Significance of Nonfocal Symptoms in Patients With Transient Ischemic Attack

Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness

Diagnosing patients presenting to the emergency department with self-limited episodes of isolated dizziness (the episodic vestibular syndrome) requires a broad differential diagnosis that includes posterior circulation transient ischemic attack. Because these patients are, by definition, asymptomatic without new neurologic findings on examination, the diagnosis, largely based on history and epidemiologic context, can be challenging. We review literature that addresses the frequency of posterior circulation transient ischemic attack in this group of patients compared with other potential causes of episodic vestibular syndrome. We present ways of distinguishing posterior circulation transient ischemic attack from vestibular migraine, the most common cause of episodic vestibular syndrome. We also present a diagnostic algorithm that may help clinicians to work their way through the differential diagnosis.

Unconsciousness as the main nonfocal symptom of anterior circulation transient ischemic attack: A case report

RATIONALE

Unconsciousness is a nonfocal symptom of transient ischemic attack (TIA) that is frequently observed in patients with vertebrobasilar artery stenosis or occlusion. Conversely, loss of consciousness due to anterior circulation involvement (e.g., middle cerebral artery [MCA]) is a rare occurrence in TIA.

PATIENT CONCERNS

This report describes a rare case in a 59-year-old woman who experienced recurrent episodes of altered consciousness because of the occlusion or stenosis of her MCAs.

DIAGNOSES

The diagnosis of the case was updated from TIA to acute cerebral infarction, finally. Following initial loss of consciousness, cranial magnetic resonance imaging (MRI) did not reveal any evidence of acute cerebral infarction. However, following the second and third episodes of unconsciousness, the MRI revealed multiple new acute cerebral infarcts affecting both the cerebral hemispheres. Further evaluation through digital subtraction angiography disclosed complete occlusion of the left MCA and severe stenosis of the right MCA.

INTERVENTIONS

Early in her illness, the patient was treated with vasodilators, aspirin and atorvastatin. Finally, 2 stents in her right and left MCAs were placed respectively, followed by treatment with aspirin, clopidogrel, and double-dosed atorvastatin calcium. Meanwhile, the patient focused on avoiding conditions which may lead to dehydration in her daily life routine.

OUTCOMES

The episodes of unconsciousness of this patient were completely resolved. During the 1-year postoperative follow-up, the patient remained clinically stable without any symptoms of unconsciousness, limb numbness or weakness, or dizziness.

LESSONS

These findings suggested that hypoperfusion in the bilateral cerebral hemispheres played a pivotal role in precipitating the patient episodes of unconsciousness. This case underscores the possibility that occlusion or severe stenosis in both MCAs can contribute to recurrent episodes of unconsciousness due to hypoperfusion. Moreover, it emphasizes the association between these episodes of unconsciousness and an increased risk of subsequent ischemic stroke.

The Impact of Sex and Gender on Stroke

Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.

Stroke Risk in Patients with Suspected Transient Ischemic Attacks with Focal and Nonfocal Symptoms: A Prospective Study

OBJECTIVES

The aim was to investigate triage methods for suspected transient ischemic attacks (TIAs) with focal or nonfocal symptoms.

MATERIALS AND METHODS

In total, 350 patients with suspected TIAs were enrolled and followed for one year. Potential high-risk factors for TIAs, such as atrial fibrillation, carotid artery stenosis, crescendo TIA, and ABCD2 score ≥ 4, were evaluated. Patients were classified into 3 groups according to the initial neurological symptoms: focal, nonfocal, and mixed (both focal and nonfocal) groups. Stroke-free survival rates were compared via Kaplan-Meier analysis.

RESULTS

Diffusion-weighted MRI (DWI) was performed for 89.8% of the patients within 7 days, and the frequency of acute brain infarction on DWI was significantly lower in the nonfocal group (focal, 24.1%; nonfocal, 7.2%; mixed, 22.2%; P < .01). There was no significant difference in the one-year event-free survival rates across the groups. Significantly higher stroke risk was observed in patients with one or more high-risk categories or the ABCD2 score (≥ 4) in the focal group (P = .021 and .26, respectively), whereas no significant difference was observed in the other groups. Across all symptom groups, significantly higher stroke risk was observed in patients showing acute infarcts on DWI evaluated within 7 days.

CONCLUSIONS

Both high-risk categorization (≥ 1 potential high-risk factors) and ABCD2 score (≥ 4) alone were useful tools for identifying higher stroke risk in patients with focal symptom but not with nonfocal symptoms in isolation. Further studies are warranted in triage methods for TIA with nonfocal in isolation in conjunction with DWI.

Application of neutrophil to lymphocyte ratio to identify CT-negative cerebral infarction with nonfocal symptoms

Background

The neutrophil to lymphocyte ratio (NLR) has emerged as a strong predictor of mortality in stroke patients. Our study aimed to investigate the correlation between NLR and cerebral infarction with nonfocal symptoms confirmed by diffusion-weighted imaging (DWI) (+).

Methods

A total of 439 patients with nonfocal stroke symptoms with CT-negative findings were included from January 1 to December 31, 2018. All patients underwent a head MRI examination within seven days following a head CT examination. The patients’ demographics, medical history, presenting symptoms, and stroke location were recorded. Logistic regression and receiver operating characteristic (ROC) curve analysis were used to identify variables with a significant association with cerebral infarction.

Results

Cerebral infarction was detected in 79 (18%) patients confirmed by DWI(+), located mostly in the cerebellum (40.51%). Dizziness (85.19%) was the most common symptom. The cerebral infarction group showed a higher prevalence of hypertension (P<0.0001), diabetes mellitus (P<0.0001), and smoking status (P=0.001) than non-cerebral infarction group. The NLR (P<0.0001) was higher in the cerebral infarction group. There was no significant difference in NIHSS (P=0.09). Logistic analysis revealed that male gender (P=0.046), a history of hypertension (P=0.001), diabetes mellitus (P=0.001), smoking (P=0.023), and NLR (P<0.0001) were the best predictors of cerebral infarction. When integrating sex, hypertension, diabetes mellitus, smoking and NLR, the area under ROC value of the combined method was 0.785, higher than any separate parameters (P<0.05).

Conclusions

NLR combined with male gender, a history of hypertension, diabetes mellitus, and smoking, could predict DWI-confirmed cerebral infarction with nonfocal neurologic symptoms with high diagnostic accuracy.

One-year prognosis of transient ischemic attacks with nonfocal symptoms

OBJECTIVE

A few studies suggested an increased risk of stroke or coronary heart disease in patients with transient ischemic attacks (TIA) presenting with nonfocal symptoms. We aimed to assess the vascular prognosis of TIA patients with and without accompanying nonfocal symptoms.

PATIENTS AND METHODS

Observational study of consecutive patients with TIA referred to a TIA Clinic from March 2004 to March 2011. Primary outcome was the composite of any event: stroke, TIA, myocardial infarction (MI) or vascular death in the first year of follow-up; secondary outcomes included individual components of the primary outcome. Hazard ratios were calculated with Cox regression.

RESULTS

429 TIA patients were enrolled, 329 (76.7 %) with only focal symptoms, and 100 (23.3 %) with both focal and nonfocal symptoms. In the first year after TIA, the primary outcome occurred in 65 patients (16.0 %; 95 % CI, 12 %-19 %): stroke, in 28 patients; TIA, in 31 patients; MI and vascular death in two patients each. The frequency of the composite outcome was similar in patients with or without nonfocal symptoms (16 events (17.0 %; 95 % CI, 10-24) vs. 49 events (15.7 %; 95 % CI, 12-20 %); p = 0.430). There were no significantly differences in the frequency of any of the secondary outcomes between patients with or without nonfocal symptoms.

CONCLUSION

Almost one-fourth of TIA patients reported concomitant nonfocal symptoms, but they had the same risk of stroke and cardiovascular events as patients with isolated focal symptoms.

Errors in the Diagnosis of Stroke-Tales of Common Stroke Mimics and Strokes in Hiding

Introduction:

Stroke mimics are some of the common causes of misdiagnosis of stroke, with an attendant surfeit of finances and resources.

Aim:

We attempt to discuss some of the common neurological conditions mimicking stroke in the emergency.

Methods:

We reviewed the articles in English discussing stroke mimics in the last 5 years of publication.

Purpose of the Review:

We discuss the most common causes of stroke mimics encountered in neurological practice. In this short communication, we shall focus on the discussion of the diagnostic pitfalls and clinical clues that will help distinguish mimics from a true stroke.