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1.  Large-Artery Stenosis Predicts Subsequent Vascular Events in Patients with Transient Ischemic Attack 
Background and purpose
We investigated subsequent vascular events in patients with transient ischemic attack (TIA) and determined the predictors of such events among vascular risk factors including large-artery disease, TIA-symptom duration, and acute ischemic lesions on diffusion-weighted imaging (DWI).
We identified 98 consecutive patients with TIA who visited a tertiary university hospital and underwent DWI and brain magnetic resonance angiography within 48 hours of symptom onset. We reviewed the medical records to assess the clinical characteristics of TIA, demographics, and the subsequent vascular events including acute ischemic stroke, TIA, and myocardial infarction.
Large-artery disease was detected in 55 patients (56%). Ten patients (10%) experienced TIA symptoms for longer than 1 hour, and acute infarctions on DWI were identified in 30 patients (31%). During the mean follow-up period of 19 months, seven patients (7%) had an acute ischemic stroke and 20 patients (20%) had TIA. Retinal artery occlusion in two patients, spinal cord infarction in one patient, and peripheral vascular claudication in one patient were also recorded. Cox proportional-hazards multivariate analysis revealed that large-artery disease was an independent predictor of subsequent cerebral ischemia (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.1-7.1; p=0.02) and subsequent vascular events (HR, 2.9; 95% CI, 1.2-6.7; p=0.01).
In patients with TIA, large-artery disease is an independent predictor of subsequent vascular events. Acute infarction on DWI and a symptom duration of more than 1 hour are not significantly correlated with a higher risk of subsequent vascular events. These findings suggest that the underlying vascular status is more important than symptom duration or acute ischemic lesion on DWI.
PMCID: PMC2686947  PMID: 19513127
Transient ischemic attack; Prognosis; Large-artery stenosis; Diffusion-weighted imaging
2.  Risk factors of short-term stroke recurrence in patients with minor ischemic cerebrovascular events 
ARYA Atherosclerosis  2013;9(2):119-127.
Assessing the risk of recurrent ischemic events in patients with transient ischemic attack (TIA) and minor ischemic stroke (MIS) is of a great importance in clinical practice.
Consecutive patients with TIA or MIS who were visited in Ghaem Hospital, (Mashhad, Iran) were enrolled in a prospective cohort study during 2010 to 2011. Diagnosis of TIA or MIS was accomplished by a stroke neurologist. Only those who presented within 24 hours from the onset of symptoms were recruited. MIS was considered as an ischemic stroke with National Institutes of Health Stroke Scale (NIHSS) < 4. The endpoint of the study was a new ischemic cerebrovascular event or vascular death in 90 days and additionally in 3 days. The decision to admit and type of treatment in each case was left to the discretion of the stroke neurologist. The association between 20 potential factors with recurrent ischemic events in 3 and 90 days was investigated using univariate and multivariate analysis (MVA).
393 TIA patients (238 males and 155 females) and 118 MIS patients (77 males and 41 females) were enrolled in the study. Stroke occurred in 117 (23.2%) patients, TIA in 99 (19.6%), and there was 11 (2.2%) vascular deaths within 3 months in the total 511 patients with minor ischemic events. Crescendo TIAs and multiple TIAs were associated with greater risk of stroke in 3 days in a univariate analysis (OR = 5.12, P < 0.001) and (OR = 3.98, P = 0.003), respectively. Patients with index stroke had 11.5% lower risk of recurrent stroke in 3 days than patients with index TIA in multivariate analysis (OR = 0.115, P = 0.039). Diabetes was independently associated with 3 months stroke recurrence in the patients with minor ischemic events (OR = 2.65, P = 0.039).
Multiple and crescendo TIAs are the main predictors of stroke recurrence, derived from the univariate analysis of the patients with minor ischemic events.
PMCID: PMC3653243  PMID: 23690811
Transient Ischemic Attacks; Infarction; Brain; Recurrence; Risk
3.  Imaging Parameters and Recurrent Cerebrovascular Events in Patients With Minor Stroke or Transient Ischemic Attack 
JAMA neurology  2016;73(5):572-578.
Neurological worsening and recurrent stroke contribute substantially to morbidity associated with transient ischemic attacks and strokes (TIA-S).
To determine predictors of early recurrent cerebrovascular events (RCVEs) among patients with TIA-S and National Institutes of Health Stroke Scale scores of 0 to 3.
A retrospective cohort study was conducted at 2 tertiary care centers (Columbia University Medical Center, New York, New York, and Tulane University Medical Center, New Orleans, Louisiana) between January 1, 2010, and December 31, 2014. All patients with neurologist-diagnosed TIA-S with a National Institutes of Health Stroke Scale score of 0 to 3 who presented to the emergency department were included.
The primary outcome (adjudicated by 3 vascular neurologists) was RCVE: neurological deterioration in the absence of a medical explanation or recurrent TIA-S during hospitalization.
Of the 1258 total patients, 1187 had no RCVEs and 71 had RCVEs; of this group, 750 patients (63.2%) and 39 patients (54.9%), respectively, were aged 60 years or older. There were 505 patients with TIA-S at Columbia University; 31 (6.1%) had RCVEs (15 patients had neurological deterioration only, 11 had recurrent TIA-S only, and 5 had both). The validation cohort at Tulane University consisted of 753 patients; 40 (5.3%) had RCVEs (24 patients had neurological deterioration only and 16 had both). Predictors of RCVE in multivariate models in both cohorts were infarct on neuroimaging (computed tomographic scan or diffusion-weighted imaging sequences on magnetic resonance imaging) (Columbia University: not applicable and Tulane University: odds ratio, 1.75; 95% CI, 0.82–3.74; P = .15) and large-vessel disease etiology (Columbia University: odds ratio, 6.69; 95% CI, 3.10–14.50 and Tulane University: odds ratio, 8.13; 95% CI, 3.86–17.12; P < .001). There was an increase in the percentage of patients with RCVEs when both predictors were present. When neither predictor was present, the rate of RCVE was extremely low (up to 2%). Patients with RCVEs were less likely to be discharged home in both cohorts.
In patients with minor stroke, vessel imaging and perhaps neuroimaging parameters, but not clinical scores, were associated with RCVEs in 2 independent data sets. Prospective studies are needed to validate these predictors.
PMCID: PMC5022560  PMID: 26998948
4.  Prediction Factors of Recurrent Ischemic Events in One Year after Minor Stroke 
PLoS ONE  2015;10(3):e0120105.
The risk of a subsequent stroke following a minor stroke is high. However, there are no effective rating scales to predict recurrent stroke following a minor one. Therefore, we assessed the risk factors associated with recurrent ischemic stroke or transient ischemic attack (TIA) within one year of minor stroke onset in order to identify possible risk factors.
Eight hundred and sixty-three non-cardioembolic ischemic stroke patients in the Chinese IntraCranial AtheroSclerosis Study that presented with minor stroke, defined as an admission National Institutes of Health stroke scale (NIHSS) score of ≤3, were consecutively enrolled in our study. Clinical information and imaging features upon admission, and any recurrent ischemic stroke or TIA within one year was recorded. Cox regression was used to identify risk factors associated with recurrent ischemic stroke or TIA within the year following stroke onset.
A total of 50 patients (6.1%) experienced recurrent ischemic stroke or TIA within one year of minor stroke onset. Multivariate Cox regression model identified lower admission NIHSS score (HR, 1.75; 95% CI, 1.32 to 2.33; P<0.0001), history of coronary heart disease (HR, 2.62; 95% CI, 1.17 to 5.86; P = 0.02), severe stenosis or occlusion of large cerebral artery (HR, 4.68; 95% CI, 1.87 to 11.7; P = 0.001), and multiple acute cerebral infarcts (HR, 2.61; 95% CI, 1.01 to 6.80; P = 0.05) as independent risk factors for recurrent ischemic stroke or TIA within one year.
Some minor stroke patients are at higher risk for recurrent ischemic stroke or TIA. Urgent and intensified therapy may be reasonable in these patients.
PMCID: PMC4361485  PMID: 25774939
5.  Short-term outcome of patients with possible transient ischemic attacks: a prospective study 
BMC Neurology  2015;15:78.
Patients with transient ischemic attack (TIA) have an increased risk of vascular events. There is scarce data regarding the prognosis of patients with transient neurological symptoms less typical of TIA, in whom a vascular origin cannot be excluded, also known as possible TIA. In this study we aimed to compare the short-term prognosis between TIA and Possible TIA patients.
Patients with transient neurological events consecutively referred to a TIA Clinic during five years were classified as TIA, Possible TIA or mimic. Patients were prospectively followed. We compared the outcome at 30 and 90 days after TIA or Possible TIA. The primary outcome was stroke and the secondary outcome was a combination of vascular events (stroke, TIA, myocardial infarction or vascular death).
Two hundred and fifty eight TIA and 109 Possible TIA patients were included. Possible TIA patients had no stroke 30 and 90 days after the event. In contrast, 3.1 % and 4 % of TIA patients had stroke at the same time points. Combined vascular events occurred in 1.9 % of Possible TIA (myocardial infarction) and 9.8 % of TIA patients (stroke and TIA) after 30 days (OR = 0.18, 95 % CI 0.04 to 0.76, P = 0.02); and in 1.9 % of Possible TIA patients (myocardial infarction) and 11.3 % of TIA patients (stroke and TIA) after 90 days (OR = 0.16, 95 % CI 0.04 to 0.67, P = 0.012).
In this exploratory study, Possible TIA patients had less short-term vascular events than TIA patients.
PMCID: PMC4431458  PMID: 25963672
Transient ischemic attacks; Possible TIA; Prognosis; Stroke; Vascular events; Prognosis
6.  Short-Term Prognosis of Transient Ischemic Attack and Predictive Value of the ABCD2 Score in Hong Kong Chinese 
Literature on prognosis of transient ischemic attack (TIA) in Chinese is scarce. The short-term prognosis of TIA and the predictive value of the ABCD2 score in Hong Kong Chinese patients attending the emergency department (ED) were studied to provide reference for TIA patient management in our ED.
A cohort of TIA patients admitted through the ED to 13 acute public hospitals in 2006 was recruited through the centralized electronic database by the Hong Kong Hospital Authority (HA). All inpatients were e-coded by the HA according to the International Classification of Diseases, Ninth Revision (ICD9). Electronic records and hard copies were studied up to 90 days after a TIA. The stroke risk of a separate TIA cohort diagnosed by the ED was compared.
In the 1,000 recruited patients, the stroke risk after a TIA at days 2, 7, 30, and 90 was 0.2, 1.4, 2.9, and 4.4%, respectively. Antiplatelet agents were prescribed in 89%, warfarin in 6.9%, statin in 28.6%, antihypertensives in 39.3%, and antidiabetics in 11.9% of patients after hospitalization. Before the index TIA, the prescribed medications were 27.6, 3.7, 11.3, 27.1, and 9.7%, respectively. The accuracy of the ABCD2 score in predicting stroke risk was 0.607 at 7 days, 0.607 at 30 days, and 0.574 at 90 days. At 30 days, the p for trend across ABCD2 score levels was 0.038 (OR for every score point = 1.36, p = 0.040). Diabetes mellitus, previous stroke and carotid bruit were associated with stroke within 90 days (p = 0.038, 0.045, 0.030, respectively). A total of 45.4% of CTs of the brain showed lacunar infarcts or small vessel disease. There was an increased stroke risk at 90 days in patients with old or new infarcts on CT or MRI. Patients with carotid stenosis ≥70% had an increased stroke risk within 30 (OR = 6.335, p = 0.013) and 90 days (OR = 3.623, p = 0.050). Stroke risks at days 2, 7, 30, and 90 in the 289 TIA patients diagnosed by the ED were 0.35, 2.4, 5.2, and 6.2%, respectively.
The short-term stroke risk in Hong Kong Chinese TIA patients is low. The administered nonurgent treatment cannot solely explain the favorable outcome, the lower risk can be due to the different pathophysiological mechanisms of stroke between Caucasians and Chinese. The predictive value of the ABCD2 score is low in our population.
PMCID: PMC3975175  PMID: 24715897
Chinese ethnicity; Transient ischemic attack; Prognosis; Stroke; Carotid stenosis; Lacunar infarct

7.  The prognosis of hospital-referred transient ischaemic attacks. 
A cohort of 469 hospital-referred patients with transient ischaemic attacks (TIA) of the brain (66%) or eye (34%) due to presumed atheromatous thromboembolism, lipohyalinosis or cardiogenic embolism, without prior stroke, was assembled between 1976-86. Follow up was prospective and complete until the patients death or the end of 1986. During a mean period of follow up of 4.1 years there were 82 deaths (58 vascular, 24 non-vascular), 63 first-ever strokes and 58 patients with coronary events. A coronary event accounted for 51% of deaths whilst stroke was the cause in 12%. The average risk of death over the first five years after TIA was 4.5% per year. The risk of stroke was 6.6% in the first year and 3.4% per year on average over the first five years. Stroke occurred in the same vascular territory as the initial TIA in about two-thirds of cases, and was of lacunar type in one fifth of these strokes. The average risk of a coronary event over the first five years after TIA was 3.1% per year, similar to that of stroke. However, the risk of a coronary event, and also death, was fairly constant each year after a TIA, in contrast to the risk of stroke which was highest in the first year. The average risk of stroke, myocardial infarction or vascular death over the first five years after TIA was 6.5% per year and the average risk of stroke, myocardial infarction or death from any cause was 7.5% per year. The prognosis of this cohort of hospital-referred TIA patients was better than that of TIA patients in the same community who presented to the Oxfordshire Community Stroke Project (OCSP), and reflected the impact of referral bias. The hospital-referred patients were younger, assessed at a later date after their last TIA, and comprised a greater proportion of patients who had had a TIA of the eye (amaurosis fugax), which had a better prognosis than TIA of the brain. Knowledge of the prognosis of different populations of TIA patients not only enhances understanding and interpretation of previous studies but is also required for optimal patient management and the planning of treatment trials.
PMCID: PMC1014519  PMID: 1955898
8.  Predicting value of ABCD2 in early ischemic stroke in patients diagnosed with transient ischemic attack 
As a significant number of patients diagnosed with transient ischemic attack (TIA) at emergency department are at risk to develop TIA or cerebral vascular accident (CVA), several attempts have been made to figure out a predictive method to detect those at higher risk of such attacks. Therefore, the present study was aimed to evaluate the role of ABCD2 scoring including age, blood pressure, clinical features, duration, and diabetes mellitus (DM), in predicting short term outcome of the patients presenting with TIA.
One hundred consecutive patients who have attended Hazrat Rasoul Akram Hospital (Kermanshah, Iran) during 2009 to 2010 and diagnosed with TIA were enrolled in the study. Their ABCD2 scores were recorded. The incidences of death, CVA, and TIA during the first week after the attack were recorded.
Eleven patients suffered from new TIA/CVA after 1 week. Sensitivity and specificity of ABCD2 score for predicting CVA/TIA at cut-off point of the 4th day were 72.7% and 52.8%, respectively. At the same cut-off point for ABCD2, positive and negative predictive values were 16% and 94 %, respectively.
Our results show that although patients with ABCD2 score greater than 4 were more likely to develop recurrent TIA/CVA in short term, those with lower scores are still susceptible to a considerable risk of TIA/CVA. Though ABCD2 as an easily applicable tool is very helpful in management of TIA patients at emergency department, but it should not be the only measure to rely on in our decision making.
Ischemic stroke, Transient ischemic attack, Cerebral vascular accident, ABCD2 scoring
PMCID: PMC3571586
9.  Risk Factors for Silent Lacunar Infarction in Patients with Transient Ischemic Attack 
Lacunar infarctions represent 25% of ischemic strokes. Lacunar stroke and transient ischemic attack (TIA) share a number of symptoms. This study aimed to assess the potential risk factors for lacunar infarction in patients with TIA.
This was a retrospective study performed at the Beijing Military General Hospital in patients with TIA admitted between March 2010 and December 2011. Patients were grouped according to lacunar vs. no lacunar infarction. All patients were diagnosed using diffusion-weighted imaging (DWI) on brain magnetic resonance imaging (MRI). Brain angiography (computed tomography and MRI) was used to measure intracranial stenosis. Carotid artery stenosis was measured by ultrasound.
Patients with TIA and lacunar infarction (n=298) were older than those without lacunar infarction (n=157) (69.4±10.0 vs. 58.9±9.0 years, P<0.001) and showed a higher frequency of males (51.7% vs. 41.4%, P=0.037), hypertension (75.3% vs. 45.9%, P<0.001), diabetes (32.6% vs. 21.0%, P=0.010), hyperlipidemia (53.4% vs. 29.3%, P<0.001), carotid stenosis (73.2% vs. 40.1%, P<0.001), and intracranial stenosis (55.6% vs. 31.9%, P<0.001), but a lower frequency of alcohol drinking (8.1% vs. 14.0%, P=0.045). Lacunar infarction mostly involved the anterior circulation (62.8%). Multivariate analysis showed that age (odds ratio (OR)=1.085, 95% confidence interval (95%CI): 1.054–1.117, P<0.001), hypertension (OR=1.738, 95%CI: 1.041–2.903, P=0.035), hyperlipidemia (OR=2.169, 95%CI: 1.307–3.601, P=0.003), and carotid stenosis (OR=1.878, 95%CI: 1.099–3.206, P=0.021) were independently associated with lacunar infarction.
Age, hypertension, hyperlipidemia, and carotid stenosis were independently associated with silent lacunar infarction in patients with TIA.
PMCID: PMC4754089  PMID: 26864634
Atherosclerosis; Carotid Arteries; Stroke, Lacunar
10.  Cardiovascular events and all-cause mortality in a cohort of 57,946 patients with type 2 diabetes: associations with renal function and cardiovascular risk factors 
Diabetes and chronic kidney disease (CKD) are independent predictors of death and cardiovascular events and their concomitant prevalence has increased in recent years. The aim of this study was to characterize the effect of the estimated glomerular filtration rate (eGFR) and other factors on the risk of death and cardiovascular events in patients with type 2 diabetes.
A cohort of 57,946 patients with type 2 diabetes who were aged 20–89 years in 2000–2005 was identified from The Health Improvement Network, a UK primary care database. Incidence rates of death, myocardial infarction (MI), and ischemic stroke or transient ischemic attack (IS/TIA) were calculated overall and by eGFR category at baseline. eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Death, MI and IS/TIA cases were detected using an automatic computer search and IS/TIA cases were further ascertained by manual review of medical records. Hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) for death, MI, and IS/TIA associated with eGFR category and other factors were estimated using Cox regression models adjusted for potential confounders.
Overall incidence rates of death (mean follow-up time of 6.76 years), MI (6.64 years) and IS/TIA (6.56 years) were 43.65, 9.26 and 10.39 cases per 1000 person-years, respectively. A low eGFR (15–29 mL/min) was associated with an increased risk of death (HR: 2.79; 95% CI: 2.57–3.03), MI (HR: 2.33; 95% CI: 1.89–2.87) and IS/TIA (HR: 1.77; 95% CI: 1.43–2.18) relative to eGFR ≥ 60 mL/min. Other predictors of death, MI and IS/TIA included age, longer duration of diabetes, poor control of diabetes, hyperlipidemia, smoking and a history of cardiovascular events.
In patients with type 2 diabetes, management of cardiovascular risk factors and careful monitoring of eGFR may represent opportunities to reduce the risks of death, MI and IS/TIA.
Electronic supplementary material
The online version of this article (doi:10.1186/s12933-015-0204-5) contains supplementary material, which is available to authorized users.
PMCID: PMC4409775  PMID: 25909295
Chronic kidney disease; Estimated glomerular filtration rate; Ischemic stroke; Mortality; Myocardial infarction; Type 2 diabetes
11.  Magnetic Resonance Imaging versus Computed Tomography in Transient Ischemic Attack and Minor Stroke: The More Υou See the More You Know 
Cerebrovascular Diseases Extra  2013;3(1):130-136.
Magnetic resonance imaging (MRI) is proposed as the preferred imaging modality to investigate patients with transient ischemic attack (TIA). This is mainly based on a higher yield of small acute ischemic lesions; however, direct prospective comparisons are lacking. In this study, we aimed to directly compare the yield of acute ischemic lesions on MRI and computed tomography (CT) in the emergency diagnosis of suspected TIA or minor stroke.
Consecutive patients aged 18 years or older presenting with minor stroke (NIHSS <4) or high-risk TIA and who were examined by a stroke neurologist within 24 h of symptom onset were prospectively enrolled in the CATCH study. Patients who had undergone both a baseline CT and an MRI within 24 h of symptom onset were included in this substudy. Baseline MRI and CT were interpreted independently to identify an acute ischemic lesion. The rates of acute ischemic lesions on CT and MRI were compared, and the volume of acute ischemic lesions was measured on MRI. In addition, the volume of acute ischemic lesions on MRI was compared between patients who had evidence of acute ischemia on CT and in those who did not.
A total of 347 patients were included, 168 with TIAs, 147 with minor strokes and 32 with a final diagnosis of a mimic. Acute ischemic lesions were detected in 39% of TIAs by using MRI versus 8% by using CT (p < 0.0001) and in 86% of minor strokes by using MRI versus 18% by using CT (p < 0.0001). Compared to MRI, CT had a sensitivity of 20% and a specificity of 98% in identifying an acute ischemic lesion. The infarct volume on diffusion-weighted MRI was larger in cases where the CT also showed an acute ischemic lesion (median 5.07 ml, IQR 10) as compared to lesions seen only on MRI (median 0.68 ml, IQR 1.31, p < 0.0001).
MRI is superior to CT in detecting the small ischemic lesions occurring after TIA and minor stroke. Since these lesions are clinically relevant, MRI should be the preferred imaging modality in this setting.
PMCID: PMC3884208  PMID: 24403904
Transient ischemic attack; Mild stroke; Magnetic resonance imaging; Diffusion-weighted magnetic resonance imaging; Computed tomography

12.  Transient ischaemic attacks: which patients are at high (and low) risk of serious vascular events? 
The aims of this study were to determine the important prognostic factors at presentation which identify patients with transient ischaemic attacks (TIA) who are at high risk (and low risk) of serious vascular events and to derive a prediction model (equation) for each of the major vascular outcome events. A cohort of 469 TIA patients referred to a University hospital, without prior stroke, were evaluated prospectively and followed up over a mean period of 4.1 years (range 1-10 years). The major outcome events of interest were 1) stroke 2) coronary event and 3) stroke, myocardial infarction or vascular death (whichever occurred first). Prognostic factors and their hazard ratios were identified by means of the Cox proportional hazards multiple regression analysis. The significant adverse prognostic factors (in order of strength of association) for stroke were an increasing number of TIAs in the three months before presentation, increasing age, peripheral vascular disease, left ventricular hypertrophy and TIAs of the brain (compared with the eye); the prognostic factors for coronary event were increasing age, ischaemic heart disease, male sex, and a combination of carotid and vertebrobasilar TIAs at presentation; and for stroke, myocardial infarction or vascular death they were increasing age, peripheral vascular disease, increasing number of TIAs in the three months before presentation, male sex, a combination of carotid and vertebrobasilar TIAs at presentation, TIAs of the brain (compared with the eye), left ventricular hypertrophy and the eye), left ventricular hypertrophy and the eye), left ventricular hypertrophy and the presence of residual neurological signs after the TIA. Prediction models (equations) of both the relative risk and absolute risk of each of the major outcome events were produced, based on the presence or level of the significant prognostic factors and their hazard. Before it can be concluded that our equations accurately predict prognosis and can be generalised to other populations, their predictive power needs to be validated in other, independent samples of TIA patients (which we are currently doing).
PMCID: PMC489198  PMID: 1527533
13.  Prognostic value of the ABCD2 score beyond short-term follow-up after transient ischemic attack (TIA) - a cohort study 
BMC Neurology  2010;10:50.
Transient ischemic attack (TIA) patients are at a high vascular risk. Recently the ABCD2 score was validated for evaluating short-term stroke risk after TIA. We assessed the value of this score to predict the vascular outcome after TIA during medium- to long-term follow-up.
The ABCD2 score of 176 TIA patients consecutively admitted to the Stroke Unit was retrospectively calculated and stratified into three categories. TIA was defined as an acute transient focal neurological deficit caused by vascular disease and being completely reversible within 24 hours. All patients had to undergo cerebral MRI within 5 days after onset of symptoms as well as extracranial and transcranial Doppler and duplex ultrasonography. At a median follow-up of 27 months, new vascular events were recorded. Multivariate Cox regression adjusted for EDC findings and heart failure was performed for the combined endpoint of cerebral ischemic events, cardiac ischemic events and death of vascular or unknown cause.
Fifty-five patients (32.0%) had an ABCD2 score ≤ 3, 80 patients (46.5%) had an ABCD2 score of 4-5 points and 37 patients (21.5%) had an ABCD2 score of 6-7 points. Follow-up data were available in 173 (98.3%) patients. Twenty-two patients (13.8%) experienced an ischemic stroke or TIA; 5 (3.0%) a myocardial infarction or acute coronary syndrome; 10 (5.7%) died of vascular or unknown cause; and 5 (3.0%) patients underwent arterial revascularization. An ABCD2 score > 3 was significantly associated with the combined endpoint of cerebral or cardiovascular ischemic events, and death of vascular or unknown cause (hazard ratio (HR) 4.01, 95% confidence interval (CI) 1.21 to 13.27). After adjustment for extracranial ultrasonographic findings and heart failure, there was still a strong trend (HR 3.13, 95% CI 0.94 to 10.49). Whereas new cardiovascular ischemic events occurred in 9 (8.3%) patients with an ABCD2 score > 3, this happened in none of the 53 patients with a score ≤ 3.
An ABCD2 score > 3 is associated with an increased general risk for vascular events in the medium- to long-term follow-up after TIA.
PMCID: PMC2906428  PMID: 20565966
14.  The QT dispersion and QTc dispersion in patients presenting with acute neurological events and its impact on early prognosis 
To find out and investigate whether the QT dispersion and QTc dispersion is related to type and prognosis of the acute stroke in patients presenting within 24 h of the onset of stroke.
Settings and Design:
This was a observational study conducted at Mahatma Gandhi Hospital, Dr. SN. Medical College, Jodhpur, during January 2014 to January 2015.
Subjects and Methods:
The patients presented within 24 h of onset of acute stroke (hemorrhagic, infarction, or transient ischemic event) were included in the study. The stroke was confirmed by computed tomography scan and magnetic resonance imaging. Patients with (i) altered sensorium because of metabolic, infective, seizures, trauma, or tumor; (ii) prior history of cardiovascular disease, electrocardiographic abnormalities’ because of dyselectrolytemia; and (iii) and patients who were on drugs (antiarrhythmic drugs, antipsychotic drugs, erythromycin, theophylline, etc.,) which known to cause electrocardiogram changes, were excluded from the study. National Institute of Health Stroke Score (NIHSS) was calculated at the time of admission and Modified Rankin Scale (MRS) at the time of discharge. Fifty age- and sex-matched healthy controls included.
Statistical Analysis Used:
Student's t-test, ANOVA, and area under curve for sensitivity and specificity for the test.
We included 52 patients (male/female: 27/25) and 50 controls (26/24). The mean age of patients was 63.17 ± 08.90 years. Of total patients, infarct was found in 32 (61.53%), hemorrhage in 18 (34.61%), transient ischemic attack (TIA) in 1 (1.9%), and subarachnoid hemorrhage in 1 (1.9%) patient. The QT dispersion and QTc dispersion were significantly higher in cases as compare to controls. (87.30 ± 24.42 vs. 49.60 ± 08.79 ms; P < 0.001) and (97.53 ± 27.36 vs. 56.28 ± 09.86 ms; P < 0.001). Among various types of stroke, the mean QT dispersion and QTc dispersion were maximum and significantly higher in hemorrhagic stroke as compared to infarct and TIA (P < 0.001). The mean QT dispersion and QTc dispersion was found significantly high in nonsurvivors (n = 16) as compared to survivors group (n = 36) (P < 0.05). The mean QT dispersion was directly correlated with the NIHSS and functional outcome score MRS. Patients with greater QT and QTc dispersion having high NIHSS had poor prognosis.
We concluded that patients presenting with acute neurological events having increased QT dispersion and QTc dispersion is related to high mortality and poor functional outcomes on hospital discharge and if the values of dispersion score are very high we can predict for hemorrhagic stroke.
PMCID: PMC4750342  PMID: 26933346
Acute stroke; hemorrhage; infarct; prognosis; QT dispersion
15.  Atrial Fibrillation in Patients with Transient Ischemic Attack in Accordance with the Tissue-Based Definition 
Transient ischemic attack (TIA) management requires a cardiac evaluation with a Holter electrocardiogram (ECG), preferably a long-term (24 h) electrocardiogram (LT-ECG), to detect atrial fibrillation (AF), which places patients at higher risk of cerebrovascular events. The aim of this study was to determine the frequency of AF using ECG and LT-ECG in patients with tissue-based TIA.
During a three-year period (starting in 2011), all consecutive patients with tissue-based TIA (no evidence of infarction by brain imaging) were included and prospectively evaluated.
Of 861 patients (mean age, 70 ± 13 years; 49.7% women), 854 patients (99.2%) had an ECG at admission, and 338 patients (39.3%) underwent 24-h LT-ECG monitoring during hospitalization. Patients who underwent LT-ECG monitoring were significantly younger (68 vs. 71 years; P=0.001) and experienced longer symptom duration (143 vs. 79 minutes; P=0.024) compared with those who did not. Furthermore, they had lower rates of unilateral weakness (32% vs. 39%; P=0.034) and previous strokes (18% vs. 26%; P=0.007). The LT-ECG investigation was also associated with longer hospitalization (7.9 vs. 5.7 days; P<0.001). A total of 77 patients (8.9%) exhibited AF on the ECG at admission. The LT-ECG revealed AF among seven patients (2.1%); five of these received a new treatment with oral anticoagulation based on the LT-ECG findings. Using the logistic regression, the presence of AF was associated with the following: age over 65 years (odds ratio [OR], 20.6; 95% confidence interval [CI], 2.8–152; P=0.003), hypertension (OR, 3.1; 95% CI: 1–8.9; P=0.041) and increased glucose level >6.05 mmol/L) on admission (OR, 1.9; 95% CI: 1–3.5; P=0.036).
Cardiac evaluation with LT-ECG appears to increase the rate of detected AF and may lead to a change in secondary prophylaxis in patients with tissue-based TIA.
PMCID: PMC4925762  PMID: 27403220
Atrial fibrillation; cardioembolism; outcome; stroke; TIA; tissue-based definition
16.  Stroke Among Patients With Dizziness, Vertigo, and Imbalance in the Emergency Department: A Population-Based Study 
Background and Purpose
Dizziness, vertigo, and imbalance are common presenting symptoms in the emergency department. Stroke is a leading concern even when these symptoms occur in isolation. The objective of the present study was to determine the “real-world” proportion of stroke among patients presenting to the emergency department with these dizziness symptoms (DS).
From a population-based study, patients >44 years of age presenting with DS to the emergency department, or directly admitted to the hospital, were identified. Demographics, the frequency of new cerebrovascular events, and the frequency of isolated DS (ie DS with no other stroke screening term or accompanying neurologic signs or symptoms) were assessed. Multivariable logistic regression was used to evaluate the association of age, gender, ethnicity, and isolated DS with stroke/transient ischemic attack (TIA). The association of the presenting symptoms with stroke/TIA was also assessed.
Stroke/TIA was diagnosed in 3.2% (53 of 1666) of all patients with DS. Only 0.7% (9 of 1297) of those with isolated DS had a stroke/TIA. Patients with stroke/TIA were slightly older than those without stroke/TIA (69.3±11.7 vs 65.3±12.9, P=0.02). Male gender was associated with stroke/TIA, whereas isolated DS was negatively associated with stroke/TIA. Patients with imbalance (dizziness as referent) were more likely to have stroke/TIA.
The proportion of cerebrovascular events in patients presenting with dizziness, vertigo, or imbalance is very low. Isolated dizziness, vertigo, or imbalance strongly predicts a noncerebrovascular cause. The symptom of imbalance is a predictor of stroke/TIA.
PMCID: PMC1779945  PMID: 16946161
cerebrovascular accident; dizziness; gait disorders; population surveillance; vertigo
17.  Implanted endocardial lead characteristics and risk of stroke or transient ischemic attack 
Patent foramen ovale (PFO) has been recently implicated as a strong predictor of stroke or transient ischemic attack (TIA) in patients with implanted pacemaker or defibrillation leads. Leads in the right heart can form thrombi that embolize to the pulmonary circulation and raise pulmonary pressure. This increases right-to-left shunting through PFO or intrapulmonary shunts and can result in paradoxical embolism. We sought to determine whether certain lead characteristics confer a higher thrombogenic risk resulting in stroke/ TIAs in patients either with or without a PFO.
We retrospectively analyzed 5,646 patients (mean age 67.3±16.3 years, 64 % male) who had endocardial device leads implanted in 2000–2010. We performed univariate and multivariate-adjusted proportional hazards models to determine association of lead characteristics with stroke/TIA during follow-up.
On univariate analysis, passively fixated tined leads were associated with more stroke/TIAs (HR 1.77, 95 % CI 1.27, 2.47; p<0.001), whereas presence of defibrillation coil was associated with fewer stroke/TIAs (HR 0.59, 95 % CI 0.42–0.84; p=0.003). Number of leads per patient, presence of atrial lead, maximum lead size, tip shape, and type of insulating material were not associated with stoke/TIA. On multivariate analyses adjusting for age, sex, diagnosis of PFO, and prior history of stroke/TIA, the presence of tined leads was associated with stroke/TIA (HR 1.41, 95 % CI 1.00–1.97; p=0.049). Defibrillation coils were no longer associated with lower stroke/TIA on multivariate analysis.
Most physical characteristics of contemporary leads do not impact rate of stroke/TIA among patients receiving implantable devices. The presence of a PFO is a major risk factor for stroke/TIA in patients with endovascular leads.
PMCID: PMC4454455  PMID: 24771226
Device; Leads; Stroke; TIA; Patent foramen ovale
18.  Heart dysfunction in patients with acute ischemic stroke or TIA does not predict all-cause mortality at long-term follow-up 
BMC Neurology  2013;13:122.
Despite heart failure being a substantial risk factor for stroke, few studies have evaluated the predictive value of heart dysfunction for all-cause mortality in patients with acute ischemic stroke, in particular in the elderly. The aim of this study was to investigate whether impaired heart function in elderly patients can predict all-cause mortality after acute ischemic stroke or transient ischemic attack (TIA).
A prospective long-term follow-up analysis was performed on a hospital cohort consisting of n = 132 patients with mean age 73 ± 9 years, presenting with acute ischemic stroke or transient ischemic attack, without atrial fibrillation. All patients were examined by echocardiography during the hospital stay. Data about all-cause mortality were collected at the end of the follow-up period. The mean follow-up period was 56 ± 22 months.
In this cohort, 58% of patients with acute ischemic stroke or TIA had heart dysfunction. Survival analysis showed that heart dysfunction did not predict all-cause mortality in this cohort. Furthermore, in multivariate regression analysis age (HR 5.401, Cl 1.97-14.78, p < 0.01), smoking (HR 3.181, Cl 1.36-7.47, p < 0.01), myocardial infarction (HR 2.826, Cl 1.17-6.83, p < 0.05) were independent predictors of all-cause mortality.
In this population with acute ischemic stroke or TIA and without non-valvular atrial fibrillation, impaired heart function does not seem to be a significant predictor of all-cause mortality at long-term follow-up.
PMCID: PMC3852256  PMID: 24053888
Echocardiography; Heart failure; Mortality; Stroke; TIA
19.  Post-Stroke Epilepsy in Young Adults: A Long-Term Follow-Up Study 
PLoS ONE  2013;8(2):e55498.
Little is known about the incidence and risk of seizures after stroke in young adults. Especially in the young seizures might dramatically influence prognosis and quality of life. We therefore investigated the long-term incidence and risk of post-stroke epilepsy in young adults with a transient ischemic attack (TIA), ischemic stroke (IS) or intracerebral hemorrhage (ICH).
Methods and Findings
We performed a prospective cohort study among 697 consecutive patients with a first-ever TIA, IS or ICH, aged 18–50 years, admitted to our hospital between 1-1-1980 till 1-11-2010. The occurrence of epilepsy was assessed by standardized questionnaires and verified by a neurologist. Cumulative risks were estimated with Kaplan-Meier analysis. Cox proportional hazard models were used to calculate relative risks. After mean follow-up of 9.1 years (SD 8.2), 79 (11.3%) patients developed post-stroke epilepsy and 39 patients (5.6%) developed epilepsy with recurrent seizures. Patients with an initial late seizure more often developed recurrent seizures than patients with an initial early seizure. Cumulative risk of epilepsy was 31%, 16% and 5% for patients with an ICH, IS and TIA respectively (Logrank test ICH and IS versus TIA p<0.001). Cumulative risk of epilepsy with recurrent seizures was 23%, 8% and 4% respectively (Logrank ICH versus IS p = 0.05, ICH versus TIA p<0.001, IS versus TIA p = 0.01). In addition a high NIHSS was a significant predictor of both epilepsy and epilepsy with recurrent seizures (HR 1.07, 95% CI 1.03–1.11 and 1.08, 95% CI 1.02–1.14).
Post-stroke epilepsy is much more common than previously thought. Especially patients with an ICH and a high NIHSS are at high risk. This calls upon the question whether a subgroup could be identified which benefits from the use of prophylactic antiepileptic medication. Future studies should be executed to investigate risk factors and the effect of post-stroke epilepsy on quality of life.
PMCID: PMC3563638  PMID: 23390537
20.  Stroke: secondary prevention  
BMJ Clinical Evidence  2010;2010:0207.
People with a history of stroke or transient ischaemic attack (TIA) are at high risk of all vascular events, such as myocardial infarction (MI), but are at particular risk of subsequent stroke (about 10% in the first year and about 5% each year thereafter).
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive non-surgical interventions in people with previous stroke or transient ischaemic attack? What are the effects of preventive surgical interventions in people with previous stroke or transient ischaemic attack? What are the effects of preventive anticoagulant and antiplatelet treatments in people with atrial fibrillation and previous stroke or transient ischaemic attack? What are the effects of preventive anticoagulant and antiplatelet treatments in people with atrial fibrillation and without previous stroke or transient ischaemic attack? What are the effects of preventive anticoagulant and antiplatelet treatments in people with atrial fibrillation and without previous stroke or transient ischaemic attack and with low to moderate risk of stroke or transient ischaemic attack? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 130 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: alternative antiplatelet regimens to aspirin, anticoagulation (oral dosing, or in those with sinus rhythm), aspirin (high or low dose), blood pressure reduction, carotid and vertebral percutaneous transluminal angioplasty (PTA), carotid endarterectomy (in people with: asymptomatic but severe carotid artery stenosis, less than 0% symptomatic carotid artery stenosis, moderate [30%–49%] symptomatic carotid artery stenosis, moderately severe [50%–69%] symptomatic carotid artery stenosis, severe [greater than 70%] symptomatic carotid artery stenosis, or symptomatic near occlusion of the carotid artery), cholesterol reduction, vitamin B supplements (including folate), and different regimens to lower blood pressure.
Key Points
Prevention in this context is the long-term management of people with previous stroke or TIA, and of people at high risk of stroke for other reasons, such as atrial fibrillation. Risk factors for stroke include: previous stroke or TIA; increasing age; hypertension; diabetes; cigarette smoking; and emboli associated with atrial fibrillation, artificial heart valves, or MI.
Antiplatelet treatment effectively reduces the risk of stroke in people with previous stroke or TIA. High-dose aspirin (500–1500 mg/day) seems as equally effective as low-dose aspirin (75–150 mg/day), although it may increase GI adverse effects. Adding dipyridamole to aspirin is beneficial in reducing composite vascular end points and stroke compared with aspirin alone. Risk reduction appears greater with extended-release compared with immediate-release dipyridamole.The net risk of recurrent stroke or major haemorrhagic event is similar with clopidogrel and aspirin plus dipyridamole.
Treatments to reduce blood pressure are effective for reducing the risk of serious vascular events in people with previous stroke or TIA. Blood pressure reduction seems beneficial irrespective of the type of qualifying cerebrovascular event (ischaemic or haemorrhagic), or even whether people are hypertensive.Aggressive blood pressure lowering should not be considered in people with acute stenosis of the carotid or vertebral arteries, because of the risk of precipitating a stroke.
Carotid endarterectomy effectively reduces the risk of stroke in people with greater than 50% carotid stenosis, is not effective in people with 30% to 49% carotid stenosis, and increases the risk of stroke in people with less than 30% stenosis. However, it does not seem beneficial in people with near occlusion.
Cholesterol reduction using statins seems to reduce the risk of stroke irrespective of baseline cholesterol or coronary artery disease (CAD). Non-statin cholesterol reduction does not seem to reduce the risk of stroke.
We found insufficient evidence to judge the efficacy of carotid percutaneous transluminal angioplasty, carotid percutaneous transluminal angioplasty plus stenting, or vertebral percutaneous transluminal angioplasty in people with recent carotid or vertebral TIA or stenosis.
Vitamin B supplements (including folate) do not seem beneficial in reducing mortality or the risk of stroke.
Anticoagulation does not seem beneficial in reducing stroke in people with previous ischaemic stroke and normal sinus rhythm, but does increase the risk of intra- and extracranial haemorrhage. This is especially true for patients with TIAs or minor ischaemic stroke as the qualifying event.
In people with atrial fibrillation, oral anticoagulants reduce the risk of stroke in people with previous stroke or TIA, and in people with no previous stroke or TIA who are at high risk of stroke or TIA, but we don't know whether they are effective in people with no previous stroke or TIA who are at low risk of stroke or TIA. In people with atrial fibrillation, we don't know whether aspirin reduces the risk of stroke in people with previous stroke or TIA, or in people without previous stroke or TIA who are at low risk of stroke or TIA, but they may be unlikely to be effective in people without previous stroke or TIA who are at high risk of stroke or TIA.
PMCID: PMC2907594
21.  Duration of Symptom and ABCD2 Score as Predictors of Risk of Early Recurrent Events after Transient Ischemic Attack: A Hospital-Based Case Series Study 
The aim of this study was to refine clinical risk factor stratification and make an optimal intervention plan to prevent ischemic stroke.
Clinical data, including diffusion-weighted imaging (DWI) findings, were collected in a cohort of hospitalized transient ischemic attack (TIA) patients from January 2010 to December 2011. Recurrent cerebrovascular events after TIA, including recurrent TIA, minor stroke, and major stroke, were identified by face-to-face follow-up. A multivariate, ordinal, logistic regression model was used to determine significant predictors of recurrent events.
Of 106 TIA patients, 24 (22.6%) had recurrent TIA and 20 (18.9%) had a stroke within 7 days. Hypertension, dyslipidemia, a history of ischemic stroke or TIA, and ABCD2 score were significantly associated with the recurrent events after TIA (P<0.001, P=0.02, P<0.001, P=0.02). Hypertension (RR=9.21; 95% CI, 3.07–27.61, P<0.001) and duration of symptom (RR=1.10; 95% CI, 1.02–1.17, P=0.01) as an item of ABCD2 score were highly predictive of the severity of recurrent events, whereas ABCD2 score as a whole (P=0.18) proved to be less strongly predictive.
A history of hypertension and long duration of symptom independently and significantly predict severe recurrent events after TIA within 7 days, but a high ABCD2 score was less strongly predictive of severe recurrent events.
PMCID: PMC4310715  PMID: 25604068
Ischemic Attack, Transient; Recurrence; Risk Assessment
22.  Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy 
Journal of vascular surgery  2016;63(5):1262-1270.e3.
Controversy persists regarding the perioperative management of clopidogrel among patients undergoing carotid endarterectomy (CEA). This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes.
Patients undergoing CEA in the Vascular Quality Initiative were analyzed (2003–2014). Patients on clopidogrel and aspirin (dual therapy) were compared with patients taking aspirin alone preoperatively. Study outcomes included reoperation for bleeding and thrombotic complications defined as transient ischemic attack (TIA), stroke, or myocardial infarction. Secondary outcomes were in-hospital death and composite stroke/death. Univariate and multivariable analyses assessed differences in demographics and operative factors. Propensity score-matched cohorts were derived to control for subgroup heterogeneity.
Of 28,683 CEAs, 21,624 patients (75%) were on aspirin and 7059 (25%) were on dual therapy. Patients on dual therapy were more likely to have multiple comorbidities, including coronary artery disease (P < .001), congestive heart failure (P < .001), and diabetes (P < .001). Patients on dual therapy were also more likely to have a drain placed (P < .001) and receive protamine during CEA (P < .001). Multivariable analysis showed that dual therapy was independently associated with increased reoperation for bleeding (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20–2.42; P = .003) but was protective against TIA or stroke (OR, 0.61; 95% CI, 0.43–0.87; P = .007), stroke (OR, 0.63; 95% CI, 0.41–0.97; P = .03), and stroke/death (OR, 0.66; 95% CI, 0.44–0.98; P = .04). Propensity score matching yielded two groups of 4548 patients and showed that patients on dual therapy were more likely to require reoperation for bleeding (1.3% vs 0.7%; P = .004) but less likely to suffer TIA or stroke (0.9% vs 1.6%; P = .002), stroke (0.6% vs 1.0%; P = .04), or stroke/death (0.7% vs 1.2%; P = .03). Within the propensity score-matched groups, patients on dual therapy had increased rates of reoperation for bleeding regardless of carotid symptom status. However, asymptomatic patients on dual therapy demonstrated reduced rates of TIA or stroke (0.6% vs 1.5%; P < .001), stroke (0.4% vs 0.9%; P = .01), and composite stroke/death (0.5% vs 1.0%; P = .02). Among propensity score-matched patients with symptomatic carotid disease, these differences were not statistically significant.
Preoperative dual antiplatelet therapy was associated with a 40% risk reduction for neurologic events but also incurred a significant increased risk of reoperation for bleeding after CEA. Given its observed overall neurologic protective effect, continued dual antiplatelet therapy throughout the perioperative period is justified. Initiating dual therapy in all patients undergoing CEA may lead to decreased neurologic complication rates.
PMCID: PMC5065102  PMID: 26947237
23.  Factors Associated with Ischemic Stroke on Therapeutic Anticoagulation in Patients with Nonvalvular Atrial Fibrillation 
Yonsei Medical Journal  2015;56(2):410-417.
In this study, we investigated the stroke mechanism and the factors associated with ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF) who were on optimal oral anticoagulation with warfarin.
Materials and Methods
This was a multicenter case-control study. The cases were consecutive patients with NVAF who developed cerebral infarction or transient ischemic attack (TIA) while on warfarin therapy with an international normalized ratio (INR) ≥2 between January 2007 and December 2011. The controls were patients with NVAF without ischemic stroke who were on warfarin therapy for more than 1 year with a mean INR ≥2 during the same time period. We also determined etiologic mechanisms of stroke in cases.
Among 3569 consecutive patients with cerebral infarction or TIA who had NVAF, 55 (1.5%) patients had INR ≥2 at admission. The most common stroke mechanism was cardioembolism (76.0%). Multivariate analysis demonstrated that smoking and history of previous ischemic stroke were independently associated with cases. High CHADS2 score (≥3) or CHA2DS2-VASc score (≥5), in particular, with previous ischemic stroke along with ≥1 point of other components of CHADS2 score or ≥3 points of other components of CHA2DS2-VASc score was a significant predictor for development of ischemic stroke.
NVAF patients with high CHADS2/CHA2DS2-VASc scores and a previous ischemic stroke or smoking history are at high risk of stroke despite optimal warfarin treatment. Some other measures to reduce the risk of stroke would be necessary in those specific groups of patients.
PMCID: PMC4329352  PMID: 25683989
Cardiac embolism; cerebral infarction; risk factors; atrial fibrillation; anticoagulation
24.  CT Angiography and Presentation NIH stroke Scale in Predicting TIA in Patients Presenting with Acute Stroke Symptoms 
Patient candidacy for acute stroke intervention, is currently assessed using brain computed tomography angiography (CTA) evidence of significant stenosis/occlusion (SSO) with a high National Institutes of Health Stroke Scale (NIHSS) (>6). This study examined the association between CTA without significant stenosis/occlusion (NSSO) and lower NIHSS (≤ 6) with transient ischemic attack (TIA) and other good clinical outcomes at discharge. Patients presenting <8 hours from stroke symptom onset, had an NIHSS assessment and brain CTA performed at presentation. Good clinical outcomes were defined as: discharge diagnosis of TIA, modified Rankin Score [mRS] ≤ 1, and home as the discharge disposition. Eighty-five patients received both an NIHSS at presentation and a CTA at 4.2 ± 2.2 hours from stroke symptom onset. Patients with NSSO on CTA as well as those with NIHSS≤6 had better outcomes at discharge (p<0.001). NIHSS ≤ 6 were more likely than NSSO (p=0.01) to have a discharge diagnosis of TIA (p<0.001). NSSO on CTA and NIHSS ≤ 6 also correlated with fewer deaths (p<0.001). Multivariable analyses showed NSSO on CTA (Adjusted OR: 5.8 95% CI: 1.2-27.0, p=0.03) independently predicted the discharge diagnosis of TIA. Addition of NIHSS ≤ 6 to NSSO on CTA proved to be a stronger independent predictor of TIA (Adjusted OR 18.7 95% CI: 3.5-98.9, p=0.001).
PMCID: PMC4025925  PMID: 24851234
Ischemic stroke; Neuroimaging; TIA; Discharge; Clinical outcome
25.  Long term evolution of patients treated in a TIA unit 
Transient ischemic attacks (TIA) entail a high risk of stroke recurrence, which depends on the etiology. New organizational models have been created, but there is not much information about the long-term evolution of patients managed according to these premises. Our aim is to refer the follow-up of patients attended according to our model of TIA Unit.
TIA Unit is located in the Emergency Department and staffed by vascular neurologists. Patients admitted during the Neurology night shift stayed in such Unit <48h with complete etiological study. Preventive treatment is instituted in patients discharged to a high resolution Neurology consult, in order to review in <2 weeks and subsequent follow-up.
During a year 161 patients were attended, being admitted to the hospital 8.6%. A total of 1470 hospital days were avoided. Recurrence at 90 days was of 0.6%. Mean follow-up was 18.14 ± 8.02 months (0–34), total recurrence 6.2% (70% cardioembolic strokes). There were no complications derived from treatment. Cardiological events were recorded in 10.6%, neoplastic in 5%, cognitive impairment in 11%. There were 3 deaths unrelated nor to the stroke or its treatment.
This model allows an early diagnosis and treatment of TIA, preventing recurrences of stroke in a long term. It detects atherothrombotic strokes, most of them admitted to the hospital, and it shows a greater difficulty for detecting all cardioembolic strokes. TIA Unit appeared to be safe in using anticoagulation therapy, as the follow-up shows. It shows the same quality of management than hospital admission, with a significant saving in hospital stays.
PMCID: PMC3716896  PMID: 23635082
TIA; Mild stroke; TIA unit; Stroke care models; TIA management

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