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Li LD, Zhou Y, Shi SF. Edaravone combined with Shuxuening versus edaravone alone in the treatment of acute cerebral infarction: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e32929. [PMID: 36862906 PMCID: PMC9981379 DOI: 10.1097/md.0000000000032929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Shuxuening injection (SXN) is a traditional Chinese medicine used in the treatment of cardiovascular diseases. Whether it can provide better outcomes when combined with edaravone injection (ERI) for the treatment of acute cerebral infarction is not well determined. Therefore, we evaluated the efficacy of ERI combined with SXN versus that of ERI alone in patients with acute cerebral infarction. METHODS PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and Wanfang electronic databases were searched up to July 2022. Randomized controlled trials comparing the outcomes of efficacy rate, neurologic impairment, inflammatory factors, and hemorheology were included. Odds ratio or standard mean difference (SMD) with corresponding 95% confidence intervals (CIs) were used to present the overall estimates. The quality of the included trials was evaluated by the Cochrane risk of bias tool. The study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. RESULTS Seventeen randomized controlled trials were included consisting of 1607 patients. Compared to ERI alone, treatment with ERI plus SXN had a greater effective rate than ER alone (odds ratio = 3.94; 95% CI: 2.85, 5.44; I2 = 0%, P < .00001), a lower National Institute of Health Stroke Scale (SMD= -1.39; 95% CI: -1.73, -1.05; I2 = 71%, P < .00001), lower neural function defect score (SMD= -0.75; 95% CI: -1.06,-0.43; I2 = 67%, P < .00001), and lower level of neuron-specific enolase (SMD= -2.10; 95% CI: -2.85, -1.35; I2 = 85%, P < .00001). ERI plus SXN treatment provided significant improvements in whole blood high shear viscosity (SMD = -0.87; 95% CI: -1.17, -0.57; I2 = 0%, P < .00001), and whole blood low shear viscosity (SMD = -1.50; 95% CI: -1.65, -1.36; I2 = 0%, P < .00001) compared to ERI alone. CONCLUSION ERI plus SXN showed better efficacy than ERI alone for patients with acute cerebral infarction. Our study provides evidence supporting the application of ERI plus SXN for acute cerebral infarction.
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Affiliation(s)
- Liang-Da Li
- Department of Neurology, The People’s Hospital Affiliated to Ningbo University, Ningbo, Zhejiang Province, China
- * Correspondence: Liang-Da Li, Department of Neurology, The People’ s Hospital Affiliated to Ningbo University, No. 251, Baizhang East Road, Yinzhou District, Ningbo, Zhejiang Province 315040, China (e-mail: )
| | - Yue Zhou
- Department of Neurology, The People’s Hospital Affiliated to Ningbo University, Ningbo, Zhejiang Province, China
| | - Shan-Fen Shi
- Department of Rheumatology, The People’s Hospital Affiliated to Ningbo University, Ningbo, Zhejiang Province, China
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Maximiliano CL, Jaime GC, Erika MH. Rivaroxaban plus aspirin versus acenocoumarol to manage recurrent venous thromboembolic events despite systemic anticoagulation with rivaroxaban. Thromb Res 2023; 222:43-48. [PMID: 36565679 DOI: 10.1016/j.thromres.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/09/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The evaluation and management of patients who sustain recurrent thromboembolic events while taking therapeutic anticoagulation have not been well characterized; moreover, there has been no systematic review or randomized trial focused on treating patients with recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE) during anticoagulant treatment. Therefore, we developed a pilot trial to compare rivaroxaban plus aspirin versus acenocoumarol in patients with recurrent venous thromboembolism despite ongoing anticoagulation with rivaroxaban. MATERIALS AND METHODS The study was a multicenter, randomized clinical trial. We randomly assigned patients with objectively documented recurrent venous thromboembolism to receive rivaroxaban (20 mg once a day) plus aspirin (300 mg once a day) or an adjusted dose of acenocoumarol. The study was designed to evaluate the incidence of recurrent thromboembolic events (recurrent ipsilateral or contralateral DVT, PE, ischemic stroke, and myocardial infarction) and hemorrhagic events. RESULTS A total of 58 patients were randomized: 28 were allocated to the rivaroxaban plus aspirin group and 30 to the acenocoumarol group. After 90 days of follow-up, three recurrent thromboembolic events (primary outcome) occurred in the acenocoumarol group - two DVTs and one ischemic stroke - and zero events in the rivaroxaban plus aspirin group (risk ratio [RR] 0.15; 95 % confidence interval [CI] 0.008-2.83; P = 0.20). Minor bleeding occurred in five patients in the acenocoumarol group and zero in the rivaroxaban plus aspirin group (RR 0.09; 95 % CI 0.005-1.68; p = 0.10). There was one non-fatal gastrointestinal major bleed in the rivaroxaban plus aspirin group. CONCLUSIONS In this pilot study, there were no significant differences in any outcome assessed; however, recurrent thromboembolic events and minor bleeding events occurred numerically less frequently in the rivaroxaban plus aspirin group. These data suggest the need to carry out more extensive randomized studies with sufficient statistical power to clarify these results.
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Affiliation(s)
- Correa Lara Maximiliano
- Centro Medico Nacional "La Raza", Instituto Mexicano del Seguro Social, Mexico City, Mexico; Environmental Toxicology Laboratory, Instituto Politécnico Nacional, Mexico.
| | - García Chavez Jaime
- Centro Medico Nacional "La Raza", Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Truong T, Koh Y, Yosufi R, Marangou J, Slack-Smith L, Katzenellenbogen JM. Understanding valvular heart disease in the dental setting. Aust Dent J 2021; 66:254-261. [PMID: 33448018 DOI: 10.1111/adj.12821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Limited evidence is available regarding dentists' knowledge and interpretation of infective endocarditis (IE) prophylaxis guidelines. The aim of this study was to determine understanding and management of rheumatic and non-rheumatic valvular heart disease (VHD) in the dental setting in Western Australia (WA). METHODS A cross-sectional survey of dentists within Perth utilized an online Qualtrics questionnaire developed after consultation with stakeholders. A sampling frame was compiled from the Australian Health Practitioner Regulation Agency with contact details obtained from the White Pages (online), using five quintiles of Socio-Economic Indexes for Areas according to dentist's place of practice. RESULTS Of 41 (13.7% of 300 approached) dentists completing the survey (95.1% general dentists, mean years of practice = 15.6), 90.2% reported following the Australian Therapeutic Guidelines (ATG) regarding IE antibiotic prophylaxis in VHD. Most (92.7%) were unaware of the rheumatic heart disease (RHD) control program. Nearly all participants indicated prophylaxis for clearly invasive procedures such as tooth extraction (100.0%) and periodontal surgery (95.1%). Many dentists made the decision to prescribe antibiotics themselves (36.6%). CONCLUSIONS The majority of dentists followed the ATG's IE prophylaxis recommendations for cardiac lesions and dental procedures. There was limited knowledge of the national RHD guidelines and the WA RHD control program.
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Affiliation(s)
- T Truong
- UWA Dental School, The University of Western Australia, Perth, WA, Australia
| | - Y Koh
- UWA Dental School, The University of Western Australia, Perth, WA, Australia
| | - R Yosufi
- UWA Dental School, The University of Western Australia, Perth, WA, Australia
| | - J Marangou
- Department of Cardiology, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA, Australia.,Department of Health Western Australia, Perth, WA, Australia
| | - L Slack-Smith
- UWA Dental School, The University of Western Australia, Perth, WA, Australia.,School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - J M Katzenellenbogen
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia.,Telethon Kids Institute, Perth, WA, Australia
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Chandra A, Stone CR, Du X, Li WA, Huber M, Bremer R, Geng X, Ding Y. The cerebral circulation and cerebrovascular disease III: Stroke. Brain Circ 2017; 3:66-77. [PMID: 30276307 PMCID: PMC6126259 DOI: 10.4103/bc.bc_12_17] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 06/15/2017] [Accepted: 06/21/2017] [Indexed: 01/18/2023] Open
Abstract
In this paper, our review series on cerebrovascular disease anatomy, physiology, and pathology ends with a thorough discussion of the most significant cerebrovascular pathology: stroke. This discussion proceeds through two layers of organization. First, stroke is divided up into its main etiologic categories (ischemic stroke/transient ischemic attack, hemorrhagic stroke, and ischemic to hemorrhagic transformation). Then, the epidemiological, pathophysiological, clinical, and therapeutic (employed currently as well as emerging) aspects of each etiology are explored; emphasis is placed upon the therapeutic aspects. Finally, once we have covered all aspects of each etiologic category, we end our review with a defense of the thesis that there is much hope for the future of stroke treatment to be derived from familiarity with the literature on emerging therapies.
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Affiliation(s)
- Ankush Chandra
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Christopher R. Stone
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiangnan Du
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - William A. Li
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mitchell Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Richard Bremer
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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G894T endothelial nitric oxide synthase polymorphism and ischemic stroke in Morocco. Meta Gene 2014; 2:349-57. [PMID: 25606419 PMCID: PMC4287825 DOI: 10.1016/j.mgene.2014.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/18/2014] [Accepted: 04/03/2014] [Indexed: 11/24/2022] Open
Abstract
Nitric oxide plays a major role in the regulation of cerebral blood flow and loss of its function leads to alteration of the vascular relaxation given its central role in the physiology of the vascular system. G894T eNOS polymorphism could have adverse effects on the expression and activity of endothelial nitric oxide synthase, which can result in functional impairment of the endothelium and contribute to the development of ischemic stroke in the different models of transmission. In this study, genotyping with PCR-RFLP and HRM (high resolution melting) methods were conducted on 165 ischemic stroke patients as well as 182 controls. The goal here was to compare genotyping with PCR-RLFP primer sequences of eNOS gene (size < 300 bp) to HRM. Our data suggests a statistically significant association between G894T eNOS polymorphism and ischemic stroke in recessive, dominant and additive models with P < 0.05 and odds ratio of 2.68 (1.08-6.70), 1.78 (1.16-2.73), and 1.71 (1.21-2.43) respectively. In sum, although the sample size is relatively small, it suggests that G894T eNOS polymorphism could be a potentially important genetic marker of ischemic stroke in the Moroccan population. Future studies should be conducted in this direction taking into consideration the functional activity of eNOS.
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Key Words
- 894T eNOS, mutant allele of endothelial nitric oxide synthase
- AB, applied biosystems
- CI, confidence interval
- DNA, deoxyribonucleic acid or deoxyribose nucleic acid
- Fig., figure
- G894T eNOS
- G894T eNOS, replacement guanine by thymine at position 894 of the endothelial nitric oxide synthase
- GG eNOS, homozygous wild of endothelial nitric oxide synthase
- GT eNOS, heterozygous mutant of endothelial nitric oxide synthase
- Genetics models
- HRM, high resolution melt
- IS, ischemic stroke
- Ischemic stroke
- LGPM, genetic and molecular pathology laboratory
- NO, nitric oxide
- OR, odds ratio
- P, P value
- PCR-RFLP, polymerase chain reaction-restriction fragment length polymorphism
- Ref., reference
- TOAST, Trial of Org 10172 in Acute Stroke Treatment
- TT eNOS, homozygous mutant of endothelial nitric oxide synthase
- bp, base pair
- eNOS, endothelial nitric oxide synthase
- vs, versus
- χ2, chi square
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Amin H, Greer DM. Cryptogenic Stroke—The Appropriate Diagnostic Evaluation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 16:280. [DOI: 10.1007/s11936-013-0280-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Influence of transoesophageal echocardiography on therapy and prognosis in young patients with TIA or ischaemic stroke. Neth Heart J 2011; 17:373-7. [PMID: 19949646 DOI: 10.1007/bf03086287] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Objective. To determine the influence of transoesophageal echocardiography (TEE) on therapy and prognosis in patients with cryptogenic transient ischaemic attack (TIA) or ischaemic stroke under the age of 50 years.Methods and results. We evaluated all patients aged 50 and under who were referred to our university hospital for cryptogenic TIA or ischaemic stroke during the period 1 January 1996 to 31 December 2004. All patients underwent both transthoracic echocardiography (TTE) and TEE. Patients with known pre-existent heart disease, such as atrial fibrillation, were excluded. Eighty-three patients with TIA (22) and ischaemic stroke (61) were enrolled. Mean age was 39+/-8 years (range 18 to 50). In 30% of the patients TEE detected one or more potential cardioembolic source, compared with 10% for TTE (p=0.003). Standard treatment (aspirin 38 mg daily) was changed in 7% of the patients due to the TEE findings. Complete followup was obtained in 93% with an average of 5+/-3 years. Twelve recurrences occurred; two out of six patients (33%) with therapy change and ten out of 71 (14%) of the patients without therapy change had a recurrent TIA or ischaemic Stroke.Conclusion. In patients with cryptogenic TIA or ischaemic stroke, TEE is superior to TTE in the detection of a potential cardiac source of embolism. However, findings obtained by TEE only influence the already initiated treatment in a small percentage of patients. The recurrence rate both in the group with and without therapy change is high. (Neth Heart J 2009;17:373-7.).
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Laufs U, Hoppe UC, Rosenkranz S, Kirchhof P, Böhm M, Diener HC, Endres M, Grond M, Hacke W, Meinertz T, Ringelstein EB, Röther J, Dichgans M. [Cardiac workup after cerebral ischemia. Consensus paper of the Working Group on Heart and Brain of the German Cardiac Society and German Stroke Society]. DER NERVENARZT 2010; 81:444-62. [PMID: 20177655 DOI: 10.1007/s00115-009-2901-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- U Laufs
- Klinik für Innere Medizin III, Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, 66421 Homburg.
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Laufs U, Hoppe UC, Rosenkranz S, Kirchhof P, Böhm M, Diener HC, Endres M, Grond M, Hacke W, Meinertz T, Ringelstein EB, Röther J, Dichgans M. Cardiological evaluation after cerebral ischaemia. Clin Res Cardiol 2010; 99:609-25. [DOI: 10.1007/s00392-010-0200-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 07/08/2010] [Indexed: 01/04/2023]
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Saidi S, Mallat SG, Almawi WY, Mahjoub T. Endothelial nitric oxide synthase Glu298Asp, 4b/a, and -786T>C gene polymorphisms and the risk of ischemic stroke. Acta Neurol Scand 2010; 121:114-9. [PMID: 19804474 DOI: 10.1111/j.1600-0404.2009.01192.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Endothelial nitric oxide synthase (eNOS) gene polymorphisms were associated with reduced NO production, and were evaluated as risk factors for ischemic stroke (IS). We investigated the association between eNOS gene -786T>C (promoter), 27-bp repeat 4b/4a (intron 4), and Glu298Asp (exon 7) polymorphisms with IS in 329 IS patients and 444 controls. MATERIALS AND METHODS Glu298Asp and -786T>C genotyping was done by PCR-RFLP, 4b/4a was assessed by PCR-ASA. The contribution of eNOS polymorphisms to IS was analyzed by haplotype and multivariate regression analysis. RESULTS Higher frequency of 298Asp allele was seen in IS patients (P = 1.2 x 10(-10)), which remained independently associated with IS on multivariate analysis after controlling for traditional cerebrovascular risk factors. Allele and genotype distribution of 4b/4a and -786T>C polymorphisms were comparable between patient and controls. Significantly higher prevalence of 298Asp/4b/-786T and 298Asp/4b/-786C haplotypes were seen in IS cases, thus conferring a disease susceptibility nature to these haplotypes. Multivariate regression analysis confirmed the association of 298Asp/4b/-786T and 298Asp/4b/-786C haplotypes, and in addition identified 298Asp/4a/-786T haplotype to be independently associated with IS, after controlling for traditional cerebrovascular risk factors. CONCLUSIONS Genetic variation at the eNOS locus represent genetic risk factor for increased susceptibility to IS.
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Affiliation(s)
- S Saidi
- Research Unit of Hematological and Autoimmune Diseases, Faculty of Pharmacy, University of Monastir, Tunisia
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Hoppe UC. [Cardiologic diagnostics after stroke: what is really important?]. Internist (Berl) 2009; 50:1210-7. [PMID: 19823795 DOI: 10.1007/s00108-009-2467-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patients with a stroke often exhibit similar risk factors compared to patients with coronary artery disease. The morbidity and mortality of patients surviving a stroke are strongly determined by cardiac co-morbidities. Moreover, ischemic stroke frequently results from cardiac embolism. Thus, for risk assessment and prevention of cardiovascular events patients should undergo cardiac evaluation after a stroke. Laboratory testing should include blood glucose, coagulation parameters, blood cell count and in the case of suspected acute coronary syndrome cardiac ischemic markers. Assessment of the lipid profile is useful to determine the overall cardiovascular risk. In all patients with a stroke an ECG should be recorded. In those with normal ECG and suspected thromboembolic stroke additional Holter is helpful to detect possible atrial fibrillation. Echocardiography should be performed in all patients with suspected cardioembolic stroke. Moreover, echocardiography may establish the diagnosis of structural heart disease, which has a major impact on prognosis in patients with a stroke.
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Affiliation(s)
- U C Hoppe
- Klinik III für Innere Medizin, Universität zu Köln, Kerpener Strasse 62, 50937, Köln, Deutschland.
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Takahashi PY, Dyrbye LN, Thomas KG, Cedeno OQ, North F, Stroebel RJ, DeJesus RS, Targonski PV. The association of transient ischemic attack symptoms with memory impairment among elderly participants of the Third US National Health and Nutrition Examination Survey. J Geriatr Psychiatry Neurol 2009; 22:46-51. [PMID: 19073836 DOI: 10.1177/0891988708328218] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is a well-known risk factor for vascular dementia. However, the association of transient ischemic attacks with cognitive impairment is less well-established. METHODS Records from Third National Health and Nutrition Examination Survey were abstracted for demographic and medical information for participants with an age >or=60 years who reported being free of stroke. Five self-reported symptoms (weakness, numbness, loss of vision, inability to speak, and severe dizziness) were used as surrogates representing transient ischemic attacks. Information on conventional risk factors for vascular dementia was also obtained. Multivariable logistic regression was used to examine risk factors for memory impairment. RESULTS 4617 participants were included with a sample-weighted prevalence of memory impairment of 6.6% (1417 participants). The final multivariable analysis revealed a significant association between transient weakness and memory impairment (odds ratio 1.52, 95% CI 1.11-2.07). The other 4 transient ischemic attacks symptoms were not significantly associated with memory impairment in the final model. Systolic blood pressure >140 was most strongly associated with prevalent memory impairment (odds ratio, 9.78, 95% CI 1.49-64.3). Other associated risk factors included non-white race, male gender, age, education <or=12 years, and history of any alcohol use. CONCLUSION Among transient ischemic attacks symptoms, self-reported weakness in the face, arm, or leg was significantly associated with memory impairment. This study indicates that transient ischemic attacks symptoms are, even in the absence of stroke, associated with memory impairment. Aggressive risk factor modification in patients with TIA symptoms may be warranted to prevent potential future memory loss.
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Affiliation(s)
- Paul Y Takahashi
- Department of Internal Medicine, Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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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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Stead LG, Bellolio MF, Suravaram S, Brown RD, Bhagra A, Gilmore RM, Boie ET, Decker WW. Evaluation of transient ischemic attack in an emergency department observation unit. Neurocrit Care 2008; 10:204-8. [PMID: 18850077 DOI: 10.1007/s12028-008-9146-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Accepted: 08/29/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the feasibility of a protocol for evaluation of transient ischemic attack (TIA) in an Emergency Department Observation Unit (EDOU), and assess the risk of early stroke after such an evaluation. METHODS All adult patients presenting to the Emergency Department (ED) with signs and symptoms consistent with TIA were prospectively enrolled in this observational study over a period of 3 years. Patients underwent a standardized TIA evaluation per protocol. Risk of subsequent stroke at 48 h, 1 week, 1 month, and 3 months was prospectively assessed. RESULTS In total, 418 patients were seen during the study period, and all were evaluated per the EDOU TIA protocol. The mean age was 73.1 (+/-13.3) years and 53.8% were males. Comorbidities included hypertension in 71.5%, diabetes mellitus in 20.1%, prior TIA in 19.6%, and prior ischemic stroke in 19.6% of the cohort. Brain CT, neurology consult, electrocardiogram, carotid ultrasound, and additional tests were performed, and education was given. A total of 30.4% of the patients were dismissed directly from the EDOU. The risk of stroke at 2 days was 0.96%, at 7 days 1.2%, at 30 days 1.9%, and 2.4% at 90 days. CONCLUSION An Emergency Department Observation Unit Protocol for TIA is a feasible option for expedited evaluation of these patients.
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Affiliation(s)
- Latha G Stead
- Department of Emergency Medicine, Division of Research, Mayo Clinic College of Medicine, Generose G-410, 200 First Street SW, Rochester, MN 55905, USA.
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Rustemli A, Bhatti TK, Wolff SD. Evaluating Cardiac Sources of Embolic Stroke with MRI. Echocardiography 2007; 24:301-8; discussion 308. [PMID: 17313647 DOI: 10.1111/j.1540-8175.2007.00393.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The evaluation of patients with stroke includes identifying its etiology in order to appropriately tailor therapy. Currently, the diagnostic work-up includes imaging of the brain, the arteries of the head and neck, the aorta, and the heart. Traditional methods of imaging include magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), duplex ultrasound, and transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE). While echocardiography remains a cornerstone in the field of cardiac imaging, MRI is increasingly able to assess for the most common causes of cardioembolic stroke such as left atrial/left atrial appendage thrombus, left ventricular thrombus, aortic atheroma, cardiac masses and patent foramen ovale. This review will focus on the advantages and limitations of echocardiography and cardiac magnetic resonance (CMR) imaging in diagnosing patients suspected of having an embolic stroke and the role these modalities play in clinical practice today.
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Affiliation(s)
- Asu Rustemli
- Division of Cardiology, Department of Medicine, Columbia University, New York, New York, USA
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Litvinas L. Stroke (Cerebrovascular Disease). Integr Med (Encinitas) 2007. [DOI: 10.1016/b978-1-4160-2954-0.50035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Purroy F, Montaner J, Delgado P, Arenillas JF, Molina CA, Santamarina E, Quintana M, Alvarez-Sabín J. Efectividad del estudio ultrasonográfico precoz en el pronóstico a corto plazo de los pacientes con un accidente vascular cerebral isquémico transitorio. Med Clin (Barc) 2006; 126:647-50. [PMID: 16759563 DOI: 10.1157/13087842] [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: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Although patients with ischemic attacks (TIA) experience cardiovascular events frequently within the first 90 days after symptoms onset, strong clinical predictors of early recurrence are lacking. We investigate the value of combined carotid/transcranial ultrasound testing (UST) on the prognosis of TIA patients. PATIENTS AND METHOD UST was performed < 24 h after symptoms onset among 311 consecutive TIA patients. Stroke recurrence, myocardial infarction, or any vascular event was recorded at 7 and 90 days of follow-up. RESULTS A total of 20 patients suffered an stroke within 7 days of symptoms onset. During the next 90 days after index TIA, 58 (18.6%) patients experienced an endpoint: 51 cerebral ischemic events, one peripheral arterial disease, 5 myocardial infarctions and one cerebellum hemorrhage. Cox proportional hazards multivariate analyses identified the presence of intracranial stenoses (HR = 3.05; 95% CI, 1.21-7.70; p = 0.018) and carotid territory implication (HR = 15.91; 95% CI, 2.11-120.04; p = 0.007) as independent predictors of stroke within the first 7 days after index TIA. Moreover, at 90 days of follow-up, large-artery occlusive disease was an independent predictor of stroke (HR = 3.07; 95% CI, 1.76-5.38; p < 0.001). CONCLUSIONS TIA patients with moderate to severe intracranial or extracranial stenoses have a higher risk of stroke recurrence. The routine use of UST within the first 24 h after index TIA can be useful for identifying those patients at high risk in order to plan aggressive prevention therapies.
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Affiliation(s)
- Francisco Purroy
- Unidad Neurovascular, Servicio de Neurología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España.
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Affiliation(s)
- Jeffrey J Pasternak
- Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
Transient ischemic attack is a common presenting problem to clinicians. Historically, these events were defined by the resolution of new neurologic symptoms within a 24-h time-frame; however, recent data suggests that a 1-h time frame is more appropriate. New imaging techniques and clinical evidence suggests that transient ischemic attacks present a higher risk of impending stroke than previously thought. This has led to a redefinition of what constitutes an attack, and also to a focus on both earlier investigation and treatment of correctable causes. New antiplatelet agents are now available and pose a challenge as to how they should be prescribed. Carotid endarterectomy is the standard of care for a subset of transient ischemic attack patients with significant carotid stenosis. Carotid angioplasty and stenting are more recent developments that may further expand treatment options.
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Affiliation(s)
- Brian Clarke
- Beaumont Hospital, Department of Medicine for the Elderly, Dublin 9, Ireland.
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