Early risk of stroke after a transient ischemic attack in patients with internal carotid artery disease

ACR Appropriateness Criteria® Cerebrovascular Diseases-Stroke and Stroke-Related Conditions

Cerebrovascular disease encompasses a vast array of conditions. The imaging recommendations for stroke-related conditions involving noninflammatory steno-occlusive arterial and venous cerebrovascular disease including carotid stenosis, carotid dissection, intracranial large vessel occlusion, and cerebral venous sinus thrombosis are encompassed by this document. Additional imaging recommendations regarding complications of these conditions including intraparenchymal hemorrhage and completed ischemic strokes are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ABCD2-I Score Predicts Unplanned Emergency Department Revisits within 72 Hours Due to Recurrent Acute Ischemic Stroke

BACKGROUND

the ABCD2 score is valuable for predicting early stroke recurrence after a transient ischemic attack (TIA), and Doppler ultrasound can aid in expediting stroke triage. The study aimed to investigate whether combining the ABCD2 score with carotid duplex results can enhance the identification of early acute ischemic stroke after TIA.

METHODS

we employed a retrospective cohort design for this study, enrolling patients diagnosed with TIA who were discharged from the emergency department (ED). The modified ABCD2-I (c50) score, which incorporates a Doppler ultrasound assessment of internal carotid artery stenosis > 50%, was used to evaluate the risk of acute ischemic stroke within 72 h. Patients were categorized into three risk groups: low risk (with ABCD2 and ABCD2-I scores = 0-4), moderate risk (ABCD2 score = 4-5 and ABCD2-I score = 5-7), and high risk (ABCD2 score = 6-7 and ABCD2-I score = 8-9).

RESULTS

between 1 January 2014, and 31 December 2019, 1124 patients with new neurological deficits were screened, with 151 TIA patients discharged from the ED and included in the analysis. Cox proportional hazards analysis showed that patients in the high-risk group, as per the ABCD2-I (c50) score, were significantly associated with revisiting the ED within 72 h due to acute ischemic stroke (HR: 3.12, 95% CI: 1.31-7.41, p = 0.0102), while the ABCD2 alone did not show significant association (HR: 1.12, 95% CI: 0.57-2.22, p = 0.7427).

CONCLUSION

ABCD2-I (c50) scores effectively predict early acute ischemic stroke presentations to the ED within 72 h after TIA.

Comparative assessment of racial disparity in 30-day outcomes for Asian Americans undergoing carotid endarterectomy

OBJECTIVE

Carotid endarterectomy (CEA) is an effective treatment for carotid stenosis. All previous studies on racial disparity of CEA outcomes omitted Asian Americans. This study aimed to address this gap by investigating racial disparities in 30-day outcomes following CEA among Asian Americans.

METHODS

Asian American and Caucasian patients who underwent CEA were identified in the American College of Surgeons National Surgical Quality Improvement Program targeted database from 2011 to 2021. Patients with age less than 18 years old were excluded. Patients with symptomatic and asymptomatic carotid stenosis were examined separately. A 1:5 propensity-score matching was used to address preoperative differences. Thirty perioperative outcomes were assessed.

RESULTS

There were 380 Asian Americans (2.27%) and 13,250 Caucasians (79.18%) with symptomatic carotid stenosis who underwent CEA. Also, 289 Asian Americans (1.40%) and 18,257 Caucasians (88.14%) with asymptomatic carotid stenosis had CEA. Asian Americans undergoing CEA presented with higher comorbid burdens and more severe symptomology. Also, asymptomatic Asian Americans were more likely to undergo surgeries for mild stenosis (<50%), which is not in line with practice guidelines. After 1:5 propensity-matching, all symptomatic Asian Americans were matched to 1550 Caucasian patients, and all asymptomatic Asian Americans were matched to 1445 Caucasians; preoperative differences were addressed. Asian Americans exhibited low overall 30-day mortality (symptomatic, 1.61%; asymptomatic, 0.35%) and stroke (symptomatic, 2.26%; asymptomatic, 0.69%). All perioperative outcomes were comparable to Caucasians, with the exception that Asian Americans experienced longer operation times.

CONCLUSIONS

Evidence suggested that Asian Americans with asymptomatic stenosis were underrepresented in CEA. After propensity-score matching, Asian Americans demonstrated comparable 30-day outcomes to Caucasians. These suggest that, when afforded equal access to quality health care, CEA serves as an effective treatment for carotid stenosis among Asian Americans. Therefore, efforts may be aimed at addressing health care access, potentially in the screening for asymptomatic carotid stenosis in Asian Americans. This would ensure they have equitable benefits from CEA. Nevertheless, the exact preoperative differences and long-term CEA outcomes in Asian Americans should warrant further examination in future studies.

The 5-Factor Modified Frailty Index is a Concise and Effective Predictor of 30-Day Adverse Outcomes in Carotid Endarterectomy

INTRODUCTION

Frailty is a clinically identifiable condition characterized by heightened vulnerability. The 5-item Modified Frailty Index provides a concise calculation of frailty that has proven effective in predicting adverse perioperative outcomes across a variety of surgical disciplines. However, there is a paucity of research examining the validity of 11-item Modified Frailty Index (mFI-5) in carotid endarterectomy (CEA). This study aimed to investigate the association between mFI-5 and 30-day outcomes of CEA.

METHODS

Patients underwent CEA were identified from American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2021. Patients with age<18 were excluded. Patients were stratified into four cohorts based on their mFI-5 scores: 0, 1, 2, or 3+. Multivariable logistic regression was used to compare 30-day perioperative outcomes adjusting for preoperative variables with P value<0.1.

RESULTS

Compared to controls (mFI-5 = 0), patients mFI-5 = 1 had higher risk of stroke (adjusted odds ratio [aOR] = 1.333, P = 0.02), unplanned operation (aOR = 1.38, P < 0.01), and length of stay (LOS) > 7 days (aOR = 0.814, P < 0.01). Patients with mFI-5 = 2 had higher stroke (aOR = 1.719, P < 0.01), major adverse cardiovascular events (MACE) (aOR = 1.315, P = 0.01), sepsis (aOR = 2.243, P = 0.01), discharge not to home (aOR = 1.200, P < 0.01), 30-day readmission (aOR = 1.405, P < 0.01). Compared with controls, patients with mFI-5≥3 had higher mortality (aOR = 1.997 P = 0.02), MACE (aOR = 1.445, P = 0.03), cardiac complications (aOR = 1.901, P < 0.01), pulmonary events (aOR = 2.196, P < 0.01), sepsis (aOR = 3.65, P < 0.01), restenosis (aOR = 2.606, P = 0.02), unplanned operation (aOR = 1.69, P < 0.01), LOS>7 days (aOR = 1.425, P < 0.01), discharge not to home (aOR = 2.127, P < 0.01), and 30-day readmission (aOR = 2.427, P < 0.01).

CONCLUSIONS

The mFI-5 is associated with 30-day mortality and complications including stroke, MACE, cardiac complications, pulmonary complications, sepsis, and restenosis. Additionally, elevated mFI-5 scores correlate with an increased likelihood of unplanned operations, extended LOS, discharge to facilities other than home, and 30-day readmissions, all of which could negatively impact long-term prognosis. Therefore, mFI-5 can serve as a concise yet effective metric of frailty in patients undergoing CEA.

Physician Approaches to Antithrombotic Therapies for Recently Symptomatic Carotid Stenosis

BACKGROUND

Whereas the beneficial effect of antiplatelet therapy for recurrent stroke prevention has been well established, uncertainties remain regarding the optimal antithrombotic regimen for recently symptomatic carotid stenosis. We sought to explore the approaches of stroke physicians to antithrombotic management of patients with symptomatic carotid stenosis.

METHODS

We employed a qualitative descriptive methodology to explore the decision-making approaches and opinions of physicians regarding antithrombotic regimens for symptomatic carotid stenosis. We conducted semi-structured interviews with a purposive sample of 22 stroke physicians (11 neurologists, 3 geriatricians, 5 interventional-neuroradiologists, and 3 neurosurgeons) from 16 centers on four continents to discuss symptomatic carotid stenosis management. We then conducted thematic analysis on the transcripts.

RESULTS

Important themes revealed from our analysis included limitations of existing clinical trial evidence, competing surgeon versus neurologist/internist preferences, and the choice of antiplatelet therapy while awaiting revascularization. There was a greater concern for adverse events while using multiple antiplatelet agents (e.g., dual-antiplatelet therapy (DAPT)) in patients undergoing carotid endarterectomy compared to carotid artery stenting. Regional variations included more frequent use of single antiplatelet agents among European participants. Areas of uncertainty included antithrombotic management if already on an antiplatelet agent, implications of nonstenotic features of carotid disease, the role of newer antiplatelet agents or anticoagulants, platelet aggregation testing, and timing of DAPT.

CONCLUSION

Our qualitative findings can help physicians critically examine the rationale underlying their own antithrombotic approaches to symptomatic carotid stenosis. Future clinical trials may wish to accommodate identified variations in practice patterns and areas of uncertainty to better inform clinical practice.

Hemodynamical behavior analysis of anemic, diabetic, and healthy blood flow in the carotid artery

The influence of blood rheology on hemodynamic parameters is investigated using Computational Fluid Dynamics on blood flow through the human carotid artery. We performed three-dimensional modeling and simulation to study blood flow through the carotid artery, which is divided into internal and exterior parts with a decreased radius. The blood flow was classified as basic pulsatile to simulate the human heart's rhythmic pulses. For hemodynamic modeling viscosity of the fluid, the Carreau model was utilized with four distinct blood instances: Anemic, diabetic, and two healthy blood types. The boundary conditions with Carreau viscosity were applied using the Ansys Fluent simulator, and the governing equations were solved using the finite volume technique. Different time steps were tested for their impact on wall deformation, strain rate, blood velocity, pressure, wall shear, and skin friction coefficient. The hemodynamical parameters were calculated using many cross-sectional planes along the artery. Finally, the impact of the four types of blood cases listed above was investigated, and we discovered that each blood case has a substantial impact on blood velocity, pressure, wall shear, and strain rate along the artery.

Update on Management of Symptomatic Carotid Stenosis

Carotid artery stenosis (CAS) is one of the leading causes of cerebral ischemia and stroke.7 When plaque builds up in the internal carotid artery, it blocks blood flow to the brain. Oftentimes, this condition only comes to light after a patient experiences a stroke or stroke-like symptoms. When this occurs, cholesterol-lowering medications and blood thinners can help to increase blood flow to the brain. However, if the plaque is so large that it severely narrows the lumen of the artery, surgery may be required to restore blood flow to the brain. Patients with severe stenosis can undergo procedures such as carotid endarterectomies (CEA), stenting, and transcarotid artery revascularization (TCAR) for this purpose. In this review, we discuss these procedures and which patients warrant which type of intervention. We look at the pathophysiology of internal carotid artery stenosis and current treatment options, while highlighting emerging treatment options. This review aims to increase understanding of the management of symptomatic carotid artery stenosis as well as provide a groundwork for more innovative treatments.

Subsequent ischemic stroke and tobacco smoking: A secondary analysis of the POINT trial

Background:

The aim of this study was to determine the effect of smoking status on subsequent stroke risk in patients with minor ischemic stroke or TIA and to determine whether smoking modifies the effect of clopidogrel-based DAPT on subsequent stroke risk.

Methods:

This was a post-hoc analysis of the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial, which had a 90-day follow-up period. We used multivariable Cox regression and subgroup interaction analysis to determine the effect of smoking on the risk of subsequent ischemic stroke and major hemorrhage, respectively.

Results:

Data from 4877 participants enrolled in the POINT trial were analyzed. Among these, 1004 were current smokers and 3873 were non-smokers at the time of index event. Smoking was associated with a non-significant trend toward an increased risk of subsequent ischemic stroke during follow up (adjusted HR, 1.31 (95% CI, 0.97–1.78), p = 0.076). The effect of clopidogrel on ischemic stroke did not differ between non-smokers (HR, 0.74 (95% CI, 0.56–0.98), p = 0.03) and smokers (HR, 0.63 (95% CI, 0.37–1.05), p = 0.078), p for interaction = 0.572. Similarly, the effect of clopidogrel on major hemorrhage did not differ between non-smokers (hazard ratio, 1.67 (95% CI, 0.40–7.00), p = 0.481) and smokers (HR, 2.59 (95% CI, 1.08–6.21), p = 0.032), p for interaction = 0.613.

Conclusions:

In this post-hoc analysis of the POINT trial we found that the effect of clopidogrel on reducing subsequent ischemic stroke as well as risk of major hemorrhage did not depend on smoking status, indicating that smokers benefit to a similar degree from DAPT as non-smokers.

Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis

IMPORTANCE

Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome.

OBJECTIVE

To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting.

DATA SOURCES

MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020.

STUDY SELECTION

Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer.

DATA EXTRACTION AND SYNTHESIS

The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models.

MAIN OUTCOMES AND MEASURES

Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days).

RESULTS

The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.

Efficacy and Safety of Adherence to dl-3-n-Butylphthalide Treatment in Patients With Non-disabling Minor Stroke and TIA-Analysis From a Nationwide, Multicenter Registry

Background: Dl-3-n-Butylphthalide (NBP) has the potential to improve clinical outcomes in acute ischemic stroke patients by improving collateral circulation. We aimed to evaluate the efficacy and safety of NBP in patients with non-disabling minor ischemic stroke and transient ischemic attack (TIA).

Methods: The BRIDGE (the observation study on clinical effectiveness of NBP on patients with non-disabling ischemic cerebrovascular disease) is a prospective registry to monitor the efficacy and safety of NBP therapy in acute non-disabling ischemic stroke or high-risk TIA. Non-disabling minor ischemic stroke patients within 48 h were enrolled across 51 stroke centers in China. We divided patients into NBP compliance or non-compliance groups according to their adherence to NBP. The primary outcome was the favorable functional outcome at 90 days, defined as a modified Rankin scale (mRS) <2.

Results: Between 10th October 2016 and 25th June 2019, 3,118 patients were included in this analysis. In multivariable analysis, after adjusting for common risk factors and demographic factors, NBP-compliance group has a higher proportion of favorable functional outcome (92.1 vs. 87.4%, adjusted odds ratio 2.00, 95% confidence interval, 1.50–2.65), and a higher stroke recurrence rate (2.40 vs. 0.31%, adjusted odds ratio 8.86, 95% confidence interval, 3.37–23.30) than the NBP-non-compliance group. There was no significant difference in death and intracranial hemorrhage rate between the two groups. In subgroup analysis, patients with National Institutes of Health Stroke Scale (NIHSS) scores from 3 to 5 who complied to NBP therapy had a higher rate of favorable functional outcomes than the NBP-non-compliance group. [88.82 vs. 76.21%, adjusted odds ratio 2.52 (1.81–3.50), adjusted interaction P = 0.00].

Conclusion: In non-disabling minor ischemic stroke or TIA patients, compliance with NBP therapy led to better 90-day functional outcomes despite a higher risk of recurrence, and this effect seems to be stronger in patients with NIHSS scores of 3–5. Further large randomized, double-blind controlled studies to analyse the association between NBP and functional outcome is warranted in the coming future.

A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis

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.

Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke: A Cohort Study

OBJECTIVE

To evaluate the effects of an outpatient clinic setup for minor stroke/TIA using subsequent admission of patients at high risk of recurrent stroke.

METHODS

We performed a cohort study of all patients with suspected minor stroke/TIA seen in an outpatient clinic at Aarhus University Hospital, Denmark, between September 2013 and August 2014. Patients with stroke were compared to historic (same hospital) and contemporary (another comparable hospital) matched, hospitalized controls on nonprioritized outcomes: length of stay, readmissions, care quality (10 process-performance measures), and mortality. Patients with TIA were compared to contemporary matched, hospitalized controls. Following complete diagnostic workup, patients with stroke/TIA were classified into low/high risk of recurrent stroke ≤7 days.

RESULTS

We analyzed 1,076 consecutive patients, of whom 253 (23.5%) were subsequently admitted to the stroke ward. Stroke/TIA was diagnosed in 215/171 patients, respectively. Fifty-six percent (121/215) of the patients with stroke were subsequently admitted to the stroke ward. Comparison with the historic stroke cohort (n = 191) showed a shorter acute hospital stay for the strokes (median 1 vs 3 days; adjusted length of stay ratio 0.49; 95% confidence interval 0.33-0.71). Thirty-day readmission rate was 3.2% vs 11.6% (adjusted hazard ratio 0.23 [0.09-0.59]), and care quality was higher, with a risk ratio of 1.30 (1.15-1.47). The comparison of stroke and TIAs to contemporary controls showed similar results. Only one patient in the low risk category and not admitted experienced stroke within 7 days (0.6%).

CONCLUSIONS

An outpatient clinic setup for patients with minor stroke/TIA yields shorter acute hospital stay, lower readmission rates, and better quality than hospitalization in stroke units.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that a neurovascular specialist-driven outpatient clinic for patients with minor stroke/TIA with the ability of subsequent admission is safe and yields shorter acute hospital stay, lower readmission rates, and better quality than hospitalization in stroke units.

Frequency, risk factors, and outcomes in patients with significant carotid artery disease admitted to King Abdulaziz Medical City, Riyadh with Ischemic Stroke

OBJECTIVE

To determine the frequency, risk factors, and outcomes of significant carotid artery disease (CAD) in patients with ischemic stroke.

METHODS

The frequency of significant CAD in patients admitted to the Stroke Unit between January 2014 and December 2015 was determined from radiological data. Outcomes were determined clinically and radiologically.

RESULTS

Among 435 patients, 273 were men (62.8%), with a mean age of 57.4+/-12.2 years. Significant CAD was found in 48 vessels in 40 (9.2%) patients, of which 30 patients were symptomatic. Nine of these patients were treated with carotid artery stenting, one underwent carotid endarterectomy, and 3 underwent an urgent thrombectomy, without stenting. Seventeen symptomatic patients were not treated for the following reasons: patient/family refusal (n=2), contraindications (n=5), and complete occlusion (n=10). One (7.7%) of the 13 treated patients had an ipsilateral stroke on follow up, one (7.7%) had contralateral transient ischemic attack (TIA), 9 (69.2%) had no recurrence, and no clinical data were available for 2 patients. Among the 17 untreated patients, one (5.9%) had an ipsilateral stroke, 7 (41.2%) had no recurrence, and 9 (52.9%) were lost to follow up.

CONCLUSION

Significant carotid artery disease is uncommon in our cohort found in less than 10% of patients. Vascular risk factors are more or less similar between patients with or without CAD except obesity which appears to have inverse relation with CAD. A small number of patients received carotid intervention with no recurrence of stroke at limited follow up.

[Early carotid endarterectomy in patients after endured acute cerebral circulation impairment]

Recent years have witnessed a series of studies dedicated to assessment of optimal terms of performing carotid endarterectomy (CEA) after sustained acute cerebral circulatory impairment (ACCI). However, there is no commonly accepted opinion concerning feasibility and safety of early CEA in 'symptomatic' patients. The 2015 Guidelines of the American Heart Association suggest that surgical intervention should be performed within the shortest terms or during 2 weeks after a neurological event (class IIb, level B evidence). In the presented herein review of literature most authors demonstrated safety and efficacy of performing early CEA after endured ACCI. However, further prospective, randomized studies are needed in order to work out new standards of examination and to determine optimal surgical policy.

Relationship Between Glycated Haemoglobin and Carotid Atherosclerotic Disease Among Patients with Acute Ischaemic Stroke

Objectives

This study aimed to determine the relationship between glycaemic control and carotid atherosclerotic disease among patients with acute ischaemic stroke (AIS).

Methods

This retrospective cross-sectional study took place in the Neurology Department of King Fahad Hospital of University, Khobar, Saudi Arabia, from April to October 2017. Data were collected from the medical records of 244 patients with a diagnosis of AIS confirmed by computed tomography. Doppler ultrasounds of the carotid artery were performed to determine the presence of increased carotid intima media thickness (CIMT) and plaques.

Results

Significantly higher mean glycated haemoglobin (HbA1c) levels were noted in cases with high CIMT values (P = 0.002), but not in cases with carotid plaques (P = 0.360). In addition, there was a significant association between diabetes mellitus (DM) and high CIMT (P = 0.045), but not with carotid plaques (P = 0.075). Finally, while dyslipidaemia and age were independently correlated with high CIMT values (P = 0.034 and <0.001, respectively) and carotid plaques (P <0.001 each), no independent relationships were noted in terms of gender and other risk factors like DM, hypertension and smoking (P >0.050 each).

Conclusion

High HbA1c levels were associated with high CIMT values, but not with carotid plaques. Therefore, HbA1c levels may be useful as an indirect marker of the initial stages of carotid artery atherosclerosis.

Evaluation of a CTA-Triage Based Transient Ischemic Attack Service: A Retrospective Single Center Cohort Study

OBJECTIVE

We designed a computed tomography angiography (CTA)-based algorithm for patients presenting to hospital with a transient ischemic attack (TIA) which identified high-risk patients, as well as inpatient versus semiurgent outpatient management following MRI, and we hypothesised that this would be effective.

METHODS

Patients seen in the ED at the Royal Adelaide Hospital from March 3, 2012 to November 30, 2016 with TIA-like symptoms were assessed for a cardioembolic source (clinical assessment, electrocardiogram) and underwent intra and extracranial CTA. Patients with a referable >50% stenosis were admitted and given dual antiplatelets. Most high-risk cardiac source patients were also admitted and anticoagulated. Other patients were loaded with aspirin, or changed to clopidogrel if on aspirin, and reviewed as outpatients following semiurgent MRI (3-4 days). We assessed the 90-day recurrent stroke risk in this cohort as a whole, and in those with a final cerebrovascular diagnosis.

RESULTS

1167 patients were diagnosed in Emergency as TIA and referred via our algorithm. A total of 150 were admitted, 78 had "high-risk" features. A total of 1017 patients were reviewed in the TIA clinic. The average age of the total cohort was 65.8 years old. Final diagnosis was TIA/minor stroke in 69% admitted patients and 30% clinic patients (P value < .0001). The 90-day recurrent stroke risk in these patients was 2.0% (5.8% admitted vs .7% clinic patients, P value < .0001). In those with noncerebrovascular diagnoses, there were no recurrent strokes within 90 days.

CONCLUSIONS

Stroke risk is very low using CTA guided semiurgent clinic review algorithm.

Assessment of boundary conditions for CFD simulation in human carotid artery

Computational fluid dynamics (CFD) is an increasingly used method for investigation of hemodynamic parameters and their alterations under pathological conditions, which are important indicators for diagnosis of cardiovascular disease. In hemodynamic simulation models, the employment of appropriate boundary conditions (BCs) determines the computational accuracy of the CFD simulation in comparison with pressure and velocity measurements. In this study, we have first assessed the influence of inlet boundary conditions on hemodynamic CFD simulations. We selected two typical patients suspected of carotid artery disease, with mild stenosis and severe stenosis. Both patients underwent digital subtraction angiography (DSA), magnetic resonance angiography, and the invasive pressure guide wire measured pressure profile. We have performed computational experiments to (1) study the hemodynamic simulation outcomes of distributions of wall shear stress, pressure, pressure gradient and (2) determine the differences in hemodynamic performances caused by inlet BCs derived from DSA and Womersley analytical solution. Our study has found that the difference is related to the severity of the stenosis; the greater the stenosis, the more the difference ensues. Further, in our study, the two typical subjects with invasively measured pressure profile and thirty subjects with ultrasound Doppler velocimeter (UDV) measurement served as the criteria to evaluate the hemodynamic outcomes of wall shear stress, pressure, pressure gradient and velocity due to different outlet BCs based on the Windkessel model, structured-tree model, and fully developed flow model. According to the pressure profiles, the fully developed model appeared to have more fluctuations compared with the other two models. The Windkessel model had more singularities before convergence. The three outlet BCs models also showed good correlation with the UDV measurement, while the Windkessel model appeared to be slightly better ([Formula: see text]). The structured-tree model was seen to have the best performance in terms of available computational cost and accuracy. The results of our numerical simulation and the good correlation with the computed pressure and velocity with their measurements have highlighted the effectiveness of CFD simulation in patient-specific human carotid artery with suspected stenosis.

[18F]-Fluorodeoxyglucose PET/CT imaging as a marker of carotid plaque inflammation: Comparison to immunohistology and relationship to acuity of events

BACKGROUND

[18F]-fluorodeoxyglucose (¹⁸FDG) uptake imaged with positron emission tomography (PET) and computed tomography (CT) may serve as a biomarker of plaque inflammation. This study evaluated the relationship between carotid plaque ¹⁸FDG uptake and a) intraplaque expression of macrophage and macrophage-like cellular CD68 immunohistology; b) intraplaque inflammatory burden using leukocyte-sensitive CD45 immunohistology; c) symptomatic patient presentation; d) time from last cerebrovascular event.

METHODS

54 patients scheduled for carotid endarterectomy underwent ¹⁸FDG PET/CT imaging. Maximum 18FDG uptake (SUV_max) and tissue-to-blood ratio (TBR_max) was measured for carotid plaques. Quantitative immunohistological analysis of macrophage-like cell expression (CD68) and leukocyte content (CD45) was performed.

RESULTS

¹⁸FDG uptake was related to CD68 macrophage expression (TBR_max: r = 0.51, p < 0.001), and total-plaque leukocyte CD45 expression (TBR_max: r = 0.632, p = 0.009, p < 0.001). ¹⁸FDG TBR_max uptake in carotid plaque associated with patient symptoms was greater than asymptomatic plaque (3.58 ± 1.01 vs. 3.13 ± 1.10, p = 0.008). ¹⁸FDG uptake differed between an acuity threshold of <90 days and >90 days (SUV_max:3.15 ± 0.87 vs. 2.52 ± 0.45, p = 0.015).

CONCLUSIONS

In this CAIN cohort, ¹⁸FDG uptake imaged with PET/CT serves a surrogate marker of intraplaque inflammatory macrophage, macrophage-like cell and leukocyte burden. 18FDG uptake is greater in plaque associated with patient symptoms and those with recent cerebrovascular events. Future studies are needed to relate ¹⁸FDG uptake and disease progression.

Factors associated with delay in carotid endarterectomy for patients with symptomatic severe internal carotid artery stenosis: a case-control study

BACKGROUND

The Canadian Best Practice Recommendations for Stroke Care (2008 update) recommend that patients with neurologic symptoms secondary to severe internal carotid artery stenosis undergo carotid endarterectomy within 14 days of symptom onset to prevent stroke. The purpose of this study was to identify patient and system factors associated with meeting, or failing to meet, the guideline.

METHODS

In this case-control study, potential study participants were identified through an electronic search of the Discharge Abstract Database. We reviewed the charts of patients who presented to our centre with neurologic symptoms ipsilateral to internal carotid artery stenosis of 70%-99% and underwent carotid endarterectomy in our centre between Jan. 1, 2009, and Dec. 31, 2014. We performed logistic regression analysis to identify factors associated with meeting, or failing to meet, the guideline.

RESULTS

Of the 412 patients who underwent carotid endarterectomy during the study period, 219 met the inclusion criteria. Sixty-seven patients (30.6%) met the 14-day guideline. Thirty (14.2%) of the 212 patients who could be classified as case or control subjects did not access the health care system within 14 days. Once in the health care system, failure to meet the guideline was associated with a presentation of amaurosis fugax (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05-0.96 compared to completed minor stroke) and presentation to a nonemergency outpatient setting (OR 9.08, 95% CI 2.51-32.80 compared to emergency department).

INTERPRETATION

Improvements in meeting the goal of carotid endarterectomy within 14 days of symptom onset for severe internal carotid artery stenosis should be directed at patient and system factors. A system for rapid diagnosis and referral of symptomatic patients to an appropriate surgeon should be established.

ACR Appropriateness Criteria® Cerebrovascular Disease

Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Cerebral ischemia and neuroregeneration

Cerebral ischemia is one of the leading causes of morbidity and mortality worldwide. Although stroke (a form of cerebral ischemia)-related costs are expected to reach 240.67 billion dollars by 2030, options for treatment against cerebral ischemia/stroke are limited. All therapies except anti-thrombolytics (i.e., tissue plasminogen activator) and hypothermia have failed to reduce neuronal injury, neurological deficits, and mortality rates following cerebral ischemia, which suggests that development of novel therapies against stroke/cerebral ischemia are urgently needed. Here, we discuss the possible mechanism(s) underlying cerebral ischemia-induced brain injury, as well as current and future novel therapies (i.e., growth factors, nicotinamide adenine dinucleotide, melatonin, resveratrol, protein kinase C isozymes, pifithrin, hypothermia, fatty acids, sympathoplegic drugs, and stem cells) as it relates to cerebral ischemia.

The effects of centralisation of vascular surgical services in the Bath, Bristol and Weston area on the carotid endarterectomy pathway

Introduction Patients who experience a transient ischaemic attack are at the highest risk of having a subsequent stroke immediately after their symptoms. A carotid endarterectomy should be performed on symptomatic, surgically suitable patients who present with a greater than 50% North American Symptomatic Carotid Endarterectomy Trial stenosis of the internal carotid artery within 2 weeks of their symptoms. This study aimed to determine whether the effectiveness of the carotid endarterectomy pathway has been impacted by the centralisation of vascular surgical services in the Bath, Bristol and Weston area. Materials and Methods From October 2013 to October 2015, critical steps in the patient carotid endarterectomy pathway that vascular surgeons from the Royal United Hospital Bath, Bristol Royal Infirmary and North Bristol NHS Trust input into the Royal College of Surgeons National Vascular Registry were collected. The dates of patient's symptoms, referral, first scan, surgical team review and surgery were analysed. Results Carotid endarterectomy data was collected for 261 patients. Overall, no significant difference in median time (days) from symptom to surgery from precentralisation data compared with post-centralisation data was seen (P = .175), with 65% patients meeting the national target of symptom to surgery in less than 14days. Discussion and Conclusion Centralisation has not significantly impacted the overall efficiency of the carotid endarterectomy pathway. This study highlights areas where improvement across the vascular network is required. This includes addressing the 35% patients that are not currently meeting the 14-day target and standardising the provision of care to outlying communities. Further follow-up is required to assess the longer term effects of centralisation.

Fast-Track Systems Improve Timely Carotid Endarterectomy in Stroke Prevention Outpatients

Background: For optimal stroke prevention, best practices guidelines recommend carotid endarterectomy (CEA) for symptomatic patients within two weeks; however, 2013 Ontario data indicated that only 9% of eligible patients from outpatient Stroke Prevention Clinics (SPCs) achieved this target. The goal of our study was to identify modifiable system factors that could enhance the quality and timeliness of care among patients needing urgent CEA. Methods: We conducted a retrospective chart review of transient ischemic attack/stroke patients assessed in Champlain Local Health Integrated Network SPCs between 2011 and 2014 who subsequently underwent CEA. Descriptive statistics were used to define patient characteristics, timelines from symptom onset to CEA, and system factors that contributed to delays or improvements in care. Multivariate analysis was used to determine statistically significant variations between groups. Results: Seventy-five records were eligible for study inclusion. Median time from initial symptoms to CEA was 31 days, with 21.3% of patients undergoing surgery within 2 weeks. Significant delays were common in patient presentation and assessment following symptom onset, wait times for vascular imaging and neurological assessment, and time from surgical assessment to CEA completion. Rapid testing and triage, coupled with collaborative initiatives among SPC, surgical, and radiology teams were associated with significantly improved timelines. Conclusions: Success factors for rapid CEA are multifaceted, including system changes that address public awareness of stroke and 911 response, improvements in vascular imaging access, and redesign of clinical services to promote collaboration and fast-tracking of care. Implementation of performance measures to monitor and guide clinical innovations is recommended.

Secondary prophylactic treatment and long-term prognosis after TIA and different subtypes of stroke. A 25-year follow-up hospital-based observational study

OBJECTIVES

To assess long-term prognosis after transient ischemic attack (TIA)/subtypes of stroke relative to secondary prophylactic treatment(s) given.

MATERIALS AND METHODS

Retro/prospective follow-up of patients hospitalized in the Stroke Unit or in the Department of Neurology, Linköping, in 1986 and followed up to Feb. 2011.

RESULTS

A total of 288 men were followed up for 2254 years (mean 7.8 years) and 261 women for 1984 years (mean 7.6 years). In men, the distribution to anticoagulants (AC) (warfarin treatment) was 18%, antiplatelet therapy (APT) usually ASA 75 mg/day 54%, untreated 27%, unknown 2%. In women, the distribution to AC was 15%, APT 60%, untreated 23%, unknown 2%, respectively. Mortality rates at 1 year, 10 years, and 25 years for men were 21%, 67%, and 93%, respectively, versus the rates in women of 24%, 71%, and 90%, respectively. Survival curves showed markedly increased risk of death compared to the normal population. AC treatment was more favorable for men regarding the annual risk of stroke, compared with APT (9.4% vs. 9.8%), as well as the risks of MI, (5.6% vs. 6.7%), and death (8.1% vs. 10.3%), compared to women for stroke (11.6% vs. 8.8%) and MI (5.3% vs. 3.7%) but not for death (8.3% vs. 8.4%). The risk of fatal bleeding was 0.86% annually on AC compared to 0.17% on APT. According to Cox regression analysis included patients with TIA/ischemic stroke, first-line treatment had beneficial effects on survival: AC OR 0.67 (0.5-0.9), APT 0.67 (0.52-0.88) versus untreated.

CONCLUSIONS

Patients with a history of TIA/stroke had a higher mortality rate versus controls, providing support for both primary and secondary prophylaxis regarding vascular risk factors for death. This study also provided support for secondary prophylactic treatment with either AC or ASA (75 mg once daily) to reduce the vascular risk of death unless there are contraindications.

Efficacy of Early Superficial Temporal Artery-Middle Cerebral Artery Double Anastomoses for Atherosclerotic Occlusion in Patients with Progressing Stroke

BACKGROUND

We investigated the efficacy of early superficial temporal artery-middle cerebral artery (STA-MCA) double anastomoses for patients with progressing stroke due to atherosclerotic occlusion.

MATERIALS AND METHODS

Nine consecutive patients who underwent early STA-MCA double anastomoses were enrolled. All patients presented with progressing stroke despite maximal medical treatment. Cerebral blood flow in 7 patients was analyzed by single-photon emission tomography. Clinical outcomes were investigated postoperatively, and we evaluated the utility of early STA-MCA double anastomoses.

RESULTS

Nine patients in the present study included those with middle cerebral artery occlusion (n = 6) and internal carotid artery occlusion (n = 3). The mean age was 58.4 years. Subjects comprised 1 female (11.1%) and 8 males (88.9%). The cause was low perfusion ischemia due to atherosclerotic occlusion with a small infarct. The mean regional cerebral blood flow (rCBF) ratio in the middle cerebral artery territory compared to the normal side was 69.6 ± 5.3%. The duration from onset to surgery was 1-8 days (median, 3.11 days). All patients underwent early STA-MCA double anastomoses, and no reperfusion-induced hemorrhage occurred. All of them slowly achieved obvious remission compared to symptoms on admission and achieved a good functional outcome.

CONCLUSIONS

Early STA-MCA double anastomoses were safe and effective, and early revascularization resulted in rapid neurological improvement. We recommend this procedure for patients with progressive ischemia due to main trunk artery occlusion, when the rCBF flow ratio with the normal side was 70 ± 10%, even at the subacute stage.

An institutional study of time delays for symptomatic carotid endarterectomy

OBJECTIVE

The aim of this study was to assess time delays between first cerebrovascular symptoms and carotid endarterectomy (CEA) at a single center and to systematically evaluate causes of these delays.

METHODS

Consecutive adult patients who underwent CEAs between January 2010 and September 2011 at a single university-affiliated center (Centre Hospitalier de l'Université Montréal-Hôtel-Dieu Hospital, Montreal) were identified from a clinical database and operative records. Covariates of interest were extracted from electronic medical records. Timing and nature of the first cerebrovascular symptoms were also documented. The first medical contact and pathway of referral were also assessed. When possible, the ABCD² score (age, blood pressure, clinical features, duration of symptoms, and diabetes) was calculated to calculate further risk of stroke. The nonparametric Wilcoxon test was used to assess differences in time intervals between two variables. The Kruskal-Wallis test was used to assess differences in time intervals in comparing more than two variables. A multivariate linear regression analysis was performed using covariates that were determined to be statistically significant in our sensitivity analyses.

RESULTS

The cohort consisted of 111 patients with documented symptomatic carotid stenosis undergoing surgical intervention. Thirty-nine percent of all patients were operated on within 2 weeks from the first cerebrovascular symptoms. The median time between the occurrence of the first neurologic symptom and the CEA procedure was 25 (interquartile range [IQR], 11-85) days. The patient-dependent delay, defined as the median delay between the first neurologic symptom and the first medical contact, was 1 (IQR, 0-14) day. The medical-dependent delay was defined as the time interval between the first medical contact and CEA. This included the delay between the first medical contact and the request for surgery consultation (median, 3 [IQR, 1-10] days). The multivariate regression model demonstrated that the emergency physician as referral source (P = .0002) was statistically significant for reducing CEA delay. Patients who were investigated as an outpatient (P = .02), first medical contact with a general practitioner (P = .0002), and hospital center I as referral center (P = .045) were also found to be statistically significant to extend CEA delay when the model was adjusted over all covariates. In this center, there was no correlation between ABCD² risk score and waiting time for surgery.

CONCLUSIONS

The majority of our cohort falls short of the recommended 2-week interval to perform CEA. Factors contributing to reduced CEA delay were presentation to an emergency department, in-patient investigations, and a stroke center where a vascular surgeon is available.

Transient Ischemic Attack Versus Seizure: Use of Complete Blood Count Parameters for Differential Diagnosis

INTRODUCTION

Seizures are an important group of diagnoses in the differential evaluation of Transient Ischemic Attack (TIA)because of their variable and temporary signs and symptoms. Physicians must frequently rule out TIA in asymptomatic patients with normal diagnostic neuroimaging.

AIM

The current study aimed to investigate the efficacy of Complete Blood Count (CBC) components in the differential diagnosis of TIA and seizures.

MATERIALS AND METHODS

Our study was a retrospective case-control study. Patients admitted to the Emergency Department (ED) and hospitalized with an initial diagnosis of TIA or seizure at the neurology clinic of Erzurum Ataturk University Training Hospital between January 1, 2012, and December 31, 2014, were recruited for the study. Patients with inaccessible or missing data were excluded.

RESULTS

We identified 1,459 ED admissions that resulted in neurology clinic hospitalizations of patients with initial diagnoses of TIA (n=911) and seizure (n=420) over a 24-month time period. A total of 128 patients were excluded from the study.

CONCLUSION

We conclude that CBC may have a diagnostic value on TIA and seizure differentiation, but this is limited because of statistical and clinical incompatibility. Elevated White Blood Cells (WBC) values of seizure patients compared with TIA patients' may help clinicians at the preliminary phase of diagnostic studies. We conclude that age is a remarkable and valuable demographic parameter in addition to physical examination, laboratory and imaging studies.

Multiparametric Approach Enhances Detection of Patients with Cerebral TIAs at Risk of Stroke: A Prospective Pilot Case Series

BACKGROUND

Patients with transient ischemic attack (TIA) are generally clinically unstable, with fear of developing a handicapping stroke. Identification of those at highest and lowest risk of stroke in the first days and weeks after a TIA would allow appropriate use of worthy secondary prevention strategies.

OBJECTIVE

Incorporation of a clinical scoring system, neurovascular imaging, and magnetic resonance-diffusion-weighted imaging (MR-DWI) to help predicting risk of developing an ischemic stroke following a TIA.

SUBJECTS AND METHODS

A prospective observational study was conducted on 25 patients with TIAs, 64% were females, and 26% were males, with a mean age of 57±10.36. Patients were assessed clinically and an ABCD(2) score was applied. Patients have undergone diffusion-weighted imaging (DWI), within 24 h from the event, and intra- and extracranial duplex study. Patients were followed up at intervals of one week, three months, six months, and one year.

RESULTS

Six patients (24%) developed stroke on their follow-up, most of them (83.3%) had their strokes within the first three months and had an initial ABCD(2) score of ≥4. The development of stroke was associated with the presence of significant extra and/or intracranial vessel disease (P=0.006) and the presence of acute lesions on their DWI (P=0.035).

CONCLUSION

Incorporation of brain MR-DWIs and neurovascular imaging together with the ABCD(2) score improves prediction of ischemic stroke following TIA.

Risk Factors for Silent Lacunar Infarction in Patients with Transient Ischemic Attack

Background

Lacunar infarctions represent 25% of ischemic strokes. Lacunar stroke and transient ischemic attack (TIA) share a number of symptoms. This study aimed to assess the potential risk factors for lacunar infarction in patients with TIA.

Material/Methods

This was a retrospective study performed at the Beijing Military General Hospital in patients with TIA admitted between March 2010 and December 2011. Patients were grouped according to lacunar vs. no lacunar infarction. All patients were diagnosed using diffusion-weighted imaging (DWI) on brain magnetic resonance imaging (MRI). Brain angiography (computed tomography and MRI) was used to measure intracranial stenosis. Carotid artery stenosis was measured by ultrasound.

Results

Patients with TIA and lacunar infarction (n=298) were older than those without lacunar infarction (n=157) (69.4±10.0 vs. 58.9±9.0 years, P<0.001) and showed a higher frequency of males (51.7% vs. 41.4%, P=0.037), hypertension (75.3% vs. 45.9%, P<0.001), diabetes (32.6% vs. 21.0%, P=0.010), hyperlipidemia (53.4% vs. 29.3%, P<0.001), carotid stenosis (73.2% vs. 40.1%, P<0.001), and intracranial stenosis (55.6% vs. 31.9%, P<0.001), but a lower frequency of alcohol drinking (8.1% vs. 14.0%, P=0.045). Lacunar infarction mostly involved the anterior circulation (62.8%). Multivariate analysis showed that age (odds ratio (OR)=1.085, 95% confidence interval (95%CI): 1.054–1.117, P<0.001), hypertension (OR=1.738, 95%CI: 1.041–2.903, P=0.035), hyperlipidemia (OR=2.169, 95%CI: 1.307–3.601, P=0.003), and carotid stenosis (OR=1.878, 95%CI: 1.099–3.206, P=0.021) were independently associated with lacunar infarction.

Conclusions

Age, hypertension, hyperlipidemia, and carotid stenosis were independently associated with silent lacunar infarction in patients with TIA.

Symptomatic carotid stenosis and stroke risk in patients with transient ischemic attack according to the tissue-based definition

BACKGROUND AND PURPOSE

Symptomatic carotid stenosis (sCS), a common cause of transient ischemic attack (TIA), is correlated with higher stroke risk. We investigated the frequency and associated factors of sCS in patients with TIA and the association between sCS and stroke risk following TIA.

METHODS

Over a three-year period (2011-2013), 861 consecutive patients with TIA, who were admitted to the Department of Neurology at the University of Lübeck, Germany, were included in a monocenter study and prospectively evaluated. Diagnosis of TIA was in accordance with the tissue-based definition (transient neurological symptoms without evidence of infarction by brain imaging).

RESULTS

Of 827 patients (mean age, 70 ± 13.2 years; 49.7% women), 64 patients (7.7%; 95% confidence interval [CI], 5.9%-9.7%) exhibited sCS and 3 patients (0.3%) showed an occlusion of the corresponding internal carotid artery. Logistic regression revealed that sCS was associated with male sex (odds ratio [OR], 2.7; 95% CI, 1.2-3.6; p = 0.012), amaurosis fugax (OR, 8.1; 95% CI, 3.4-19-4; p < 0.001), unilateral weakness (OR, 3.4; 95% CI, 1.9-6.1; p < 0.001), symptom duration less than 1 h (OR, 2.0; 95% CI, 1.1-3.4; p = 0.019) and previous stroke (OR, 2.7; 95% CI, 1.5-4.7; p = 0.001). During hospitalization (mean, 6.6 days), five patients (0.6%; 95% CI, 0.1%-1.2%) suffered from stroke. The stroke risk was higher in patients with sCS than in those without sCS (6.3% vs. 0.1%; p < 0.001), whereas the recurrent TIA risk (2.6%) did not differ between the groups (4.7% vs. 2.5%; p = 0.29).

CONCLUSION

SCS appears to be associated with a higher risk of stroke in patients with TIA defined according to the tissue-based definition.

ABCD2 score and secondary stroke prevention: meta-analysis and effect per 1,000 patients triaged

OBJECTIVE

Patients with TIA have high risk of recurrent stroke and require rapid assessment and treatment. The ABCD2 clinical risk prediction score is recommended for patient triage by stroke risk, but its ability to stratify by known risk factors and effect on clinic workload are unknown.

METHODS

We performed a systematic review and meta-analysis of all studies published between January 2005 and September 2014 that reported proportions of true TIA/minor stroke or mimics, risk factors, and recurrent stroke rates, dichotomized to ABCD2 score </≥4. We calculated the effect per 1,000 patients triaged on stroke prevention services.

RESULTS

Twenty-nine studies, 13,766 TIA patients (range 69-1,679), were relevant: 48% calculated the ABCD2 score retrospectively; few reported on the ABCD2 score's ability to identify TIA mimics or use by nonspecialists. Meta-analysis showed that ABCD2 ≥4 was sensitive (86.7%, 95% confidence interval [CI] 81.4%-90.7%) but not specific (35.4%, 95% CI 33.3%-37.6%) for recurrent stroke within 7 days. Additionally, 20% of patients with ABCD2 <4 had >50% carotid stenosis or atrial fibrillation (AF); 35%-41% of TIA mimics, and 66% of true TIAs, had ABCD2 score ≥4. Among 1,000 patients attending stroke prevention services, including the 45% with mimics, 52% of patients would have an ABCD2 score ≥4.

CONCLUSION

The ABCD2 score does not reliably discriminate those at low and high risk of early recurrent stroke, identify patients with carotid stenosis or AF needing urgent intervention, or streamline clinic workload. Stroke prevention services need adequate capacity for prompt specialist clinical assessment of all suspected TIA patients for correct patient management.

Stroke prevention

The short-term risk of stroke after transient ischemic attack (TIA) is about 10% to 20% in the first 3 months, with much of the risk front-loaded in the first week. Unfortunately, little is known about the best therapies for hyperacute stroke prevention after TIA. A recent trial referred to by the acronym MATCH (for Management of Atherothrombosis With Clopidogrel in High-risk Patients With Recent Transient Ischemic Attack or Ischemic Stroke) provides hypothesis-generating data to suggest that double antiplatelet therapy in the short term may be appropriate. Here, the authors discuss treatment considerations, outlining the current knowledge and stressing the need for formal randomized trials to definitively establish the effectiveness of preventive therapies after minor stroke or TIA.

Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis

BACKGROUND

The aim of this study was to compare outcomes of early (<15 days) versus delayed carotid endarterectomy (CEA) in symptomatic patients.

METHODS

All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and myocardial infarction (MI) rates were analyzed in the early and delayed CEA groups.

RESULTS

During the study period, 149 patients were included. Carotid revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%) patients. The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range 1-15) in the early surgery group and 47.9 days (range 16-157) in the delayed surgery group. Thirty-day combined stroke and death rates were, respectively, 1.7% and 3.5% in the early and the delayed surgery groups. Thirty-day combined stroke, death, and MI rates were, respectively, 1.7% and 5.9% in the early and the delayed surgery groups.

CONCLUSION

During the study period, the reduction of the symptom-to-knife time in application to the carotid revascularization guidelines did not impact our outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA.

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

BACKGROUND

Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.

OBJECTIVES

Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention?

DATA SOURCES

Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.

REVIEW METHODS

Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.

RESULTS

The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective.

LIMITATIONS

Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.

CONCLUSIONS

Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Carotid Revascularization: An Update

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.

Recommendations for the evaluation and management of observation services: a consensus white paper: the Society of Cardiovascular Patient Care

Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. A well-structured observation program will help hospitals reduce the number of inappropriate, costly inpatient admissions while avoiding the potential of inappropriate discharges. Observation medicine is a complicated multidimensional issue that has generated much confusion. This service is designed to provide the best possible patient care in a value-based purchasing environment where quality, cost, and patient satisfaction must continually be addressed. Observation medicine is a service not a status. Therefore, patients are admitted to the service as outpatients no matter whether they are placed in a virtual or dedicated observation unit. The key to a successful observation program is to determine how to maximize efficiencies. This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.

Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death

INTRODUCTION

The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA.

METHODS

Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year.

RESULTS

We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified.

CONCLUSIONS

In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.

Differentiation of true transient ischemic attack versus transient ischemic attack mimics

BACKGROUND

Previous literatures have shown a transient ischemic attack (TIA) mimic rate of 9-31%. We aimed to ascertain the proportion of stroke mimics amongst suspected TIA patients.

METHODS

A prospective observational study was performed in Ghaem Hospital, Mashhad, Iran during 2012-2013. Consecutive TIA patients were identified in a stroke center. The initial diagnosis of TIA was made by the resident of neurology and final diagnosis of true TIA versus TIA mimics was made after 3 months follow-up by stroke subspecialist.

RESULTS

A total of 310 patients were assessed during a 3-month period of which 182 (58.7%) subjects were male and 128 (41.3%) were female. Ten percent of the patients was categorized as a TIA mimic. The presence of hypertension, aphasia, duration of symptoms, and increased age was the strongest predictor of a true TIA. Migraine was the most common etiology of stroke mimic in our study.

CONCLUSION

It seems that many signs and symptoms have low diagnostic usefulness for discrimination of true TIA from non-cerebrovascular events and predictive usefulness of any sign or symptom should be interpreted by a stroke neurologist.

Carotid stenosis management: a review for the internist

Stroke is one of the most important causes of mortality and morbidity worldwide and, for a long time, was the leading cause of death in developed countries. Atherothrombotic carotid stenosis is one of the most important etiologies behind this event. If properly recognized and treated, lives can be saved, as well as long-term disabilities prevented. With population aging and improvements in surgical and clinical care, patients with several comorbidities will be referred for revascularization procedures more frequently, posing a challenge for physicians. The purpose of this review is to provide internists and clinicians with information based on several studies so they can offer to their patients, the best evidence-based care, indicating appropriate medical therapy, as well as referral to a vascular surgeon, or what contraindicates endarterectomy or angioplasty, depending on individual characteristics.

Can shape analysis differentiate free-floating internal carotid artery thrombus from atherosclerotic plaque in patients evaluated with CTA for stroke or transient ischemic attack?

RATIONALE AND OBJECTIVES

Patients presenting with transient ischemic attack or stroke may have symptom-related lesions on acute computed tomography angiography (CTA) such as free-floating intraluminal thrombus (FFT). It is difficult to distinguish FFT from carotid plaque, but the distinction is critical as management differs. By contouring the shape of these vascular lesions ("virtual endarterectomy"), advanced morphometric analysis can be performed. The objective of our study is to determine whether quantitative shape analysis can accurately differentiate FFT from atherosclerotic plaque.

MATERIALS AND METHODS

We collected 23 consecutive cases of suspected carotid FFT seen on CTA (13 men, 65 ± 10 years; 10 women, 65.5 ± 8.8 years). True-positive FFT cases (FFT+) were defined as filling defects resolving with anticoagulant therapy versus false-positives (FFT-), which remained unchanged. Lesion volumes were extracted from CTA images and quantitative shape descriptors were computed. The five most discriminative features were used to construct receiver operator characteristic (ROC) curves and to generate three machine-learning classifiers. Average classification accuracy was determined by cross-validation.

RESULTS

Follow-up imaging confirmed sixteen FFT+ and seven FFT- cases. Five shape descriptors delineated FFT+ from FFT- cases. The logistic regression model produced from combining all five shape features demonstrated a sensitivity of 87.5% and a specificity of 71.4% with an area under the ROC curve = 0.85 ± 0.09. Average accuracy for each classifier ranged from 65.2%-76.4%.

CONCLUSIONS

We identified five quantitative shape descriptors of carotid FFT. This shape "signature" shows potential for supplementing conventional lesion characterization in cases of suspected FFT.

The need for emergency treatment of transient ischemic attack and minor stroke

The risk of recurrent stroke following transient ischemic attack or minor stroke has recently been shown to be 5-10% at 1 week and 10-20% at 3 months, depending on study population and methods. This is considerably higher than previously estimated and current clinical guidelines reflect the need for rapid assessment although a wide variation in practice exists. Effective management of patients with transient ischemic attack or minor stroke, therefore, requires identification of individuals at the highest (and lowest) risk and initiation of appropriate secondary prevention. Risk can be stratified at initial presentation by the presence or absence of simple clinical features and following subsequent investigation. For transient ischemic attack patients, older age, diabetes, longer duration of symptoms and weakness or speech disturbance identify patients at highest risk, as does the presence of large artery atherosclerosis (mainly internal carotid artery stenosis) and lesions on diffusion-weighted magnetic resonance imaging. Strong evidence exists for the benefit of some early interventions (carotid endarterectomy and antiplatelet agents), but is circumstantial or awaited for others (statins and antihypertensives). In order for the public health challenge posed by transient ischemic attack and minor stroke to be met, considerable change is required in both public education (to ensure correct recognition of symptoms and swift presentation to medical attention) and the provision of clinical services to ensure the timely initiation of effective treatment.