Headache due to Vascular Disorders

Headache and cerebrovascular disease (CVD) are inextricably linked. Although in some cases headache complicating CVD may be little more than a symptomatic afterthought, in other cases, early recognition of headache's role in the CVD process is critical to effective management. In other words, headaches secondary to CVD span a spectrum, and in this article, we will review that spectrum.

Subclavian steal syndrome: a case study of diagnosis, management, and successful surgical resolution

Subclavian steal syndrome (SSS) is a rare vascular condition characterized by retrograde blood flow in the vertebral artery, often discovered incidentally in asymptomatic patients. We present a 65-year-old male with recurrent transient ischemic attacks (TIAs) attributed to 99% stenosis at the origin of the left subclavian artery, leading to SSS. Diagnostic modalities included duplex ultrasound, confirming inverted left vertebral artery flow, and multi-slice computed tomography angiography, confirming the diagnosis. Despite an unsuccessful attempt at balloon angioplasty, successful vascular surgery was performed, establishing a left carotid-vertebral artery bypass. The patient recovered well without complications. This case underscores the importance of considering SSS in TIA cases, utilizing non-invasive diagnostic tools, and highlighting the successful management of symptomatic SSS through surgical intervention.

Stroke and high-risk TIA outcomes with reduction of treatment duration when treatment initiated in emergency rooms (SHORTER-study)

BACKGROUND

Following transient ischemic attack (TIA) and minor stroke, the risk of recurrent stroke can be significantly reduced with short-duration dual antiplatelet therapy (DAPT). We wish to investigate whether 10 days of DAPT is as effective as 21 days' treatment.

STUDY DESIGN

This is an open-label, randomized, parallel-group study comparing whether 10 days of DAPT treatment (ASA + clopidogrel) is non-inferior to 21 days of DAPT in patients with acute ischemic stroke (AIS) or high-risk TIA. In both groups, DAPT is started within 24 hours of symptom onset. This study is being conducted in approximately 15 study sites in the Kingdom of Saudi Arabia. The planned sample size is 1932.

OUTCOMES

Non-inferiority of 10 days compared to 21 days of DAPT in the prevention of the composite endpoint of stroke and death at 90 days in AIS/TIA patients. The primary safety outcome is major intra-cranial and systemic hemorrhage.

STUDY PERIOD

Enrolment started in the second quarter of 2023, and the completion of the study is expected in the fourth quarter of 2025.

DISCUSSION

The trial is expected to show that 10 days of DAPT is non-inferior for the prevention of early recurrence of vascular events in patients with high-risk TIAs and minor strokes.

Association of Impedance Aggregometry-Measured Platelet Aggregation With Thromboembolic Events in Patients Who Undergo Carotid Endarterectomy: A Pilot Study

OBJECTIVES

The aim of the current study was to assess the relationship among thrombin receptor activator peptide 6 (TRAP test), adenosine-5'-diphosphate (ADP test), arachidonic acid (ASPI test), and stroke/transient ischemic attack (TIA), using the multiple electrode aggregometry (Multiplate) in patients undergoing carotid thromboendarterectomy (CEA).

DESIGN

A retrospective study.

SETTING

Vascular surgery operating rooms of a university hospital.

PARTICIPANTS

One hundred thirty-one out of 474 patients undergoing CEA between November 2020 and October 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A preoperative blood sample of all enrolled patients was analyzed using the Multiplate analyzer. Receiver operating characteristics curves, were generated to test the ability of TRAP, ADP, and ASPI in discriminating perioperative thromboembolic stroke/TIA. A logistic LASSO regression model was used to identify factors independently associated with stroke/TIA. Eight patients experienced a perioperative stroke/TIA. Although all the platelet functional assays showed excellent predictive performance, an ADP value exceeding 72 U showed the highest specificity (87%) and sensitivity (68%) in discriminating patients who had a perioperative thromboembolic stroke/TIA, with a negative predictive value of 99% and a positive predictive value of 15%. After LASSO regression, an ADP >72 U and the need for a shunt during CEA were the only 2 variables independently associated with perioperative stroke/TIA.

CONCLUSION

Because the ADP test was independently associated with perioperative stroke/TIA, the assessment of platelet reactivity using Multiplate may offer potential utility in monitoring patients undergoing CEA.

Changes in stroke and TIA admissions during the COVID-19 pandemic: A meta-analysis

PURPOSE

To perform a meta-analysis on how the admissions of stroke and transient ischemic attack (TIA) changed during the Corona Virus infection-19 (COVID-19) pandemic and evaluate if the effect was depending on stroke severity.

METHODS

Observational cohort studies comparing the number of stroke and/or TIA admissions during a period of the pandemic compared to a period before the pandemic were identified in PubMed and Embase. After excluding studies with overlapping populations and studies without satisfactory case ascertainment, data was extracted and meta-analyzed.

FINDINGS

A total of 59 studies were included. During the pandemic, there was a decrease in admissions of ischemic stroke (admission rate ratio (ARR) = 0.77, 95% confidence interval (CI): 0.72, 0.82), intracerebral hemorrhage (ARR = 0.79, 95% CI: 0.70, 0.90) and TIA (ARR = 0.66, 95% CI: 0.58, 0.75). Albeit admission rates of both mild (ARR = 0.61, 95% CI: 0.49, 0.77) and severe (ARR = 0.82, 95% CI = 0.71, 0.95) strokes decreased, milder strokes decreased more (proportion ratio (PR) = 0.76, 95% CI: 0.65, 0.89).

DISCUSSION

Potential causes for the admission reduction could be strict prioritizations within the health care, patients' fear of acquiring COVID-19, or decreased access to health care due to lockdowns.

CONCLUSION

During the COVID-19 pandemic, there was a reduction in admissions of stroke and TIA, possibly caused by reluctance to seek medical care.

Patent Foramen Ovale: The Unresolved Questions

Patent Foramen Ovale (PFO) is a remnant of fetal circulation that could be observed in the 25% of the population worldwide. PFO is associated to numerous clinical conditions as migraines, coronary embolization, transient ischemic attacks, and stroke. The main PFO concerns are related to its correlation to stroke, in particular in young adults. Despite the impact on morbidity that PFO could have, to date there is not clear evidence about its management and treatment. In this narrative review our aim is to summarize the more recent evidence in the literature dealing with PFO, in order to provide an updated overview on this topic.

Rapid outpatient transient ischemic attack clinic and stroke service activity during the SARS-CoV-2 pandemic: a multicenter time series analysis

Background and aim

Rapid outpatient evaluation and treatment of TIA in structured clinics have been shown to reduce stroke recurrence. It is unclear whether short-term downtrends in TIA incidence and admissions have had enduring impact on TIA clinic activity. This study aims to measure the impact of the pandemic on hospitals with rapid TIA clinics.

Methods

Relevant services were identified by literature search and contacted. Three years of monthly data were requested - a baseline pre-COVID period (April 2018 to March 2020) and an intra-COVID period (April 2020 to March 2021). TIA presentations, ischemic stroke presentations, and reperfusion trends inclusive of IV thrombolysis (IVT) and endovascular thrombectomy (EVT) were recorded. Pandemic impact was measured with interrupted time series analysis, a segmented regression approach to test an effect of an intervention on a time-dependent outcome using a defined impact model.

Results

Six centers provided data for a total of 6,231 TIA and 13,191 ischemic stroke presentations from Australia (52.1%), Canada (35.0%), Italy (7.6%), and England (5.4%). TIA clinic volumes remained constant during the pandemic (2.9, 95% CI -1.8 to 7.6, p = 0.24), as did ischemic stroke (2.9, 95% CI -7.8 to 1.9, p = 0.25), IVT (-14.3, 95% CI -36.7, 6.1, p < 0.01), and EVT (0, 95% CI -16.9 to 16.9, p = 0.98) counts. Proportion of ischemic strokes requiring IVT decreased from 13.2 to 11.4% (p < 0.05), but those requiring EVT did not change (16.0 to 16.7%, p = 0.33).

Conclusion

This suggests that the pandemic has not had an enduring effect on TIA clinic or stroke service activity for these centers. Furthermore, the disproportionate decrease in IVT suggests that patients may be presenting outside the IVT window during the pandemic - delays in seeking treatment in this group could be the target for public health intervention.

Angiographic Pattern of M1 Stenosis Predicts Territorial Stroke in Patients Receiving Aggressive Medication without Stenting

OBJECTIVE

To evaluate the relationship between different angiographic patterns of middle cerebral artery M1 segment stenosis and related territorial stroke in patients receiving aggressive medical treatment without stenting.

METHODS

We retrospectively reviewed our patient registry database to identify ICAS patients diagnosed by digital subtraction angiography between January 2017 and December 2020 and identified 3 different angiographic patterns (normal, shift, and dilation) in 124 patients with M1 stenosis. The association between these patterns and recurrent ischemic stroke in the M1 territory was analyzed.

RESULTS

The rates of recurrent M1 territorial stroke and transient ischemic attack in the normal group, shift group, dilation group and shift-dilation group were 34.5%, 35.0%, 78.3%, and 44.4% respectively. In patients with the shift pattern, the rate of recurrent stroke is significantly higher at a deflection angle ≥9.32° than at a deflection angle <9.32°(P < 0.05). In patients with dilation pattern, the rate of recurrent stroke is significantly higher than patients with non-dilation pattern (72.3% vs. 36.8%, P < 0.05).

CONCLUSIONS

Angiographic patterns of M1 stenosis may predict recurrent territorial strokes, thus providing a surrogate marker to identify high-risk patients for potential endovascular treatment.

The mid-term results of the Carotid Asymptomatic Stenosis (CARAS) observational study

INTRODUCTION

Carotid endarterectomy (CEA) in patients with asymptomatic carotid stenosis (ACAS) remains a subject of debate. Current recommendations are based on randomized trials conducted over 20 years ago and improvements in medical therapies may have reduced the risk of cerebral ischemic events (CIE). This study presents a mid-term analysis of results from an ongoing prospective observational study of ACAS patients to assess their CIE risk in a real-world setting.

METHODS

This is a prospective observational cohort study of patients with ACAS >60 % (NASCET criteria) identified in a single duplex ultrasonography (DUS) vascular laboratory (trial registered: NCT04825080). Patients were not considered for CEA due to their short life expectancy (<3 year) or absence of signs of plaque vulnerability (ulceration, ipoechogenic core). Patient enrollment started in January 2019 and ended in March 2020 with a targeted sample size of 300 patients.A 5-year follow-up was scheduled. Clinical characteristics, risk factors, and medical therapies were documented, and, when necessary, the best medical therapy (BMT), involving antiplatelet agents, blood pressure control, and statins, was recommended during clinical visits. The primary endpoint was to asses CIEs (including strokes, transient ischemic attacks, amaurosis-fugax) ipsilateral to ACAS along with plaque progression rate and patients survival. Follow-up involved annual clinical visit and carotid DUS examination, complemented by telephone interviews at six-month intervals.

RESULTS

The study included 307 patients, with an average age of 80 ± 7 years, of whom 55 % were male. Contralateral stenosis exceeding 60 % was present in 61 (20 %) patients. Seventy-seven percent of patients were on BMT. At a mean follow-up of 41±9 months, 7 ispilateral strokes and 9 TIAs occurred, resulting in 14 CIEs (2 patients experienced both TIA and stroke). According to Kaplan-Meier analysis, the 4-year CIE rate was 6±2 %, with an annual CIE rate of 1.5 %. Fifty-eight (19 %) patients had a stenosis progression which was associated with a higher 4-year estimated CIE rate compared to patients with stable plaque (10.3 % vs 3.2 %, P=.01). Similarly, a contralateral carotid stenosis >60 % was associated with a higher 4-year estimated CIE rate: 11.7 % vs 2.9 %, P=.002. These factors were independently associated with high risk for CIE at the multivariate COX analysis: Hazard Ratio (HR): 3.2; 95 % Confidence Interval: 1.1-9.2 and HR: 3.6; 95 % CI: 1.2-10.5.

CONCLUSION

The mid-term results of this prospective study suggest that the incidence of CIE in ACAS patients should not be underestimated, with plaque progression and contralateral stenosis serving as primary predictors of CIEs.

Time-Activity data fitting in molecular Radiotherapy: Methodology and pitfalls

Absorbed radiation doses are essential in assessing the effects, e.g. safety and efficacy, of radiopharmaceutical therapy (RPT). Patient-specific absorbed dose calculations in the target or the organ at risk require multiple inputs. These include the number of disintegrations in the organ, i.e. the time-integrated activities (TIAs) of the organs, as well as other parameters describing the process of radiation energy deposition in the target tissue (i.e. mean energy per disintegration, radiation dose constants, etc). TIAs are then estimated by incorporating the area under the radiopharmaceutical's time-activity curve (TAC), which can be obtained by quantitative measurements of the biokinetics in the patient (typically based on imaging data such as planar scintigraphy, SPECT/CT, PET/CT, or blood and urine samples). The process of TAC determination/calculation for RPT generally depends on the user, e.g., the chosen number and schedule of measured time points, the selection of the fit function, the error model for the data and the fit algorithm. These decisions can strongly affect the final TIA values and thus the accuracy of calculated absorbed doses. Despite the high clinical importance of the TIA values, there is currently no consensus on processing time-activity data or even a clear understanding of the influence of uncertainties and variations in personalised RPT dosimetry related to user-dependent TAC calculation. As a first step towards minimising site-dependent variability in RPT dosimetry, this work provides an overview of quality assurance and uncertainty management considerations of the TIA estimation.

Small vessel disease in primary familial brain calcification with novel truncating PDGFB variants

INTRODUCTION

Primary familial brain calcification (PFBC) is a neurodegenerative disease characterised by bilateral calcification in the brain, especially in the basal ganglia, leading to neurological and neuropsychiatric manifestations. White matter hyperintensities (WMH) have been described in patients with PFBC and pathogenic variants in the gene for platelet-derived growth factor beta polypeptide (PDGFB), suggesting a manifest cerebrovascular process. We present below the cases of two PFBC families with PDGFB variants and stroke or transient ischaemic attack (TIA) episodes. We examine the possible correlation between PFBC and vascular events as stroke/TIA, and evaluate whether signs for vascular disease in this condition are systemic or limited to the cerebral vessels.

MATERIAL AND METHODS

Two Swedish families with novel truncating PDGFB variants, p.Gln140* and p.Arg191*, are described clinically and radiologically. Subcutaneous capillary vessels in affected and unaffected family members were examined by light and electron microscopy.

RESULTS

All mutation carriers showed WMH and bilateral brain calcifications. The clinical presentations differed, with movement disorder symptoms dominating in family A, and psychiatric symptoms in family B. However, affected members of both families had stroke, TIA, and/or asymptomatic intracerebral ischaemic lesions. Only one of the patients had classical vascular risk factors. Skin microvasculature was normal.

CONCLUSIONS

Patients with these PDGFB variants develop microvascular changes in the brain, but not the skin. PDGFB-related small vessel disease can manifest radiologically as cerebral haemorrhage or ischaemia, and may explain TIA or stroke in patients without other vascular risk factors.

Transient ischemic attack and minor stroke as "surgeons affairs": a narrative review

OBJECTIVE

The scope of this paper is to review the subtypes of transient ischemic attack (TIA) and minor stroke (mS) in which a surgical treatment is needed, discussing the importance and the timing of a multidisciplinary approach, in order to achieve an optimized management and prevent major strokes or other critical complications.

MATERIALS AND METHODS

The keywords "transient ischemic attack," "minor stroke," "surgical treatment," "vascular surgery," "heart surgery," "neurosurgery," and "multidisciplinary" were searched using MEDLINE, EMBASE, and Scopus. Relevant search results were discussed by the authors for references inclusion.

RESULTS

Notwithstanding that best medical therapy is usually the first choice for the most part of cases, there are specific but recurrent etiologies that must be properly recognized because of a potential surgical approach, even in urgency. In fact, symptomatic carotid stenosis, or particular cases of hemodynamic cerebrovascular events, should be promptly referred to vascular surgeon, since increasing evidences highlighted a benefit from an early artery revascularization. In addition, beyond arrhythmic causes, cardioembolic events due to bacterial endocarditis and atrial myxoma should be quickly diagnosed, possibly in emergency department, because they are a presumptive urgency for heart surgery. In addition to the above-mentioned conditions, in patients suffering from vertebrobasilar TIA or mS, clinicians should keep in mind the Bow Hunter disease, because surgical artery decompression can represent the only suitable treatment in selected cases.

CONCLUSIONS

TIA and mS require a multidisciplinary in order to discuss therapeutic options, comparing risks and benefits and determining the best timing for an optimized management.

Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting

BACKGROUND/AIMS

Data are limited on the frequency of 'consensus decisions' between sub-specialists attending a neurovascular multidisciplinary meeting (MDM) regarding management of patients with extracranial carotid/vertebral stenoses and post-MDM 'adherence' to such advice.

METHODS

This prospective audit/quality improvement project collated prospectively-recorded data from a weekly Neurovascular/Stroke Centre MDM documenting the proportion of extracranial carotid/vertebral stenosis patients in whom 'consensus management decisions' were reached by neurologists, vascular surgeons, stroke physicians-geriatricians and neuroradiologists. Adherence to MDM advice was analysed in asymptomatic carotid stenosis (ACS), symptomatic carotid stenosis (SCS), 'indeterminate symptomatic status stenosis' (ISS) and vertebral artery stenosis (VAS) patients, including intervals between index event to MDM + / - intervention.

RESULTS

One hundred fifteen patients were discussed: 108 with carotid stenosis and 7 with VAS. Consensus regarding management was noted in 96.5% (111/115): 100% with ACS and VAS, 96.2% with SCS and 92.9% with ISS. Adherence to MDM management advice was 96.4% (107/111): 100% in ACS, ISS and VAS patients; 92% (46/50) in SCS patients. The median interval from index symptoms to revascularisation in 50-99% SCS patients was 12.5 days (IQR: 9-18.3 days; N = 26), with a median interval from MDM to revascularisation of 5.5 days (IQR: 1-7 days). Thirty patients underwent revascularisation. Two out of twenty-nine patients (6.9%) with either SCS or ISS had a peri-procedural ipsilateral ischaemic stroke, with no further strokes/deaths during 3-months follow-up.

CONCLUSIONS

The high frequency of inter-specialty consensus regarding management and adherence to proposed treatment supports a collaborative/multidisciplinary model of care in patients with extracranial arterial stenoses. Service development should aim to shorten times between MDM discussion-intervention and optimise prevention of stroke/death.

Appropriate use of antiplatelet medications following transient ischemic attacks and stroke: a 9-year study from the Middle East

Background and purpose

Guidelines recommend that patients with high-risk TIAs and minor strokes presenting within 1-3 days from onset should be offered dual antiplatelet therapy (DAPT). There are little data on real-world adherence to these recommendations. We evaluated the appropriateness of DAPT use in TIA and stroke patients in a prospective database.

Methods

The Qatar Stroke Database began the enrollment of patients with TIAs and acute stroke in 2014 and currently has ~16,000 patients. For this study, we evaluated the rates of guideline-adherent use of antiplatelet treatment at the time of discharge in patients with TIAs and stroke. TIAs were considered high-risk with an ABCD2 score of 4, and a minor stroke was defined as an NIHSS of 3. Patient demographics, clinical features, risk factors, previous medications, imaging and laboratory investigations, final diagnosis, discharge medications, and discharge and 90-day modified Rankin Scale (mRS) were analyzed.

Results

After excluding patients with ICH, mimics, and rare secondary causes, 8,082 patients were available for final analysis (TIAs: 1,357 and stroke: 6,725). In high-risk TIAs, 282 of 666 (42.3%) patients were discharged on DAPT. In patients with minor strokes, 1,207 of 3,572 (33.8%) patients were discharged on DAPT. DAPT was inappropriately offered to 238 of 691 (34.4%) low-risk TIAs and 809 of 3,153 (25.7%) non-minor stroke patients.

Conclusion

This large database of prospectively collected patients with TIAs and stroke shows that, unfortunately, despite several guidelines, a large majority of patients with TIAs and stroke are receiving inappropriate antiplatelet treatment at discharge from the hospital. This requires urgent attention and further investigation.

Urinary ketone bodies and stroke recurrence in patient with acute ischemic stroke or TIA

BACKGROUND

Urine ketone bodies may appear in different states in the acute stage of stroke. We aimed to examine the association between urine ketone bodies and recurrent stroke in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) in this study.

METHODS

In Third China National Stroke Registry (CNSR-III), 14,015 patients with AIS or TIA were screened for urine ketone bodies. The outcomes were any stroke, ischemic stroke and combined vascular events within 1 year. The association of urine ketone bodies with recurrent stroke were analyzed by Cox proportional hazards.

RESULTS

During 1 year of follow-up, 1,335 (9.53%) participants experienced recurrent stroke. After adjustment for conventional confounding factors, patients with urine ketone bodies test positive had a higher risk of recurrent stroke (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.13-1.82), compared to those were negative. The correlation between positive urine ketone bodies and recurrent stroke were consistent in patient with (HR, 1.45; 95% CI, 1.00-2.12) and without (HR, 1.40; 95% CI, 1.02-1.94) diabetes. No significant interaction between urine ketone bodies and diabetes were observed.

CONCLUSIONS

Positive ketone bodies in urine was independently associated with recurrent stroke in patients with AIS or TIA.

Characteristics, management and outcome of stroke: Observations from the Sri Lanka Stroke Clinical Registry

BACKGROUND

Stroke registries are pivotal to the monitoring and improvement of the quality of stroke care. We report data from the initial phase of a nationally representative hospital-based stroke registry in Sri Lanka.

METHODS

Based on an observational cohort design, all consecutive patients aged ≥18 years with a diagnosis of stroke or transient ischemic attack (TIA) presenting to six tertiary-care hospitals in the Western, Eastern, Southern, Northern and Central provinces of Sri Lanka within 14 days of onset were recruited.

RESULTS

During a period of 14 months, 5893 patients with a stroke/TIA (58.8% men; mean age 65.22 years, SD=13.28) were entered into the database; 69.8% (n=4111) had an ischaemic stroke (IS); 20.9% (n=1233) had a haemorrhagic stroke (HS); 7.2% (424) had a TIA; and 2.1% (125) had a venous stroke. While IS were more common among women (71.7% vs 68.4%; p=0.006), HS were more common among men (22.3% vs 19.0%; p=0.003). Hemiparesis (86.2% vs 83.2%; p=0.011), headache (29% vs 11.6%; p<0.001), seizures (5.9% vs 4.2%; p=0.013), sphincter dysfunction (11.8% vs 7.7%; p<0.001) and hypertension (72% vs 67.3%, p=0.002) were more common in HS while dysphasia (63.2% vs 50.0%; p<0.001), ataxia (9.6% vs 7.3%; p=0.014), sensory disturbances (10.8% vs 6.0%; p<0.001) and diabetes mellitus (37.9% vs 28.1%; p<0.001) were more common in IS. Thrombolysis was administered in only 2.1% while only 14.6% had access to stroke units. The mean door-to-needle time was 100.2 (SD=46.0) minutes. The hospital mortality rate was 8.3%. Recurrent strokes within three months were more common in HS than IS (3.2% vs 1.6%; p=0.007).

CONCLUSIONS

While stroke characteristics in Sri Lanka are similar to that of other populations, the rate of thrombolysis and access to stroke units are inadequate. The stroke registry provides useful data for the appraisal and improvement of stroke services.

Secondary Prevention of Cryptogenic Stroke and Outcomes Following Surgical Patent Foramen Ovale Closure Plus Medical Therapy vs. Medical Therapy Alone: An Umbrella Meta-Analysis of Eight Meta-Analyses Covering Seventeen Countries

Background

Cryptogenic stroke (CS) is an exclusion diagnosis that accounts for 10-40% of all ischemic strokes. Patent foramen ovale (PFO) is found in 66% of patients with CS, while having a prevalence of 25-30% in the general population. The primary aim was to evaluate the risk of recurrent stroke following surgical PFO closure plus medical therapy vs. medical therapy alone amongst CS, an embolic stroke of undetermined source (ESUS), or transient ischemic attack (TIA). The secondary aim was to evaluate new-onset non-valvular atrial fibrillation, mortality, and major bleeding.

Methods

We conducted an umbrella meta-analysis using PRISMA guidelines on English studies comparing surgical PFO closure plus medical therapy versus medical therapy alone for managing CS. We extracted data on interventions and outcomes and used random-effects models with generic inverse variance to calculate relative risks (RRs) with 95% confidence intervals for outcome calculations.

Results

A comprehensive search yielded 54,729 articles on CS and 65,001 on surgical PFO closure, with 1,591 studies focusing on PFO closure and medical therapy for secondary CS, ESUS, or TIA prevention. After excluding non-meta-analyses, 52 eligible meta-analyses were identified, and eight studies were selected for outcome evaluation, excluding non-English, non-human, and studies before January 2019 as of August 31, 2021. Among a total of 41,880 patients, 14,942 received PFO closure + medical therapy, while 26,938 patients received medical therapy alone. Our umbrella meta-analysis showed that PFO closure plus medical therapy had a 64% lower risk of recurrent strokes than medical therapy alone (pooled RR: 0.36). PFO closure plus medical therapy was associated with 4.94 times higher risk of atrial fibrillation. There was no difference in the risk of death or bleeding between both groups.

Conclusion

In patients with CS, PFO closure, in addition to medical therapy, reduces the risk of recurrence. More research is needed to assess the efficacy of early closure as well as specific risk profiles that would benefit from early intervention to reduce the burden of stroke.

Multimodal MRI study of the relationship between plaque characteristics and hypoperfusion in patients with transient ischemic attack

Objective

Transient ischemic attack is a significant risk factor for acute cerebral infarction. Previous studies have demonstrated that hypoperfusion in patients with transient ischemic attack was associated with the recurrence of transient ischemic attack, stroke, and persistent worsening of neurological symptoms. Moreover, transient ischemic attack patients classified as high-risk group according to the ABCD2 score have a higher incidence of stroke. Therefore, the objective of this study was to investigate the plaque characteristics of transient ischemic attack patients with concomitant cerebral hypoperfusion using multimodal MRI, as well as hemodynamic changes in the high-risk group with transient ischemic attack patients.

Materials and methods

A total of 151 patients with transient ischemic attack were prospectively recruited for this study. All enrolled patients underwent multimodal MRI, including DWI, TOF-MRA, HR-VWI, and DSC-PWI. Finally, 56 patients met the inclusion criteria. Based on DSC-PWI images, patients were divided into two groups: hypoperfusion (n = 41) and non-hypoperfusion (n = 15). Clinical baseline characteristics and plaque characteristics were analyzed between the two groups. Furthermore, within the hypoperfusion group, patients were further classified into low-risk (n = 11) and high-risk (n = 30) subgroups based on the ABCD2 score. Hemodynamic differences between these subgroups were also analyzed.

Results

Compared with the non-hypoperfusion group, the hypoperfusion group had a significantly higher prevalence of hypertension (68.3% vs. 33.3%, p = 0.019) and hyperhomocysteinemia (65.9% vs. 33.3%, p = 0.029). Moreover, the hypoperfusion group exhibited more significant luminal stenosis degree [41.79 ± 31.36 vs. 17.62± 13.62, p = 0.006] and greater NWI (57.1%± 20.47% vs. 40.21%± 21.56%, p = 0.009) compared to the non-hypoperfusion group. In addition, the high-risk group identified by the ABCD2 score had a higher rMTT [117.6(109.31-128.14) vs. 108.36(100.67-119.92), p = 0.037].

Conclusion

Transient ischemic attack patients with hypoperfusion exhibited a higher prevalence of hypertension and hyperhomocysteinemia, as well as higher luminal stenosis degree, and greater NWI. Furthermore, Transient ischemic attack patients in the high-risk group demonstrated higher MTT.

A review of international trade and investment agreements and nutrition policy space in the Pacific

Small Island Developing States (SIDS) in the Pacific are heavily reliant on imported foods which are often nutritionally deficient, and typically high in salt, fat, and sugar. To curb nutrition-related non-communicable diseases, nutrition policies are needed to create food environments that promote healthy diets. However, international trade and investment agreements (TIAs) may interfere with the policy space for SIDS to regulate their food environments by requiring member states to meet trade obligations that could conflict with their nutrition policy goals. In this review, we identify real examples of where TIAs have been responsible for changes in Pacific SIDS' nutrition policies alongside the potential for further constraints on healthy nutrition policies from Pacific Island participation in TIAs. In addition, we note the effects of regulatory chill from TIA obligations in Pacific SIDS, whereby healthy nutrition policies are not considered, developed, or implemented due to the threat of trade disputes or the complexity of TIA procedural requirements. Existing literature indicates that TIAs have shaped nutrition policies to fit within the global trade paradigm despite SIDS' nutrition policy imperatives. More can be done locally, regionally, and internationally to increase the importance of nutrition in the trade agenda, leverage regional institutions to champion nutrition regulation and support SIDS in navigating the trade and nutrition policy environment.

Severe hypocalcemia as a cause of transient ischemic attack? A debatable case and evidence from literature

Hypocalcemia and transient ischemic attack (TIA) are different medical disorders; however, limited evidence suggests a possible link between the two. The underlying pathomechanisms by which hypocalcemia may cause cerebrovascular damage are difficult to comprehend. The aim of the study was to present an individual experiencing TIA that possibly due to severe hypocalcemia that associated with hypoparathyroidism after total thyroidectomy; and to explore the available evidence of its cause-effect relationship through available literature. A 68-year-old man presented to Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia with complaints of weakness, especially in the right limbs that had worsened in the last week. The patient experienced unconsciousness for an hour before the admission; disorientation and anterograde amnesia over the time of recovering of consciousness. Other complaints included frequent muscle cramps, numbness in both arms and legs, dizziness, swallowing difficulty, nausea, and vomiting. The patient had a history of total thyroidectomy for a large struma diffuse 18 years ago and was prescribed several medications. However, the patient was overwhelmed by forgetfulness which had become more frequent in recent months resulting in medication nonadherence. The vital sign was stable and Chovsteck's sign was positive. The Montreal Cognitive Assessment (MoCA) revealed impairment in the visuospatial/executive component and delayed memory. Laboratory tests revealed severe hypocalcemia, altered thyroid function, hypomagnesemia, elevated D-dimer and fibrinogen, and vitamin D deficiency. TIA and severe hypocalcemia were proposed as the diagnosis. Prompt initiation of appropriate treatment, including calcium supplementation, anticoagulation, and neuroprotective agents, led to significant clinical improvement. Evidence from available literature suggests that there is a possible link between severe hypocalcemia and TIA that occurred in this patient. However, more studies are warrant to establish this cause-effect relationship.

Editor's Choice - Sex Related Differences in Indication and Procedural Outcomes of Carotid interventions in VASCUNET

OBJECTIVE

It has been suggested that peri-operative complications after carotid surgery may be higher in women than in men. This assumption may affect the treatment patterns, and it is thus possible that carotid endarterectomy (CEA) is provided to women less often. The aim of the current VASCUNET study was to determine sex related differences in operative risk in routine clinical practice among non-selected patients undergoing carotid revascularisation.

METHODS

Data on CEA and carotid artery stenting (CAS) from 14 vascular registries were collected and amalgamated. Comprehensive data were available for 223 626 carotid artery procedures; these were analysed overall and by country. The primary outcome was any stroke and or death within 30 days of carotid revascularisation. Secondary outcomes were stroke, death, or any major cardiac event or haemorrhage leading to re-operation.

RESULTS

Of the procedures, 34.8% were done in women. The proportion of CEA for asymptomatic stenosis compared with symptomatic stenosis was significantly higher among women than men (38.4% vs. 36.9%, p < .001). The proportion of octogenarians was higher among women than men who underwent CEA in both asymptomatic (21.2% vs. 19.9%) and symptomatic patients (24.3% vs. 21.4%). In the unadjusted analysis of symptomatic and asymptomatic patients, there were no significant differences between men and women in the rate of post-operative combined stroke and or death, any major cardiac event, or combined death, stroke, and any major cardiac event after CEA. Also, after stenting for asymptomatic or symptomatic carotid stenosis, there were no significant differences between men and women in the rate of post-operative complications. In adjusted analyses, sex was not significantly associated with any of the end points. Higher age and CAS vs. CEA were independently associated with all four end points.

CONCLUSION

This study confirmed that, in a large registry among non-selected patients, no significant sex related differences were found in peri-operative complication rates after interventions for carotid stenosis.

Lasting impairments following transient ischemic attack and minor stroke: a systematic review protocol

Introduction

The focus on medical management and secondary prevention following Transient Ischemic Attack (TIA) and minor stroke is well-established. Evidence is emerging that people with TIA and minor stroke can experience lasting impairments as fatigue, depression, anxiety, cognitive impairment, and communication difficulties. These impairments are often underrecognized and inconsistently treated. Research in this area is developing rapidly and an updated systematic review is required to evaluate new evidence as it emerges. This living systematic review aims to describe the prevalence of lasting impairments and how they affect the lives of people with TIA and minor stroke. Furthermore, we will explore whether there are differences in impairments experienced by people with TIA compared to minor stroke.

Methods

Systematic searches of PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Libraries will be undertaken. The protocol will follow the Cochrane living systematic review guideline with an update annually. A team of interdisciplinary reviewers will independently screen search results, identify relevant studies based on the defined criteria, conduct quality assessments, and extract data. This systematic review will include quantitative studies on people with TIA and/or minor stroke that report on outcomes in relation to fatigue, cognitive and communication impairments, depression, anxiety, quality of life, return to work/education, or social participation. Where possible, findings will be grouped for TIA and minor stroke and collated according to the time that follow-up occurred (short-term < 3 months, medium-term 3-12 months, and long-term > 12 months). Sub-group analysis on TIA and minor stroke will be performed based on results from the included studies. Data from individual studies will be pooled to perform meta-analysis where possible. Reporting will follow the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) guideline.

Perspectives

This living systematic review will collate the latest knowledge on lasting impairments and how these affect the lives of people with TIA and minor stroke. It will seek to guide and support future research on impairments emphasizing distinctions between TIA and minor stroke. Finally, this evidence will allow healthcare professionals to improve follow-up care for people with TIA and minor stroke by supporting them to identify and address lasting impairments.

Acute stroke in COVID-19 patients: A first year experience in a Colombian hospital

Background

COVID-19 may be a new risk factor for stroke. Stroke in COVID-19 varies from 1.1 to 8.1%. Various pathophysiological pathways predispose SARS-CoV-2 infected patients to stroke.

Aim

To describe COVID-19 patients with acute stroke in one Colombian Center.

Methods

From March 6 2020 and March 6 2021 records of patients with acute stroke and in-hospital positive PCR (Polymerase Chain Reaction) test for Sars-CoV-2 infection were reviewed. Demographic, stroke and COVID-19 characteristics were extracted. Continuous variables were reported in means and ranges. Categorical variables were presented in frequencies and percentage. A descriptive narrative was performed.

Results

Of 328 acute stroke patients 14 (4.2%) tested positive for PCR SARS-CoV-2. Mean age 56.4 years with 57% males. Five were (35.7%) without vascular risk factors but 9 (64.3%) overweight. Brain infarct diagnosed in 11 (78.5%), 53% with anterior circulation syndromes. Mean NIHSS score 11.8 and 7 (63%) received intravenous thrombolysis. Acute inflammatory blood biomarkers (D-dimer, ferritin, LDH elevated) were positive in all. 11 (78.5%) had symptomatic COVID-19 before stroke with a mean latency of 7 days. 12 (85.7%) had severe COVID-19 and 6 (42.8%) required mechanical ventilation. Outcome was unfavorable in 9 (64.3%) (The Modified Rankin Scale (mRS) > 2), mean hospital stay was 21.8 days and in-hospital case fatality rate was 14.2%.

Conclusion

In susceptible individuals COVID-19 predisposes to stroke. Hypercoagulation and immune thrombosis may be at the culprit for this state. In Colombia, COVID-19 patients with stroke have similar characteristics to the described worldwide.

Echocardiography in acute stroke patients: a nationwide analysis in departments with certified stroke units in Germany

BACKGROUND

Echocardiography is highly relevant in patients with ischemic stroke or TIA. Utilization of routine echocardiographic examinations [transthoracic (TTE) or transesophageal (TEE)] on stroke units remains however unknown. To representatively examine echocardiographic rates on stroke units in Germany and to evaluate structural factors that may influence the decision to conduct echocardiography.

METHODS

A nationwide analysis was performed by using certification audit data of all primary and comprehensive stroke centers (pSC and cSC) in Germany.

RESULTS

Structural and organizational requirements of 310 departments (cSCs: 42.6%) were extracted. Median TTE rate was 63.3% (IQR 39.3-80.8), median TEE rate 21.3% (IQR 16.4-29.5). A cardiological department on site was present in 74.2%, and they were associated with higher TEE rates. TTE rates decreased with increasing numbers of patients (p = 0.026). Likewise, TEE rates decreased with increasing numbers of patients (p = 0.006), mediated by departments with cSCs (p = 0.008 for cSCs vs p = 0.230 for pSCs). TTE rates were far more inhomogeneously distributed than TEE rates and higher in pSCs (p = 0.011). Overall, 12.9% of centers did not perform any echocardiographic examination in at least 50% of all stroke patients.

CONCLUSION

More detailed recommendations regarding echocardiography should be included in future guidelines. Moreover, evaluating the impact of echocardiographic examinations on long-term prognosis in stroke patients should be focus of further evaluations.

Predictive Factors for Stroke and TIA Following Carotid Artery Stenting

PURPOSE

Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to explore independent risk factors to predict cerebrovascular events following CAS to identify high-risk patients and improve the safety of CAS in this population.

MATERIALS AND METHODS

HISPANIAS is a national prospective multicenter study that included 14 hospitals that collected data from patients who underwent CAS. We analyzed morbidity and mortality within 30 days after CAS, looking for factors that might be associated with cerebrovascular events (stroke and transient ischemic attack [TIA]).

RESULTS

The HISPANIAS cohort included 757 patients: 80.32% were men, the mean age was 70.73 years, and 82.96% underwent symptomatic CAS. Cerebrovascular complications occurred in 42 patients (5.6%), including TIA in 24 patients (70.8% ipsilateral; mean 2.79 days after CAS) and stroke in 18 patients (72.2% ipsilateral; mean 6.72 days after CAS). The main independent clinical predictors of stroke/TIA identified by logistic regression were female sex (odds ratio [OR] 2.29, 95% CI 1.15-4.54) and diabetes (OR 3.29, 95% CI 1.71-6.40). Survival analysis showed that diabetic women, compared with the rest of the patients, had a higher number of events concentrated mainly in the first days after the intervention (p=0.003).

CONCLUSION

Cerebrovascular ischemic complications after CAS continue to be a challenge for the management of these patients. Although there are other factors, female sex and the presence of diabetes are emerging as strong risk factors for the development of complications after symptomatic CAS.

CLINICAL IMPACT

Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. Although CAS has been regarded as a reliable and safety approach, some studies reported that CAS was associated with a higher risk of procedure-related stroke. Cerebrovascular complications after CAS continue to be a main problem and a challenge for the management of these patients. Therefore, it is essential to identify the factors involved in the development of these complications. Our study shows that the combination of female sex and diabetes is associated with a clearly worse outcome, with a greater number of events concentrated mainly in the first days. This is different from other studies that have explored each factor separately. It would be interesting to perform separate interventions for this group given the increased risk of complications.

The use of dual antiplatelet therapy for ischemic cerebrovascular events

In the last 10 years, the use of dual antiplatelet therapy (DAPT) in the neurological ambit has been explored in patients with non-cardioembolic ischemic stroke, transient ischemic attack (TIA), and intracranial atherosclerotic disease. Two clinical trials (CHANCE and POINT) showed that in patients with minor non-cardioembolic ischemic stroke or high-risk TIA, the addition of clopidogrel to aspirin reduces the risk of stroke recurrence. Another trial (THALES) evaluated the association of ticagrelor and aspirin in mild-to-moderate non-cardioembolic ischemic stroke or high-risk TIA, showing a reduced risk of subsequent stroke compared to aspirin alone. Finally, the use of DAPT has been assessed in the treatment of stroke associated with atherosclerotic intracranial stenosis in the SAMMPRIS trial, showing a favorable profile compared to percutaneous angioplasty and stenting. The aim of this article is, after a review the major trials evaluating DAPT in patients with ischemic cerebrovascular events and the ways they have been implemented in Italian, European, and USA guidelines, to provide a practical algorithm to help clinicians in their everyday clinical practice and to outline possible caveats in the practical implementation of guidelines. Possible limitations and gaps in knowledge regarding specific conditions (e.g., the use of DAPT after acute phase therapies) are also underlined.

A Great Heist: Subclavian Steal Syndrome Causing Posterior Transient Ischemic Attack and Stroke

Introduction Subclavian steal syndrome is a phenomenon of arterial flow reversal secondary to occlusive disease in proximal subclavian arteries, occasionally resulting in neurologic sequelae. Case Presentation The authors present the case of a 67-year-old man with stroke risk factors and a history of receiving head and neck radiation therapy who developed subclavian steal physiology leading to a transient ischemic attack and posterior circulation stroke. He was medically optimized without substantial progression or recurrence of disease. Conclusion This case illustrates a case of vertebrobasilar transient ischemic attack and posterior circulation stroke from subclavian steal syndrome in the setting of prior radiation therapy manifesting as extremity weakness and discoordination. Further research on therapeutic radiation dosages and subsequent incidence of arterial disease which could contribute to subclavian steal syndrome is necessary.

Screening for OSA in stroke patients: The role of a sleep educator

Obstructive Sleep Apnea (OSA) is prevalent in patients with stroke or Transient Ischemic Attack (TIA). OSA is also a risk factor for recurrent stroke and TIA. Screening for and addressing OSA in acute stroke settings is difficult because of variety of factors not the least of which is the added burden on the healthcare team. We describe the preliminary results of a pilot program instituted at our medical center and the positive impact it has on OSA screening in the acute stroke unit.

Topics Mentioned by Stroke Patients during Supportive Phone Calls-Implications for Individualized Aftercare Programs

By understanding stroke as a chronic disease, aftercare becomes increasingly important. For developing aftercare programs, the patients' perspective regarding, for example, stroke-related symptoms and interactions with the healthcare system is necessary. Records from a local stroke pilot program were used to extract relevant topics from the patients' perspective, as mentioned during a phone call two months after hospital discharge. Data from 157 patients with ischemic stroke or transient ischemic attack (TIA) were included. "Rehabilitation" was mentioned by 67.5% of patients, followed by "specialist physician", "symptoms", and "medication". Compared with severely disabled patients, those with no relevant disability at hospital discharge mentioned "symptoms" significantly more often. Regarding rehabilitation, "outpatient care" was mentioned more often by patients in an inpatient setting, and 11.8% without rehabilitation mentioned "depression". Patients in single-compared to multi-person households differed, for example, in the frequency of mentioning "specialist physicians" and gradually "outpatient care". A multivariate model yielded associations between the disability at discharge and the probability of mentioning relevant topics afterward. This study provided insights into the patients' perspective and identified topics that need attention while accompanying stroke and TIA patients after discharge. Further, the degree of disability at discharge might be helpful for planning individual aftercare.

Returning to Leisure Activity Post-Stroke: Barriers and Facilitators to Engagement

OBJECTIVES

To identify barriers and facilitators to engagement when returning to, or participating in, leisure activity post-stroke or Transient Ischemic Attack (TIA).

DESIGN

Sequential explanatory, mixed methods study.

SETTING

21 hospital sites across England, Wales and Northern Ireland.

PARTICIPANTS

Adults with a clinical diagnosis of first/recurrent stroke or TIA. Patients approaching end of life were excluded. Participants were recruited as in-patients or at first clinic appointment and a baseline questionnaire was completed. A 6-month follow-up questionnaire was sent to participants for self-completion. Open-text questions were asked about barriers and facilitators when returning to, or participating in, leisure activity. Responses were thematically analysed and explored by participant characteristics, including type of leisure activity undertaken. Characteristics also included measures of socioeconomic deprivation, mood, fatigue and disability.

RESULTS

2000 participants returned a 6-month follow-up questionnaire (78% stroke, 22% TIA); 1045 participants responded to a question on barriers and 820 on facilitators. Twelve themes were identified and the proportion of responses were reported (%). Barriers: physical difficulties (69%), lower energy levels (17%), loss of independence (11%), psychological difficulties (10%), hidden disabilities (7%), and delay or lack of healthcare provision (3%). Facilitators: family support (35%), healthcare support (27%), well-being and fitness (22%), friendship support (20%), self-management (19%), and returning to normality (9%). 'Physical difficulties' was the most reported barrier across all participant characteristics and activity types. Family support was the most reported facilitator except for those with greater disability, where it was healthcare support and those without fatigue where it was well-being and exercise.

CONCLUSIONS

Physical difficulties and lack of energy are problematic for stroke and TIA survivors who want to return to or participate in leisure activity. Healthcare support alone cannot overcome all practical and emotional issues related to leisure activity engagement. Family support and improving well-being are important facilitators and future research should explore these mechanisms further.

Life and Leisure Activities following Stroke or Transient Ischaemic Attack (TIA): An Observational, Multi-Centre, 6-Month Follow-Up Study

OBJECTIVE

To examine changes in leisure participation following stroke/transient ischaemic attack (TIA) and explore its relationship to modifiable and non-modifiable participant characteristics.

DESIGN

An observational study design with self-report questionnaires collected at two time points (baseline and 6-months).

SETTING

The study was conducted across 21 hospital sites in England, Wales, and Northern Ireland.

PARTICIPANTS

Participants were aged 18+ and had experienced a first or recurrent stroke or TIA and had a post-stroke/TIA modified Rankin score (mRS) of ≤3.

PROCEDURE

Research practitioners at each site approached potential participants. Individuals who agreed to participate completed a baseline questionnaire whilst an inpatient or at a first post-stroke/TIA clinic appointment. A follow-up questionnaire was posted to participants with a freepost return envelope. Two questionnaires were developed that collected demographic information, pre-stroke/TIA mRS, social circumstances (e.g., employment situation) and incorporated the shortened Nottingham Leisure Questionnaire (sNLQ).

RESULTS

The study recruited eligible participants (N = 3295); 2000 participants returned questionnaires at follow-up. Data showed three participant variables were significant predictors of engagement in leisure activities post-stroke/TIA: age, sex, and deprivation decile. There was an overall decline in the number and variety of leisure activities, with an average loss of 2.2 activities following stroke/TIA. Only one activity, "exercise/fitness" saw an increase in engagement from baseline to follow-up; watching TV remained stable, whilst participation in all other activities reduced between 10% and 40% with an average activity engagement reduction of 22%.

CONCLUSIONS

Some groups experienced a greater reduction in activities than others-notably older participants, female participants, and those living in a low socioeconomic area.

REGISTRATION

researchregistry4607.

STRENGTHS AND LIMITATIONS OF THIS STUDY

1. This is the largest-ever study to survey life and leisure activity engagement following stroke/TIA. 2. Survey responses were self-reported retrospectively and, therefore, may have been misreported, or misremembered. 3. Despite the large cohort, there were few participants, and so respondents, from ethnic minority groups.

Safety and usability of wearable accelerometers for stroke detection the STROKE ALARM PRO 1 study

OBJECTIVES

The introduction of time-dependent reperfusion therapies in acute ischemic stroke has increased the need for early identification. We explore the safety and feasibility of STROKE ALARM which detects sudden arm paresis, the most frequent symptom in stroke.

MATERIALS AND METHODS

Consecutive patients admitted with a stroke or TIA at Skåne University Hospital were screened according to inclusion and exclusion criteria, and included in the STROKE ALARM PRO 1 Study aiming to explore the feasibility of prolonged use (30 days) of the system in the community. STROKE ALARM consists of paired arm bracelets with accelerometers, coupled with a stroke test in a smartphone application. In case of an imbalance in arm movements, the user is prompted to perform an app-based stroke test. Failure to respond or to complete the stroke test correctly, triggers notification by SMS to predefined emergency contacts. Patients were followed up by telephone after completion.

RESULTS

Thirty patients were included and 28 completed follow-up. Median age was 68 years and 36.7% were female. No stroke events were recorded during follow-up. False indications occurred in all but one patient, and 22 (78.6%) experienced alarms to their emergency contacts. Despite a high level of false alarms, general user experience was rated in a positive or neutral manner by almost 90%. Very frequent alarms were probably due to mild arm paresis not detected in routine clinical assessment.

CONCLUSIONS

Use of STROKE ALARM for 30 days after stroke/TIA was well tolerated warranting further study for early automated detection of stroke recurrence.

Volumetric Flow Assessment in Extracranial Arteries in Patients with 70-99% Internal Carotid Artery Stenosis

Background: Cerebral blood flow (CBF) can be related to the risk of occurrence of neurological symptoms. Well-developed collateral circulation is a good prognostic factor in patients with cerebrovascular disease. Understanding the mechanisms of collateral circulation may be important in the diagnosis, treatment, and monitoring in this group of patients. The aim of this study covered the assessment of CBF in patients with 70−99% Internal carotid artery (ICA) stenosis, focusing on the circulation pathways and flow volume in extracranial arteries. Materials and methods: 53 patients with 70−99% ICA stenosis (mean age 73.4 ± 7 years old; 17 female, mean age 73.9 ± 7.5 years old; 36 male, mean age 73.2 ± 6.8 years old) were included in the study. In all patients a Doppler ultrasound (DUS) examination, measuring blood flow volume in the internal carotid artery (ICA), external carotid artery (ECA), and vertebral artery (VA), was performed. The cerebral blood flow (CBF) was compared to the previously reported CBF values in the healthy population > 65 years old. Results: Among the study groups three subgroups with flow differences were identified: patients with elevated CBF (significant volumetric flow compensation—26/53, 49%), patients with CBF similar to (mild compensation—17/53, 32%), and patients with CBF lower than (no compensation—10/53, 19%) the healthy, equally aged population. The percentage of patients with significant volumetric flow compensation was the highest in age groups 65−69 years old (62.5%) and >80 years old (60%). In the oldest age group (>80 years old) no patients without flow compensation (0%) were observed. The level of compensation depends on the number of the arteries with compensatory increased flow. In patients with significant volumetric flow compensation, the compensatory increased flow was observed, on average, in 3.31 arteries, in the mild compensation group—in 2.18 arteries, and in the no compensation group only in 1 artery. ICA plays the most important role in the volumetric flow compensation—the increase in the flow volume, in comparison to the reference values, was between 116.7 mL/min and 251.9 mL/min (in the ECA 57.6 mL/min−110.4 mL/min; in the VA 73.9 mL/min−104.9 mL/min). The relative flow increase was highest in the VA: 215−246%, then in the ECA: 163−206%, and finally in the ICA: 148.6−192%. The increased flow was most commonly observed in the VA—57 arteries, in second place in the ECA—42 arteries, and ICA—31 arteries. In patients with unilateral ICA stenosis, the volumetric flow increase was stated more frequently in the ipsilateral ECAs then in the contralateral ones (23 vs. 14). In the VA the opposite tendency was observed (29 contralateral vs. 23 ipsilateral). The ability of volumetric flow compensation decreased significantly with increasing age. Conclusions: Understanding the mechanisms of collateral circulation and their assessment in Doppler ultrasonography may provide a novel and easily accessible tool of identifying and monitoring patients with cerebrovascular disease.

Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging

PURPOSE

Imaging guidelines for transient ischemic attack (TIA) recommend that patients undergo urgent brain and neurovascular imaging within 48 hours of symptom onset. Prior research suggests that most patients with TIA discharged from the emergency department (ED) do not complete recommended TIA imaging workup during their ED encounters. The purpose of this study was to determine the nationwide percentage of patients with TIA discharged from EDs with incomplete imaging workup who complete recommended imaging after discharge.

METHODS

Patients discharged from EDs with the diagnosis of TIA were identified from the Medicare 5% sample for 2017 and 2018 using International Classification of Diseases, tenth rev, Clinical Modification codes. Imaging performed was identified using Current Procedural Terminology codes. Incomplete imaging workup was defined as a TIA encounter without cross-sectional brain, brain-vascular, and neck-vascular imaging performed within the subsequent 30 days of the initial ED encounter. Patient- and hospital-level factors associated with incomplete TIA imaging were analyzed in a multivariable logistic regression.

RESULTS

In total, 6,346 consecutive TIA encounters were analyzed; 3,804 patients (59.9%) had complete TIA imaging workup during their ED encounters. Of the 2,542 patients discharged from EDs with incomplete imaging, 761 (29.9%) completed imaging during the subsequent 30 days after ED discharge. Among patients with TIA imaging workup completed after ED discharge, the median time to completion was 5 days. For patients discharged from EDs with incomplete imaging, the odds of incomplete TIA imaging at 30 days after discharge were highest for black (odds ratio, 1.84; 95% confidence interval, 1.27-2.66) and older (≥85 years of age; odds ratio, 2.41; 95% confidence interval, 1.78-3.26) patients. Reference values were age cohort 65 to 69 years; male gender; white race; no co-occurring diagnoses of hypertension, hyperlipidemia, or diabetes mellitus; household income > $63,029; hospital in the Northeast region; urban hospital location; hospital size > 400 beds; academically affiliated hospital; and facility with access to MRI.

CONCLUSIONS

Most patients discharged from EDs with incomplete TIA imaging workup do not complete recommended imaging within 30 days after discharge.

MRA-detected intracranial atherosclerotic disease in patients with TIA and minor stroke

OBJECTIVES

Patients with TIA and minor stroke commonly undergo CT and CTA in the emergency department with subsequent MRI with MRA for further workup. The purpose of this study was to review outpatient MRIs for TIA/stroke patients to assess the additional benefit, if any, of the MRA sequence in the detection of intracranial atherosclerotic disease in patients for whom CTA had already been performed.

METHODS

The radiology reports of outpatient MRIs of the brain for TIA/minor stroke patients were retrospectively reviewed via the hospital PACS system. Following this, the imaging report from the patient's initial presentation to the emergency department was reviewed. This index imaging and subsequent MRI were compared to assess the incidence of new vascular findings detected on the MRA sequence in patients for whom CTA had already been performed. Where new lesions had been identified at follow-up, the imaging was retroactively reviewed to assess if they were present on the index imaging.

RESULTS

Two hundred seven consecutive patients were reviewed. Significant (> 50%) intracranial atherosclerotic disease was present on MRA in 18 patients (8.7%). This was a new finding in 11 patients. Five had initial CTA where the atherosclerosis was not detected. All 5 of these cases were located in the posterior cerebral arteries. Incidental aneurysms were seen in 14 (6.7%); 12 were a new finding at time of MRI.

CONCLUSION

The MRA sequence provides additional value by increasing the detection of clinically important intracranial atherosclerotic disease which may inform management in patients with minor stroke and TIA.

Association Between High-Sensitivity C-Reactive Protein and Prognosis in Different Periods After Ischemic Stroke or Transient Ischemic Attack

Background

The aim of this study was to investigate the association between hsCRP (high‐sensitivity C‐reactive protein) and prognosis over time after stroke onset.

Methods and Results

In this prespecified prospective substudy of the Third China National Stroke Registry, a total of 9438 patients with acute ischemic stroke or transient ischemic attack and measured hsCRP were included. Patients were categorized into 3 groups according to the sampling time after index onset (<24 hours, 24–72 hours, 72 hours–8 days). The outcomes consisted of stroke recurrence and combined vascular events within 1 year, and dependence or death defined as modified Rankin Scale score of 3 to 6 at 1 year. The associations between hsCRP and outcomes in different groups were analyzed by using Cox proportional hazards and logistic regression models. The median levels of hsCRP within 24 hours, between 24 and 72 hours and between 72 hours and 8 days were 2.01, 1.72, and 1.72 mg/L, respectively (P < 0.05). Compared with the bottom quartile, patients in the top quartile measured within 72 hours were at increased risk of recurrent stroke (<24 hours: adjusted hazard ratio [HR], 1.57 [95% CI, 1.05–2.35], P = 0.03; 24–72 hours: adjusted HR, 1.60 [95% CI, 1.18–2.17], P = 0.003). Association was attenuated after further adjusting for the Org 10 172 test in the Treatment of Acute Stroke classification (<24 hours: adjusted HR, 1.51 [95% CI, 1.01–2.27]; P = 0.05; 24–72 hours: adjusted HR, 1.55 [95% CI, 1.14–2.10]; P = 0.01). The association only existed in patients with large‐artery atherosclerosis (adjusted HR, 1.68 [95% CI, 1.06–2.64]; P = 0.03). However, the association was not found in the hsCRP level measured between 72 hours and 8 days. Similar results were found for the outcome of combined vascular events. Additionally, hsCRP levels measured between 24 and 72 hours were associated with an increased risk of poor functional outcomes.

Conclusions

Elevated levels of hsCRP measured in the first 72 hours after ischemic stroke or transient ischemic attack but not 72 hours to 8 days, were associated with an increased risk of 1‐year stroke recurrence.

Cerebral ischemic events ipsilateral to carotid artery stenosis. The Carotid Asymptomatic Stenosis (CARAS) observational study: First year preliminary results

OBJECTIVE

To report the characteristics of the prospective observational cohort study "Carotid Asymptomatic Stenosis (CARAS)", including patients with asymptomatic carotid stenosis under medical treatment and their first year of follow-up, in order to estimate the risk of cerebral ischemic events.

METHODS

This is a prospective observational cohort study of CARAS>60% (Nascet criteria) patients, identified in a single duplex-ultrasonography (DUS) vascular laboratory (trail registration N: NCT04825080). Patient's enrollment started in January 2019 and ended in March 2020 with the follow-up conclusion scheduled in December 2025. The aimed sample size was calculated at 300 patients for a 5-year follow-up. The primary outcome were the incidence of ipsilateral neurologic ischemic events (stokes and transient ischemic attacks [TIA]), plaque progression rate, and survival. The follow-up was scheduled at six-month intervals for clinical visit and annually for DUS examination.

RESULTS

a total of 307 patients completed the first follow-up year. The mean age was 81±4 years, 55% were male. Contralateral stenosis >60% was present in 90 (29%) patients. Antiplatelet therapy and statins adherence was 80% and 88%, respectively. During the first year, 3 ispilateral strokes (1%) and 4 TIAs (1.3%) occurred, for a total of 2.3% ipsilateral ischemic events. During the first year, 43 (14%) plaques had a stenosis progression, which was correlated with the occurrence of neurological events (9.3% vs. 1.1%, P=.001, OR: 8.9; 95%CI: 1.9-41); 6 deaths (2%) occurred in the same period.

CONCLUSION

the preliminary one-year results of this prospective study suggest that the overall rate of any ipsilateral ischemic event, and specifically ipsilateral strokes, correlates with plaque progression.

Cryptogenic stroke and TIA: Suggested diagnostic approach while waiting for evaluation and treatment guidelines

Background

Empiric strategies for secondary prevention in cryptogenic stroke and cryptogenic TIA are lacking. The best therapy to prevent recurrence depends on the cause of stroke. Attempting a correct diagnosis is therefore the fundamental goal of stroke treatment. Further investigation into the source of embolism if suspected, and determination of the etiology, even if demanding, is the needed prerequisite for optimal secondary prevention and risk reduction.

Aims

This paper discusses evaluation and treatment of cryptogenic stroke in light of recent years’ clinical trials results and developments in cardiology and neuroradiology. No ethical approval was needed for this work.

Results

Cardioembolism due to paroxysmal atrial fibrillation, patent foramen ovale, or cardiomyopathy; occult atherosclerosis from unstable plaques and hypercoagulable conditions seem to be the most common underlying causes to be revealed by further investigations. Treatment of these conditions can reduce the stroke recurrence significantly.

Conclusions

An individual approach and targeted diagnostics using advanced medical technologies in selected patients, who may benefit from a tailored treatment regimen, can help reveal a probable cause in the majority of strokes and TIAs previously classified as cryptogenic.

Factors influencing follow-up care post-TIA and minor stroke: a qualitative study using the theoretical domains framework

Background

Follow-up care after transient ischaemic attack (TIA) and minor stroke has been found to be sub-optimal, with individuals often feeling abandoned. We aimed to explore factors influencing holistic follow-up care after TIA and minor stroke.

Methods

Qualitative semi-structured interviews with 24 healthcare providers (HCPs): 5 stroke doctors, 4 nurses, 9 allied health professionals and 6 general practitioners. Participants were recruited from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Interview transcripts were deductively coded using the Theoretical Domains Framework and themes were generated from coded data.

Results

There was no clear pathway for supporting people with TIA or minor stroke after rapid specialist review in hospital; consequently, these patients had limited access to HCPs from all settings (‘Environmental context and resources’). There was lack of understanding of potential needs post-TIA/minor stroke, in particular residual problems such as anxiety/fatigue (‘Knowledge’). Identification and management of needs was largely influenced by HCPs’ perceived role, professional training (‘Social professional role and identity’) and time constraints (‘Environmental context and resources’). Follow-up was often passive – with onerous on patients to seek support – and predominantly focused on acute medical management (‘Intentions’/‘Goal’).

Conclusions

Follow-up care post-TIA/minor stroke is currently sub-optimal. Through identifying factors which influence follow-up, we can inform guidelines and practical strategies to improve holistic healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07607-0.

Biomarkers for Transient Ischemic Attack: A Brief Perspective of Current Reports and Future Horizons

Cerebrovascular disease is the leading cause of long-term disability in the world and the third-leading cause of death in the United States. The early diagnosis of transient ischemic attack (TIA) is of great importance for reducing the mortality and morbidity of cerebrovascular diseases. Patients with TIA have a high risk of early subsequent ischemic stroke and the development of permanent nervous system lesions. The diagnosis of TIA remains a clinical diagnosis that highly relies on the patient's medical history assessment. There is a growing list of biomarkers associated with different components of the ischemic cascade in the brain. In this review, we take a closer look at the biomarkers of TIA and their validity with a focus on the more clinically important ones using recent evidence of their reliability for practical usage.

Volumetric Flow Assessment in Doppler Ultrasonography in Risk Stratification of Patients with Internal Carotid Stenosis and Occlusion

(1) Background: Alterations of blood flow volume in extracranial arteries may be related to the risk of occurrence of neurological symptoms. The aim of this study was the estimation of cerebral blood flow (CBF) in Doppler ultrasonography, as well as comparison of the flow volume in asymptomatic patients over 65 years old with ≥50%, and symptomatic patients with ≥70% internal carotid artery (ICA) stenosis, in order to assess whether the changes in the CBF correlates with the presence of neurological symptoms. (2) Methods: 308 patients over 65 years old were included in the retrospective cohort observational study: 154 asymptomatic with ≥50% ICA stenosis, 123 healthy volunteers, and 31 symptomatic referred for surgical treatment. The study group was split according to ICA stenosis (50–69%, 70–99% and occlusion). In all patients an extensive Doppler ultrasound examination with measurements of flow volume in common, internal, external carotid (ECA) and vertebral arteries (VA) was performed. (3) Results: Among asymptomatic (A) and symptomatic (S) patients with carotid stenosis 3 subgroups were identified: 57/154—37% (A) and 8/31—25.5% (S)—with significantly increased flow volume (CBF higher than reference range: average CBF + std. dev in the group of healthy volunteers), 67/154—43.5% (A) and 12/31—39% (S)—with similar to reference group flow volume (CBF within range average ± std.dev), and 30/154—19.5% (A) and 11/31—35.5% (S)—with decreased flow volume in extracranial arteries (flow lower than average-std.dev. in healthy volunteers). In symptomatic patients the percentage of patients with significant compensatory increased flow tends to raise with the severity of the stenosis, while simultaneous decline of number of patients with mild compensation (unchanged total CBF) is observed. The percentage of patients without compensation remains unchanged. In the group referred for surgical treatment (symptomatic, ≥70% ICA stenosis) the percentage of patients with flow compensation is twice as low as in the asymptomatic ones with similar degree of the ICA stenosis (8/31—25.8% vs. 26/53—49%, p = 0.04). Compensatory elevated flow was observed most frequently in ECA. (4) Conclusions: The presence of significant volumetric flow compensation has protective influence on developing ischaemic symptoms, including TIA or stroke. The assessment of cerebral inflow in Doppler ultrasonography may provide novel and easily accessible tool of identifying patients prone to cerebral ischaemia. The multivessel character of compensation with enhanced role of ECA justifies the importance of including this artery in the estimation of CBF.

Diagnostic and Prognostic Blood Biomarkers in Transient Ischemic Attack and Minor Ischemic Stroke: An Up-To-Date Narrative Review

INTRODUCTION

Early diagnosis and correct risk stratification in patients with transient ischemic attack (TIA) and minor ischemic stroke (MIS) is crucial for the high rate of subsequent disabling stroke. Although highly improved, diagnosis and prognostication of TIA/MIS patients remain still based on clinical and neuroimaging findings, with some inter-rater variability even among trained neurologists.

OBJECTIVES

To provide an up-to-date overview of diagnostic and prognostic blood biomarkers in TIA and MIS patients.

MATERIAL AND METHODS

We performed a bibliographic search on PubMed database with last access on July 10^th 2021. More than 680 articles were screened and we finally included only primary studies on blood biomarkers.

RESULTS

In a narrative fashion, we discussed about blood biomarkers investigated in TIA/MIS patients, including inflammatory, thrombosis, neuronal injury and cardiac analytes, antibodies and microRNAs. Other soluble molecules have been demonstrated to predict the risk of recurrent cerebrovascular events or treatment response in these patients. A rapid point of care assay, combining the determination of different biomarkers, has been developed to improve triage recognition of acute cerebrovascular accidents.

CONCLUSIONS

The implementation of blood biomarkers in the clinical management of TIA/MIS could ameliorate urgent identification, risk stratification and individual treatment choice. Large prospective and longitudinal studies, adopting standardized sampling and analytic procedures, are needed to clarify blood biomarkers kinetic and their relationship with TIA and minor stroke etiology.

Mechanisms and Critical Technologies of Transport Inhibitor Agent (TIA) throughout C-S-H Nano-Channels

The critical issue of the durability of marine concrete lies in the continuous penetration and rapid enrichment of corrosive ions. Here a new ion transfer inhibitor, as TIA, with calcium silicate hydrate (C-S-H) interfacial affinity and hydrophobicity is proposed through insights from molecular dynamics into the percolation behavior of the ion solution in C-S-H nano-channels and combined with molecular design concepts. One side of the TIA can be adsorbed on the surface of the cement matrix and can form clusters of corrosive ions to block the gel pores so as to resist the ion solution percolation process. Its other side is structured as a hydrophobic carbon chain, similar to a door hinge, which can stick to the matrix surface smoothly before the erosion solution is percolated. It can then change into a perpendicular chain shape to reduce the percolation channel’s diameter and thereby inhibit the percolation when ions meet the inhibitor. Therefore, once the erosion solution contacts TIA, it can quickly chelate with calcium ions and erosion ions at the interface to form clusters and compact pores. In addition, the water absorption, chloride migration coefficient, and chloride content of concrete samples decreased significantly after adding TIA, proving that TIA can effectively enhance the durability of cement-based materials. The structure–activity relationship of ion transfer that is proposed can provide new ideas for solving the critical problems of durability of cement-based materials and polymer molecular design.

Cerebral hemodynamic effects of early blood pressure lowering after TIA and stroke in patients with carotid stenosis

BACKGROUND

Effects of early blood pressure (BP) lowering on cerebral perfusion in patients with moderate/severe occlusive carotid disease after transient ischemic attack (TIA) and non-disabling stroke are uncertain.

AIMS

We aimed to evaluate the changes in transcranial Doppler (TCD) indices in patients undergoing blood pressure lowering soon after TIA/non-disabling stroke.

METHODS

Consecutive eligible patients (1 November 2011 to 30 October 2018) attending a rapid-access clinic with TIA/non-disabling stroke underwent telemetric home blood pressure monitoring (HBPM) for 1 month and middle cerebral artery velocities measurements ipsilateral to carotid stenosis on TCD ultrasound in the acute setting and at 1 month. Hypertensive patients (HBPM ⩾ 135/85) underwent intensive BP-lowering guided by HBPM unless they had bilateral severe occlusive disease (⩾ 70%). Changes in BP and TCD parameters were compared in patients with extracranial moderate/severe carotid stenosis (between 50% and occlusion) versus those with no or mild (< 50%) stenosis.

RESULTS

Of 764 patients with repeated TCD measures, 42 had moderate/severe extracranial carotid stenosis without bilateral severe occlusive disease. HBPM was reduced from baseline to 1 month in hypertensive patients both with versus without moderate/severe carotid stenosis (-12.44/15.99 vs -13.2/12.2 mmHg, respectively, p-difference = 0.82), and changes in TCD velocities (4.69/14.94 vs 2.69/13.86 cm/s, respectively, p-difference = 0.52 for peak systolic velocity and 0.33/7.06 vs 1.75/6.84 cm/s, p-difference = 0.34 for end-diastolic velocity) were also similar, with no evidence of greater hemodynamic compromise in patients with stenosis/occlusion.

CONCLUSION

There was no evidence of worsening of TCD hemodynamic indices in patients with moderate/severe occlusive carotid disease treated with BP-lowering soon after TIA/non-disabling stroke, suggesting that antihypertensive treatment in this group of patients is safe in the acute setting of TIA clinics.

Evaluation of Transient Ischemic Attack and Minor Stroke: A Rapid Outpatient Model for the COVID-19 Pandemic and Beyond

The grim circumstances of the COVID-19 pandemic have highlighted the need to refine and adapt stroke systems of care. Patients' care-seeking behaviors have changed due to perceived risks of in-hospital treatment during the pandemic. In response to these challenges, we optimized a recently implemented, novel outpatient approach for the evaluation and management of minor stroke and transient ischemic attack, entitled RESCUE-TIA. This modified approach incorporated telemedicine visits and remote testing, and proved valuable during the pandemic. In this review article, we provide the evidence-based rationale for our approach, describe its operationalization, and provide data from our initial experience.

Detection of paroxysmal atrial fibrillation in 994 patients with a cerebrovascular event by intermittent 21-day ECG-monitoring and 7-day continuous Holter-recording

BACKGROUND

The detection of paroxysmal atrial fibrillation (AF) is of importance in stroke care. The method used is continuous electrocardiogram (ECG)-monitoring or multiple short ECG-recordings during an extended period. Their relative efficiency is a matter of discussion. In a retrospective cohort study on 994 patients with an ischemic stroke or transient ischemic attack (TIA), we have compared continuous 7-day monitoring to intermittent recording 60 sec three times daily with a handheld device during 3 weeks. We related the result to subsequent occurrence of AF as detected in 12-lead ECG recordings.

METHODS

The patients were identified in the local database of cardiovascular investigations. Their clinical profile and vital status during the follow-up were obtained from the Swedish Stroke Register and the Swedish general population registry. For comparison, we used an age- and sex-matched population with no known cerebrovascular event and a population with a cerebrovascular event that was not screened.

RESULTS

AF was detected in 7.1% by continuous screening and in 5.1% by intermittent screening (P = 0.3). During follow-up of 32 months, AF in 12-lead ECG was found in 7.0%. In the subgroup with positive screening, 46.3% had AF compared with 6.7% in the subgroup with negative screening (P < 0.0001).

CONCLUSIONS

The two screening approaches had a similar yield of arrhythmia, in spite of the group with intermittent monitoring having a more favorable clinical profile. A positive screening was highly predictive of AF in ECG during the follow-up.

Chronic cerebral infarctions and white matter lesions link to long-term survival after a first ischemic event: A cohort study

BACKGROUND AND PURPOSE

To investigate the association of different phenotypes, count, and locations of chronic covert brain infarctions (CBI) with long-term mortality in patients with first-ever manifest acute ischemic stroke (AIS) or transient ischemic attack (TIA). Additionally, to analyze their potential interaction with white matter hyperintensities (WMH) and predictive value in addition to established mortality scores.

METHODS

Single-center cohort study including consecutive patients with first-ever AIS or TIA with available MRI imaging from January 2015 to December 2017. Blinded raters adjudicated CBI phenotypes and WMH (age-related white matter changes score) according to established definitions. We compared Cox regression models including prespecified established predictors of mortality using Harrell's C and likelihood ratio tests.

RESULTS

A total of 2236 patients (median [interquartile range] age: 71 [59-80] years, 43% female, National Institutes of Health Stroke Scale: 2 [1-6], median follow-up: 1436 days, 21% death during follow-up) were included. Increasing WMH (per point adjusted Hazard Ratio [aHR] = 1.29 [1.14-1.45]), but not CBI (aHR = 1.21 [0.99-1.49]), were independently associated with mortality. Neither CBI phenotype, count, nor location was associated with mortality and there was no multiplicative interaction between CBI and WMH (p &gt; .1). As compared to patients without CBI or WMH, patients with moderate or severe WMH and additional CBI had the highest hazards of death (aHR = 1.62 [1.23-2.13]). The Cox regression model including CBI and WMH had a small but significant increment in Harrell's C when compared to the model including 14 clinical variables (0.831 vs. 0.827, p &lt; .001).

DISCUSSION

WMH represent a strong surrogate biomarker of long-term mortality in first-ever manifest AIS or TIA patients. CBI phenotypes, count, and location seem less relevant. Incorporation of CBI and WMH slightly improves predictive capacity of established risk scores.

Antithrombotic Therapy in the Prevention of Stroke

OVERVIEW

Ischemic stroke is a leading cause of death and disability throughout the world. Antithrombotic therapy, which includes both antiplatelet and anticoagulant agents, is a primary medication of choice for the secondary prevention of stroke. However, the choices vary with the need to incorporate evolving, newer information into the clinical scenario. There is also the need to factor in co-morbid medical conditions as well as the cost ramifications for a particular patient as well as compliance with the regimen. Pertinent Updates: In the acute setting, dual antiplatelet therapy from three weeks to up to three months has become recognized as a reasonable approach for patients with either minor stroke or transient ischemic attack or those with symptoms associated with higher-grade intracranial stenosis. This approach is favored for non-cardioembolic stroke as a cardiogenic mechanism tends to be best managed with attention to the cardiac condition as well as anticoagulant therapy. Risk stratification for recurrent stroke is important in weighing potential risk versus benefits. For example, prolonged dual antiplatelet therapy, with a combination such as aspirin and clopidogrel or aspirin and ticagrelor, tends to have negation of the potential clinical benefit of stroke prevention, over time, by the enhanced bleeding risk. Anticoagulant choices are now impacted by newer agents, initially identified as novel oral anticoagulants (NOACs), which also became associated with "non-vitamin K" agents as they are no longer considered novel. Alternatively, they are now often identified as direct oral anticoagulants (DOACs). They tend to be viewed as superior or non-inferior to warfarin with the caveat that warfarin is still viewed as the agent of choice for stroke prevention in patients with mechanical heart valves.

CONCLUSION

Based upon cumulative information from multiple clinical trials of secondary prevention of stroke, there is an increasing array of approaches in an effort to provide optimal management. Antithrombotic therapy, including in combination with anticoagulant therapy, continues to evolve with the general caveat that "one size does not fit all". In view of this, we desire to provide an evidence-based approach for the prevention of stroke with antithrombotic agents.

"Timing to carotid endarterectomy affects early and long term outcomes of symptomatic carotid stenosis."

OBJECTIVE

The aim of this study is to evaluate early and long-term outcomes according to the timing to carotid endarterectomy (CEA) of symptomatic carotid stenosis.

METHODS

Consecutive CEAs with selective shunting for symptomatic carotid stenosis ≥50% performed between 2009 and 2020. Patients had acute neurological impairment on presentation, defined as <5 points on the National Institutes of Health Stroke Scale(NIHSS). We grouped patients according to time between index event and CEA: the first group was operated between 0-2 days, the second group between 3 and 7 days, the third group between 8 and 14 days and the last group after 15 days. Thirty-day neurological status improvement was defined as a decrease (≥1) in the 30-day NIHSS score vs. NIHSS score immediately before surgery.

RESULTS

500 CEAs were performed. The perioperative combined stroke and mortality rate was 3.6% (18/500), representing a perioperative mortality rate of .2 (n=1) and stroke rate of 3.4% (n=17). Overall freedom from stroke was 95% at 1 year, 89 % at 6 years, and 88% at 10 years. Annual stroke rate was 0.6% after the 30-day period. Thirty-day improvement in neurologic status occurred in 103 patients (20.6%), while in 380 (76%) neurologic status was unchanged, and 17 (3.4%) experienced worsening of their neurologic status. Patients treated within 7 days from the index event had significant benefit (OR=2.6) in the 30-day neurological improvement vs. those treated after 7 days from the index event. Timing to CEA <2 days increased significantly the risk of late stroke (OR=9.7).

CONCLUSIONS

The ideal timing for performing CEA is between 3 and 7 days from the index event if NIHSS <5 as it is associated with the best rates of improvement in neurological status and durability in the long term. Very early CEA (<48 hours) was associated with increased late stroke occurrence.