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Shu C, Zheng C, Luo D, Song J, Jiang Z, Ge L. Acute ischemic stroke prediction and predictive factors analysis using hematological indicators in elderly hypertensives post-transient ischemic attack. Sci Rep 2024; 14:695. [PMID: 38184714 PMCID: PMC10771433 DOI: 10.1038/s41598-024-51402-2] [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: 06/20/2023] [Accepted: 01/04/2024] [Indexed: 01/08/2024] Open
Abstract
Elderly hypertensive patients diagnosed with transient ischemic attack (TIA) are at a heightened risk for developing acute ischemic stroke (AIS). This underscores the critical need for effective risk prediction and identification of predictive factors. In our study, we utilized patient data from peripheral blood tests and clinical profiles within hospital information systems. These patients were followed for a three-year period to document incident AIS. Our cohort of 11,056 individuals was randomly divided into training, validation, and testing sets in a 5:2:3 ratio. We developed an XGBoost model, developed using selected indicators, provides an effective and non-invasive method for predicting the risk of AIS in elderly hypertensive patients diagnosed with TIA. Impressively, this model achieved a balanced accuracy of 0.9022, a recall of 0.8688, and a PR-AUC of 0.9315. Notably, our model effectively encapsulates essential data variations involving mixed nonlinear interactions, providing competitive performance against more complex models that incorporate a wider range of variables. Further, we conducted an in-depth analysis of the importance and sensitivity of each selected indicator and their interactions. This research equips clinicians with the necessary tools for more precise identification of high-risk individuals, thereby paving the way for more effective stroke prevention and management strategies.
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Affiliation(s)
- Chang Shu
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, 300350, China.
| | - Chenguang Zheng
- Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin, China
| | - Da Luo
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, 300350, China
| | - Jie Song
- Academy of Medical Engineering and Translational Medicine, Intelligent Medical Engineering, Tianjin University, Tianjin, China
| | - Zhengyi Jiang
- Academy of Medical Engineering and Translational Medicine, Intelligent Medical Engineering, Tianjin University, Tianjin, China
| | - Le Ge
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, 300350, China.
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2
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Ahsan T, Shoily SS, Ahmed T, Sajib AA. Role of the redox state of the Pirin-bound cofactor on interaction with the master regulators of inflammation and other pathways. PLoS One 2023; 18:e0289158. [PMID: 38033031 PMCID: PMC10688961 DOI: 10.1371/journal.pone.0289158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/10/2023] [Indexed: 12/02/2023] Open
Abstract
Persistent cellular stress induced perpetuation and uncontrolled amplification of inflammatory response results in a shift from tissue repair toward collateral damage, significant alterations of tissue functions, and derangements of homeostasis which in turn can lead to a large number of acute and chronic pathological conditions, such as chronic heart failure, atherosclerosis, myocardial infarction, neurodegenerative diseases, diabetes, rheumatoid arthritis, and cancer. Keeping the vital role of balanced inflammation in maintaining tissue integrity in mind, the way to combating inflammatory diseases may be through identification and characterization of mediators of inflammation that can be targeted without hampering normal body function. Pirin (PIR) is a non-heme iron containing protein having two different conformations depending on the oxidation state of the iron. Through exploration of the Pirin interactome and using molecular docking approaches, we identified that the Fe2+-bound Pirin directly interacts with BCL3, NFKBIA, NFIX and SMAD9 with more resemblance to the native binding pose and higher affinity than the Fe3+-bound form. In addition, Pirin appears to have a function in the regulation of inflammation, the transition between the canonical and non-canonical NF-κB pathways, and the remodeling of the actin cytoskeleton. Moreover, Pirin signaling appears to have a critical role in tumor invasion and metastasis, as well as metabolic and neuro-pathological complications. There are regulatory variants in PIR that can influence expression of not only PIR but also other genes, including VEGFD and ACE2. Disparity exists between South Asian and European populations in the frequencies of variant alleles at some of these regulatory loci that may lead to differential occurrence of Pirin-mediated pathogenic conditions.
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Affiliation(s)
- Tamim Ahsan
- Molecular Biotechnology Division, National Institute of Biotechnology, Savar, Dhaka, Bangladesh
| | - Sabrina Samad Shoily
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh
| | - Tasnim Ahmed
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh
| | - Abu Ashfaqur Sajib
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh
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3
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Zafar M, Shotton O, Abousamra A, Kaluram RK, Mucci E. Amaurosis fugax and crescendo transient ischaemic attacks. Br J Hosp Med (Lond) 2022; 83:1-4. [DOI: 10.12968/hmed.2021.0654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mansoor Zafar
- Department of Gastroenterology, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
- Department of General Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
| | - Oliver Shotton
- Department of Gastroenterology, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
- Department of General Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
| | - Ahmed Abousamra
- Department of General Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
- Department of Medicine for the Elderly, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
| | - Rajesh K Kaluram
- Emergency Department, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
| | - Elena Mucci
- Department of General Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
- Department of Medicine for the Elderly, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards on Sea, East Sussex, UK
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4
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Current aspects of TIA management. J Clin Neurosci 2020; 72:20-25. [PMID: 31911111 DOI: 10.1016/j.jocn.2019.12.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/09/2019] [Accepted: 12/16/2019] [Indexed: 02/01/2023]
Abstract
Transient Ischaemic Attack (TIA) if untreated carries a high risk of early stroke and is associated with poorer long-term survival [1]. There is emerging evidence of a reduction in stroke risk following TIA. Time critical investigations and management, as well as service organisation remain key to achieving good outcomes. Patients are diagnosed with TIA if they have transient, sudden-onset focal neurological symptoms which usually completely and rapidly resolve by presentation. The tissue based definition of TIA guides the fact that patients with residual symptoms should be considered as potentially having a stroke, with urgent evaluation regarding eligibility for thrombolysis and/or endovascular clot retrieval (ECR). Essential investigations for all patients with TIA should include early brain imaging, ECG, and carotid imaging in patients with anterior circulation symptoms. After brain imaging, exclusion of high risk indicators and immediate administration of an antiplatelet agent, subsequent attention to other mechanistic factors can be managed safely as part of a structured clinical pathway supervised by stroke specialists. This is in line with the recently revised Stroke Foundation Clinical Guidelines for Stroke Management (2017).
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Wu CT, Yang TH, Chen MC, Chung YP, Guan SS, Long LH, Liu SH, Chen CM. Low Intensity Pulsed Ultrasound Prevents Recurrent Ischemic Stroke in a Cerebral Ischemia/Reperfusion Injury Mouse Model via Brain-derived Neurotrophic Factor Induction. Int J Mol Sci 2019; 20:ijms20205169. [PMID: 31635269 PMCID: PMC6834125 DOI: 10.3390/ijms20205169] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/13/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023] Open
Abstract
The incidence of stroke recurrence is still higher despite the advanced progression of therapeutic treatment and medical technology. Low intensity pulsed ultrasound (LIPUS) has been demonstrated to possess therapeutic effects on neuronal diseases and stroke via brain-derived neurotrophic factor (BDNF) induction. In this study, we hypothesized that LIPUS treatment possessed therapeutic benefits for the improvement of stroke recurrence. Adult male C57BL/6J mice were subjected to a middle cerebral artery occlusion (MCAO) surgery and then followed to secondary MCAO surgery as a stroke recurrence occurred after nine days from the first MCAO. LIPUS was administered continuously for nine days before secondary MCAO. LIPUS treatment not only decreased the mortality but also significantly moderated neuronal function injury including neurological score, motor activity, and brain pathological score in the recurrent stroke mice. Furthermore, the administration of LIPUS attenuated the apoptotic neuronal cells and increased Bax/Bcl-2 protein expression ratio and accelerated the expression of BDNF in the brain of the recurrent stroke mice. Taken together, these results demonstrate for the first time that LIPUS treatment arouses the expression of BDNF and possesses a therapeutic benefit for the improvement of stroke recurrence in a mouse model. The neuroprotective potential of LIPUS may provide a useful strategy for the prevention of a recurrent stroke.
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Affiliation(s)
- Cheng-Tien Wu
- Department of Nutrition, China Medical University, Taichung 40402, Taiwan.
- Master Program of Food and Drug Safety, China Medical University, Taichung 40402, Taiwan.
| | - Ting-Hua Yang
- Department of Otolaryngology, College of Medicine and Hospital, National Taiwan University, Taipei 10051, Taiwan.
| | - Man-Chih Chen
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan.
| | - Yao-Pang Chung
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan.
| | - Siao-Syun Guan
- Institute of Nuclear Energy Research, Atomic Energy Council, Taoyuan 32546, Taiwan.
| | - Lin-Hwa Long
- Division of Neurosurgery, Department of Surgery, College of Medicine and Hospital, National Taiwan University, Taipei 10051, Taiwan.
| | - Shing-Hwa Liu
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan.
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan.
- Department of Pediatrics, College of Medicine and Hospital, National Taiwan University, Taipei 10051, Taiwan.
| | - Chang-Mu Chen
- Division of Neurosurgery, Department of Surgery, College of Medicine and Hospital, National Taiwan University, Taipei 10051, Taiwan.
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Dominici C, Salsano A, Nenna A, Spadaccio C, El‐Dean Z, Bashir M, Mariscalco G, Santini F, Chello M. Neurological outcomes after on‐pump vs off‐pump CABG in patients with cerebrovascular disease. J Card Surg 2019; 34:941-947. [DOI: 10.1111/jocs.14158] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Carmelo Dominici
- Department of Cardiovascular SurgeryUniversità Campus Bio‐Medico di Roma Rome Italy
| | - Antonio Salsano
- Department of Cardiac SurgeryUniversity of Genoa Genoa Italy
| | - Antonio Nenna
- Department of Cardiovascular SurgeryUniversità Campus Bio‐Medico di Roma Rome Italy
| | | | - Zein El‐Dean
- Department of Cardiac Surgery, Glenfirld HospitalUniversity Hospitals of Leicester Leicester UK
| | - Mohamad Bashir
- Thoracic Aortic Aneurysm ServiceLiverpool Heart and Chest Hospital Liverpool UK
| | - Giovanni Mariscalco
- Department of Cardiac SurgeryUniversity of Genoa Genoa Italy
- Department of Cardiac Surgery, Glenfirld HospitalUniversity Hospitals of Leicester Leicester UK
| | | | - Massimo Chello
- Department of Cardiovascular SurgeryUniversità Campus Bio‐Medico di Roma Rome Italy
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7
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Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department. Ann Emerg Med 2016; 68:354-370.e29. [DOI: 10.1016/j.annemergmed.2016.06.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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8
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Musuka TD, Wilton SB, Traboulsi M, Hill MD. Diagnosis and management of acute ischemic stroke: speed is critical. CMAJ 2015; 187:887-93. [PMID: 26243819 PMCID: PMC4562827 DOI: 10.1503/cmaj.140355] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Tapuwa D Musuka
- Department of Clinical Neurosciences, Cumming School of Medicine (Musuka), Department of Cardiac Sciences, Libin Cardiovascular Institute (Wilton, Traboulsi), Department of Clinical Neurosciences, Hotchkiss Brain Institute (Hill), and Departments of Radiology and Community Health Sciences, Cumming School of Medicine (Hill), University of Calgary, Calgary, Alta
| | - Stephen B Wilton
- Department of Clinical Neurosciences, Cumming School of Medicine (Musuka), Department of Cardiac Sciences, Libin Cardiovascular Institute (Wilton, Traboulsi), Department of Clinical Neurosciences, Hotchkiss Brain Institute (Hill), and Departments of Radiology and Community Health Sciences, Cumming School of Medicine (Hill), University of Calgary, Calgary, Alta
| | - Mouhieddin Traboulsi
- Department of Clinical Neurosciences, Cumming School of Medicine (Musuka), Department of Cardiac Sciences, Libin Cardiovascular Institute (Wilton, Traboulsi), Department of Clinical Neurosciences, Hotchkiss Brain Institute (Hill), and Departments of Radiology and Community Health Sciences, Cumming School of Medicine (Hill), University of Calgary, Calgary, Alta
| | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine (Musuka), Department of Cardiac Sciences, Libin Cardiovascular Institute (Wilton, Traboulsi), Department of Clinical Neurosciences, Hotchkiss Brain Institute (Hill), and Departments of Radiology and Community Health Sciences, Cumming School of Medicine (Hill), University of Calgary, Calgary, Alta.
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9
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Abstract
Symptomatic extracranial internal carotid artery stenosis poses a high short-time risk of ischemic cerebral stroke, as high as 20% to 30% in the first three months. Timely performed carotid endarterectomy (CEA) has been shown to be highly effective in reducing this risk although, in recent years, there has been great interest in replacing this procedure with less invasive carotid angioplasty and stenting (CAS). In this update we review recent studies and provide recommendations regarding the indications, methods and timing of surgical intervention as well as the anaesthetic management of CEA, and we report on recently published randomized controlled trials comparing CEA to CAS. We also provide recommendations regarding the sometime neglected but important medical management of patients undergoing carotid intervention, including antithrombotic and antihypertension therapy, lipid lowering agents, assistance with smoking cessation, and diabetes control.
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10
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Bae YJ, Jung C, Kim JH, Choi BS, Kim E, Han MK, Bae HJ, Han MH. Potential for the use of the Solitaire stent for recanalization of middle cerebral artery occlusion without a susceptibility vessel sign. AJNR Am J Neuroradiol 2014; 35:149-55. [PMID: 23744693 DOI: 10.3174/ajnr.a3562] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Absence of the MCA susceptibility vessel sign (negative MCA susceptibility vessel sign) on gradient recalled-echo MR imaging in acute stroke is commonly associated with in situ stenosis and thrombotic occlusion. We evaluated the effectiveness and safety of the Solitaire stent as the first-line device for the recanalization of MCA occlusion with a negative MCA susceptibility vessel sign. MATERIALS AND METHODS Thirty-eight consecutive patients presenting with acute ischemic stroke due to MCA occlusion were treated by using the Solitaire AB stent alone or combined with thrombolytic drugs. Among these patients, 11 (7 men and 4 women; median age, 70 years; range, 49-89 years) who underwent multimodal stroke MR imaging before the endovascular procedure and had no MCA susceptibility vessel sign on the initial gradient recalled-echo MR imaging were included in this study. The primary end point was the recanalization of the occluded artery evaluated by the arterial occlusive lesion score. Clinical outcome was assessed at discharge and 90 days, as was the degree of residual MCA stenosis or reocclusion. RESULTS Successful recanalization (arterial occlusive lesion score ≥ II) without balloon angioplasty was obtained in 9 patients (81.8%). Six patients (54.5%) had an mRS score of ≤2 at 90 days. After a median of 147 days, no patient showed reocclusion on follow-up imaging. There were no symptomatic intracerebral hemorrhages. CONCLUSIONS The Solitaire stent is a feasible tool as the first-line device for multimodal endovascular recanalization therapy in acute ischemic stroke with a negative MCA susceptibility vessel sign. It has a good rate of successful and complete recanalization and is a fast yet safe procedure.
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11
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Wang LM, Wang YJ, Cui M, Luo WJ, Wang XJ, Barber PA, Chen ZY. A dietary polyphenol resveratrol acts to provide neuroprotection in recurrent stroke models by regulating AMPK and SIRT1 signaling, thereby reducing energy requirements during ischemia. Eur J Neurosci 2013; 37:1669-81. [PMID: 23461657 DOI: 10.1111/ejn.12162] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/17/2013] [Accepted: 01/21/2013] [Indexed: 01/04/2023]
Abstract
Polyphenol resveratrol (RSV) has been associated with Silent Information Regulator T1 (SIRT1) and AMP-activated protein kinase (AMPK) metabolic stress sensors and probably responds to the intracellular energy status. Our aim here was to investigate the neuroprotective effects of RSV and its association with SIRT1 and AMPK signaling in recurrent ischemia models. In this study, elderly male Wistar rats received a combination of two mild transient middle cerebral artery occlusions (tMCAOs) as an in vivo recurrent ischemic model. Primary cultured cortical neuronal cells subjected to combined oxygen-glucose deprivation (OGD) were used as an in vitro recurrent ischemic model. RSV administration significantly reduced infarct volumes, improved behavioral deficits and protected neuronal cells from cell death in recurrent ischemic stroke models in vivo and in vitro. RSV treatments significantly increased the intracellular NAD(+) /NADH ratio, AMPK and SIRT1 activities, decreased energy assumption and restored cell energy ATP level. SIRT1 and AMPK inhibitors and specific small interfering RNA (siRNA) for SIRT1 and AMPK significantly abrogated the neuroprotection induced by RSV. AMPK-siRNA and inhibitor decreased SIRT1 activities; however, SIRT1-siRNA and inhibitor had no impact on phospho-AMPK (p-AMPK) levels. These results indicated that the neuroprotective effects of RSV increased the intracellular NAD(+) /NADH ratio as well as AMPK and SIRT1 activities, thereby reducing energy ATP requirements during ischemia. SIRT1 is a downstream target of p-AMPK signaling induced by RSV in the recurrent ischemic stroke model.
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Affiliation(s)
- Li-Mei Wang
- Department of Neurobiology, Shandong Provincial Key Laboratory of Mental Disorders, School of Medicine, Shandong University, Jinan, Shandong, 250012, China.
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12
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Massengo SA, Cisse M, Guiziou C, Leray E, Rajabally YA, Edan G. Knowledge of TIA among general practitioners and emergency department physicians. A questionnaire survey in a French semi-rural area. Clin Neurol Neurosurg 2013; 115:1457-63. [PMID: 23454886 DOI: 10.1016/j.clineuro.2013.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Revised: 12/23/2012] [Accepted: 01/30/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Management of transient ischemic attacks (TIAs) is of vital importance in an attempt to prevent stroke. However, suboptimal management still raise concern among general practitioners (GPs) and emergency department (ED) physicians-the first medical contact of most TIA patients. This may relate to their poorly updated knowledge about TIA. The study was designed to assess knowledge of TIA among these non-neurologists. METHODS The study was a post-mailed questionnaire survey among GPs and ED physicians. The questionnaire related to selective clinical aspects on TIA. RESULTS There were a total of 85 respondents for analysis, mostly GPs (n=64; 75.3%), out of 177 mailed physicians. Response rate was 52.7%. Many of these respondents were unaware of the newly proposed TIA definition (59%), unfamiliar with TIA mimics and predictors of post-TIA early stroke recurrence and therefore with the rationales underlying the need of emergency management of TIA. More than one third (39%) were unaware of the relevant national guidelines. Guidelines-aware respondents performed better in most part of the mailed questionnaire. CONCLUSION Our results show that poorly updated knowledge about TIA among non-neurologists represents a potential contributing factor to the persisting sub-optimal management of the disorder. Although further studies are needed to confirm this, improved continuous medical education of this group of health care professionals appears warranted.
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Affiliation(s)
- Serge A Massengo
- Service de Neurologie, Centre Hospitalier de Lannion, Hôpital Pierre Le Damany, Lannion, France.
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13
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Qiao M, Zhao Z, Barber P, Foniok T, Sun S, Tuor U. Development of a model of recurrent stroke consisting of a mild transient stroke followed by a second moderate stroke in rats. J Neurosci Methods 2009; 184:244-50. [DOI: 10.1016/j.jneumeth.2009.08.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 07/24/2009] [Accepted: 08/13/2009] [Indexed: 11/28/2022]
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14
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Ruff NL, Johnston SC. Identification, risks, and treatment of transient ischemic attack. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:453-473. [PMID: 18804664 DOI: 10.1016/s0072-9752(08)93023-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Naomi L Ruff
- Communications Services in Science and Medicine, Department of Neurology, University of California, San Francisco, CA 94143, USA
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15
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van Dellen D, Tiivas CAS, Jarvi K, Marshall C, Higman DJ, Imray CHE. Transcranial Doppler ultrasonography-directed intravenous glycoprotein IIb/IIIa receptor antagonist therapy to control transient cerebral microemboli before and after carotid endarterectomy. Br J Surg 2008; 95:709-13. [PMID: 18425794 DOI: 10.1002/bjs.6204] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with a transient focal neurological deficit, critical carotid stenosis and/or microemboli detected by transcranial Doppler ultrasonography (TCD) have a significant risk of stroke. The effect of tirofiban, a selective glycoprotein IIb/IIIa inhibitor, was assessed in patients with microembolic signals on TCD after transient ischaemic attacks or carotid endarterectomy (CEA). METHODS Thirty-three patients with microemboli on TCD (13 symptomatic preoperative, 19 postoperative, one both) were treated with tirofiban between 2002 and 2007. All patients had carotid stenosis greater than 70 per cent. TCD monitoring was used during and after tirofiban therapy. RESULTS The median (range) rate of microemboli decreased from 22 (4-260) per h before surgery and 81 (44-216) per h after surgery to 0 (0-9) per h in both groups (P < 0.001, Mann-Whitney U test). This occurred rapidly (preoperative median 30 min; postoperative median 45 min) and was well tolerated in all patients, with no serious adverse effects. CONCLUSION Cerebral microemboli were controlled by tirofiban both before and after CEA. Further study is required to compare the relative efficacy of tirofiban and dextran.
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Affiliation(s)
- D van Dellen
- Coventry and Warwickshire County Vascular Unit, University Hospitals Coventry and Warwickshire NHS Trust, Walsgrave Hospital, Coventry, UK
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16
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Ovbiagele B. Antiplatelet therapy in management of transient ischemic attack: overview and evidence-based rationale. J Emerg Med 2008; 34:389-396. [PMID: 18207691 DOI: 10.1016/j.jemermed.2007.08.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Revised: 06/18/2007] [Accepted: 08/07/2007] [Indexed: 05/25/2023]
Abstract
As many as 300,000 transient ischemic attacks (TIAs) occur in the United States each year, accounting for 0.3% of all Emergency Department visits. An under-recognized and under-treated problem, TIA is associated with up to a 10% risk of subsequent stroke within 7 days and a 25% risk of death at 1 year. Antiplatelet therapy can result in significant reductions in secondary stroke risk. However, nearly 50% of patients with TIA leave the Emergency Department without any medication. This article discusses recent results from major antiplatelet clinical trials in stroke prevention and highlights the need for appropriate and timely initiation of antiplatelet treatment in patients with TIA.
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Affiliation(s)
- Bruce Ovbiagele
- Department of Neurology, University of California at Los Angeles, Los Angeles, California 90095, USA
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17
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Weinberger J. Antiplatelet agents for stroke prevention following transient ischemic attack. South Med J 2008; 101:70-8. [PMID: 18176296 DOI: 10.1097/smj.0b013e31815d2b6b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Regardless of extent or duration of acute effects, transient ischemic attack (TIA) is a marker for cerebrovascular ischemia and carries risk for secondary stroke comparable to that associated with ischemic stroke. Pharmacologic and nonpharmacologic interventions aimed at reducing risk of secondary stroke should be implemented as soon as possible after characterization of the initial event. Medical strategies for secondary prevention include modifying general cardiovascular risk factors but are centered on the specific reduction of stroke risk by antiplatelet agents. Aspirin and clopidogrel have each demonstrated efficacy in reducing secondary event risk; however, clopidogrel has not been shown specifically to prevent secondary events in patients who have had a TIA or stroke. Combination therapy using aspirin plus dipyridamole is the only combination approach to demonstrate additive benefit that is significantly greater than that conferred by aspirin. In contrast, the combination of clopidogrel plus aspirin has not demonstrated significant benefit over monotherapy with either agent and has been associated with increased risk of bleeding episodes.
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Affiliation(s)
- Jesse Weinberger
- Department of Neurology, Mount Sinai School of Medicine, New York, New York 10029, USA.
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18
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Abstract
The risk for disabling stroke is greatest in the period immediately following a transient ischemic attack (TIA), thus, TIA is a medical emergency. A universities medical center's emergency department-based TIA evaluation and management program is presented as an example of the pragmatic enactment of current guidelines for TIA evaluation and management. A discussion of modifications that can be made for an outpatient setting evaluation and a review of the literature follow.
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Affiliation(s)
- Marian P Lamonte
- Department of Neurology and Emergency Medicine, University of Maryland School of Medicine, University of Maryland Medical Center, Room N4W46, 22 South Greene Street, Baltimore, MD 21201, USA.
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Bray JE, Coughlan K, Bladin C. Can the ABCD Score be dichotomised to identify high-risk patients with transient ischaemic attack in the emergency department? Emerg Med J 2007; 24:92-5. [PMID: 17251611 PMCID: PMC2658215 DOI: 10.1136/emj.2006.041624] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Recent evidence shows a substantial short-term risk of ischaemic stroke after transient ischaemic attack (TIA). Identification of patients with TIA with a high short-term risk of stroke is now possible through the use of the "ABCD Score", which considers age, blood pressure, clinical features and duration of symptoms predictive of stroke. AIM To evaluate the ability of dichotomising the ABCD Score to predict stroke at 7 and 90 days in a population with TIA presenting to an emergency department. METHODS A retrospective audit was conducted on all probable or definite TIAs presenting to the emergency department of a metropolitan hospital from July to December 2004. The ABCD Score was applied to 98 consecutive patients with TIA who were reviewed for subsequent strokes within 90 days. Patients obtaining an ABCD Score > or = 5 were considered to be at high risk for stroke. RESULTS Dichotomising the ABCD Score categorised 48 (49%) patients with TIA at high risk for stroke (ABCD Score > or = 5). This high-risk group contained all four strokes that occurred within 7 days (sensitivity 100% (95% confidence interval (CI) 40% to 100%), specificity 53% (95% CI 43% to 63%), positive predictive value 8% (95% CI 3% to 21%) and negative predictive value 100% (95% CI 91% to 100%)), and six of seven occurring within 90 days (sensitivity 86% (95% CI 42% to 99%), specificity 54% (95% CI 43% to 64%), positive predictive value 12.5% (95% CI 5% to 26%) and negative predictive value 98% (95% CI 88% to 100%)). Removal of the "age" item from the ABCD Score halved the number of false-positive cases without changing its predictive value for stroke. CONCLUSION In this retrospective analysis, dichotomising the ABCD Score was overinclusive but highly predictive in identifying patients with TIA at a high short-term risk of stroke. Use of the ABCD Score in the emergency care of patients with TIA is simple, efficient and provides a unique opportunity to prevent stroke in this population of patients.
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Affiliation(s)
- Janet E Bray
- Eastern Melbourne Neurosciences, Box Hill Hospital, Deakin University, Melbourne, Victoria, Australia
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Edlow JA, Kim S, Pelletier AJ, Camargo CA. National Study on Emergency Department Visits for Transient Ischemic Attack, 1992–2001. Acad Emerg Med 2006. [DOI: 10.1111/j.1553-2712.2006.tb01029.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Edlow JA, Kim S, Pelletier AJ, Camargo CA. National study on emergency department visits for transient ischemic attack, 1992-2001. Acad Emerg Med 2006; 13:666-72. [PMID: 16609106 DOI: 10.1197/j.aem.2006.01.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic attack (TIA) and to measure rates of antiplatelet medication use, neuroimaging, and hospitalization during a ten-year time period. METHODS The authors obtained data from the 1992-2001 National Hospital Ambulatory Medical Care Survey. TIA cases were identified by having ICD-9 code 435. RESULTS From 1992 to 2001, there were 769 cases, representing 2,969,000 ED visits for TIA. The population rate of 1.1 ED visits per 1,000 U.S. population (95% CI = 0.92 to 1.30) was stable over time. TIA was diagnosed in 0.3% of all ED visits. Physicians administered aspirin and other antiplatelet agents to a small percentage of patients, and 42% of TIA patients (95% CI = 29% to 55%) received no medications at all in the ED. Too few data points existed to measure a statistically valid trend over time. Physicians performed computed tomography scanning in 56% (95% CI = 45% to 66%) of cases and performed magnetic resonance imaging (MRI) in < 5% of cases, and there was a trend toward increased imaging over time. Admission rates did not increase during the ten-year period, with 54% (95% CI = 42% to 67%) admitted. Regional differences were noted, however, with the highest admission rate found in the Northeast (68%). CONCLUSIONS Between 1992 and 2001, the population rate of ED visits for TIA was stable, as were admission rates (54%). Antiplatelet medications appear to be underutilized and to be discordant with published guidelines. Neuroimaging increased significantly. These findings may reflect the limited evidence base for the guidelines, educational deficits, or other barriers to guideline implementation.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Frenkel D, Huang Z, Maron R, Koldzic DN, Moskowitz MA, Weiner HL. Neuroprotection by IL-10-producing MOG CD4+ T cells following ischemic stroke. J Neurol Sci 2005; 233:125-32. [PMID: 15894335 DOI: 10.1016/j.jns.2005.03.022] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mucosal tolerance has been used successfully to treat animal models of autoimmune diseases and is being tested in human diseases. In this work we demonstrate the reduction of infarct size following mucosal tolerance by myelin oligodendrocyte glycoprotein (MOG) (35-55) peptide in mouse stroke model. Nasal MOG was most efficacious and reduced ischemic infarct size by 70% at 24 h as well as improving behavior score. Using immunohistological methods and IL-10 -/- mice, we demonstrate the importance of IL-10-producing CD4+ T cells in the reduction of the ischemic infarct volume following middle cerebral artery occlusion (MCAO). Furthermore, adoptive transfer of CD4+ T cells from nasally tolerized mice to untreated mice prior to MCAO surgery significantly decreased stroke size (p<0.001 vs. control), whereas CD4+ T cells from nasally tolerized IL-10-deficient mice had no significant effect. Based on these results, modulation of cerebral inflammation by mucosal tolerance to myelin antigens may have applicability both as prophylactic therapy and treatment following ischemia attacks.
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Affiliation(s)
- Dan Frenkel
- Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Louridas G, Junaid A. Management of carotid artery stenosis. Update for family physicians. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2005; 51:984-9. [PMID: 16060177 PMCID: PMC1479527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To clarify the definition of carotid artery diseases, the appropriateness of screening for disease, investigation and management of patients presenting with transient ischemic attacks, and management of asymptomatic carotid bruits. SOURCES OF INFORMATION MEDLINE: was searched using the terms carotid endarterectomy, carotid disease, and carotid stenosis. Most studies offer level II or III evidence. Consensus statements and guidelines from various neurovascular societies were also consulted. MAIN MESSAGE Patients with symptoms of hemispheric transient ischemic attacks associated with >70% stenosis of the internal carotid artery are at highest risk of major stroke or death. Risk is greatest within 48 hours of symptom onset; patients should have urgent evaluation by a vascular surgeon for consideration of carotid endarterectomy (CEA). Patients with 50% to 69% stenosis might benefit from urgent surgical intervention depending on clinical features and associated comorbidity. Patients with <50% stenosis do not benefit from surgery. Asymptomatic patients with >60% stenosis should be considered for elective CEA. CONCLUSION Symptomatic carotid artery syndromes need urgent carotid duplex evaluation to determine the need for urgent surgery. Those with the greatest degree of stenosis derive the greatest benefit from timely CEA.
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