52% of men reported some degree of ED (17.1% mild, 25.2% moderate, 9.6% total). In the UK, an estimated 17 - 19% of men are thought to suffer from ED. This problem is more common with advancing age and since this proportion of the population is increasing, the prevalence of ED is expected to rise. Endothelin-1 (ET-1) belongs to a family of potent vasoconstrictor peptides consisting of 21 amino acids. We review the evidence showing that ET-1 plays a role via (ET(A) and ET(B) receptors) in the regulation of cavernosal smooth muscle tone. We also consider the various risk factors that are involved in the pathogenesis of ED and how these relate to the action of ET-1. In particular, the role of diabetes, hypertension, smoking and dyslipidaemia are discussed. The pharmaceutical industry has declared an interest in the development of ET antagonists for use in the treatment of various diseases including ED. We briefly comment on experimental ET-1 antagonists that may be of therapeutic benefit in ED.

Cerebral emboli in cryptogenic ischemia: A reason to enforce diagnostic testing

BACKGROUND

Stroke of unknown origin is a diagnostic and therapeutic challenge. A subgroup-analysis was performed to evaluate microembolus detection in these cryptogenic strokes.

METHODS AND RESULTS

In this study, 78 patients with acute cerebral ischemia in the anterior circulation were monitored for microembolic signals (MES) by the use of transcranial doppler at admittance and 2 times at 24-hour intervals. All patients underwent routine stroke work-up. Twenty patients presented with cryptogenic ischemia. Of these 20 patients, 30% (6/20) showed MES during examination 1, 20% (4/20) in examination 2, and 20% (4/20) in examination 3.

CONCLUSION

MES could be detected in 45% of patients with cryptogenic ischemia. Thus, the underlying pathology may be in part embolic. The detection of MES in cryptogenic ischemia should therefore be an argument for extensive retesting to maybe identify a potential embolic source.