Transient Ischemic Attack (TIA)

This review provides an update on interdisciplinary treatment for dizziness. Dizziness can have various causes and the treatment offered should depend on the cause. After reading this article, the clinician will have an overview of current treatment recommendations. Recommendations are made for the most prevalent causes of dizziness including acute and chronic vestibular syndromes, vestibular neuritis, benign paroxysmal positional vertigo, endolymphatic hydrops and Menière’s disease, vestibular paroxysmia and vestibular migraine, cardiac causes, transient ischaemic attacks and strokes, episodic ataxia type 2, persistent postural-perceptual dizziness, bilateral vestibulopathy, degenerative, autoimmune and neoplastic diseases, upbeat- and downbeat nystagmus. Recommendations include clinical approaches (repositioning manoeuvres), medication (adding, removing or changing current medication depending on aetiology), vestibular physiotherapy, ergotherapy and rehabilitation, treatment of ch...

Study objective: The Cincinnati Prehospital Stroke Scale (CPSS) is a 3-item scale based on a simplification of the National Institutes of Health (NIH) Stroke Scale. When performed by a physician, it has a high sensitivity and specificity in identifying patients with stroke who are candidates for thrombolysis. The objective of this study was to validate and verify the reproducibility of the CPSS when used by prehospital providers. Methods: The CPSS was performed and scored by a physician certified in the use of the NIH Stroke Scale (gold standard). Simultaneously, a group of 4 paramedics and EMTs scored the same patient. Results: A total of 860 scales were completed on a convenience sample of 171 patients from the emergency department and neurology inpatient service. Of these patients, 49 had a diagnosis of stroke or transient ischemic attack. High reproducibility was observed among prehospital providers for total score (intraclass correlation coefficient [rI], .89; 95% confidence interval [CI], .87 to .92) and for each scale item: arm weakness, speech, and facial droop (.91, .84, and .75, respectively). There was excellent intraclass correlation between the physician and the prehospital providers for total score (rI, .92; 95% CI, .89 to .93) and for the specific items of the scale (.91, .87, and .78, respectively). Observation by the physician of an abnormality in any 1 of the 3 stroke scale items had a sensitivity of 66% and specificity of 87% in identifying a stroke patient. The sensitivity was 88% for identification of patients with anterior circulation strokes. Conclusion: The CPSS has excellent reproducibility among prehospital personnel and physicians. It has good validity in identifying patients with stroke who are candidates for thrombolytic therapy, especially those with anterior circulation stroke. [Kothari RU, Pancioli A, Liu T, Brott T, Broderick J: Cincinnati Prehospital Stroke Scale: Reproducibility and validity. Ann Emerg Med April 1999;33:373-378.]

Background and Purpose— The discrimination between paroxysmal and sustained (persistent or permanent) atrial fibrillation (AF) has not been considered in the approach to secondary stroke prevention. We aimed to assess the differences in clinical outcomes between mostly anticoagulated patients with sustained and paroxysmal AF who had previous ischemic stroke or transient ischemic attack. Methods— Using data from 1192 nonvalvular AF patients with acute ischemic stroke or transient ischemic attack who were registered in the SAMURAI-NVAF study (Stroke Management With Urgent Risk-Factor Assessment and Improvement-Nonvalvular AF; a prospective, multicenter, observational study), we divided patients into those with paroxysmal AF and those with sustained AF. We compared clinical outcomes between the 2 groups. Results— The median follow-up period was 1.8 (interquartile range, 0.93–2.0) years. Of the 1192 patients, 758 (336 women; 77.9±9.9 years old) and 434 (191 women; 77.3±10.0 years old) w...

We present an analysis of 37 interventions in the arteries of the lower limbs via a transbrachial arterial approach. Twenty-six patients (42–79 years) underwent 37 interventional procedures in the lower extremities (iliac n = 6, iliac + femoro-popliteal n = 1, femoro-popliteal n = 30) with a vascular approach via the brachial artery (33 left sided, 4 right sided, introducer sheath 4–7 F). The transbrachial approach was chosen to avoid puncture of femoral bypass graft material. Technical success could be achieved in 11/13 thrombolyses, 8/9 PTAs, 7/10 combinations of thrombolysis and percutaneous transluminar angioplasty (PTA) and in the placement of two stents. One patient suffered from periprocedural severe re-thrombosis due to insufficient anticoagulation during fibrinolysis, and twice thrombolysis was incomplete. One puncture-related false aneurysm of the brachial artery had to be corrected surgically. One transient ischemic attack (TIA) and four minor complications occurred. Transbrachial vascular approach for arterial interventions in iliac and femoro-popliteal pathologies is a reasonable alternative to the transaxillary access if transfemoral puncture has to be avoided. The technical success rate is comparable with the results of the transaxillary and transfemoral approach. To minimize, at least theoretically, the risk of cerebral complications, the left- sided approach should be preferred and intravenous heparin should be administered routinely.

Cerebrovascular diseases present the leading cause of mortality and permanent disability. A large number of medicinal and surgical meth- ods of treatment and prevention, many of which showed its high ef ciency, were created and in- troduced in clinical practice. The development of new therapies based on the use of mobilizing own resources of organism is promising. The increased tolerance of tissues to ischemia, that is, is consid- erably interesting. The method is based on the possibility of increasing the tolerance of the me- dulla to ischemia due to its reversible episodes of ischemia, which have not led to the development of its structural damage. Results of the analysis of modern researches devoted to the study of the protective effects of ischemic preconditioning in patients with coronary and cerebrovascular diseases are shown. The possibility of clinical appli- cation of ischemic preconditioning is considered.

Background and Purpose— Intracranial internal carotid artery calcification is associated with cerebrovascular risk factors and stroke, but few quantification methods are available. We tested the reliability of visual scoring, semiautomated Agatston score, and calcium volume measurement in patients with recent stroke. Methods— We used scans from a prospective hospital stroke registry and included patients with anterior circulation ischemic stroke or transient ischemic stroke whose noncontrast cranial computed tomographic scans were available electronically. Two raters measured semiautomatic quantitative Agatston score, and calcium volume, and performed qualitative visual scoring using the original 4-point Woodcock score and a modified Woodcock score, where each image on which the internal carotid arteries appeared was scored and the slice scores summed. Results— Intra- and interobserver coefficient of variations were 8.8% and 16.5% for Agatston, 8.8% and 15.5% for calcium volume, and...

Background Risk of a subsequent stroke following an acute transient ischemic attack (TIA) or minor stroke is high. The ABCD2 tool was proposed as a method to triage these patients using five clinical factors. Modern imaging of the brain was not included. The present study quantified the added value of magnetic resonance imaging (MRI) factors to the ABCD2 tool.Methods Patients with TIA or minor stroke were examined within 12 h and had a brain MRI within 24 h of symptom onset. Primary outcomes were recurrent stroke and functional impairment at 90 days. A new tool, ABCD2+MRI, was created by adding diffusion-weighted imaging lesion and vessel occlusion status to the ABCD2 tool. The predictive accuracy of both tools was quantified by the area under the curve (AUC).Results One hundred and eighty patients were enrolled and 11·1% had a recurrent stroke within 90 days. The predictive accuracy of the ABCD2+MRI was significantly higher than ABCD2 (AUC of 0·88 vs. 0·78, P=0·01). Those with a high score (7–9) had a 90-day recurrent stroke risk of 32·1%, moderate score (5–6) risk of 5·4%, and low score (0–4) risk of 0·0%. The ABCD2 tool did not predict risk of functional impairment at 90 days (P=0·33), unlike the ABCD2+MRI (P=0·02): high score (22·9%), moderate (7·5%), low (7·7%).Conclusions Risk of recurrent stroke and functional impairment after a TIA or minor stroke can be accurately predicted by a scoring system that utilizes both clinical and MRI information. The ABCD2+MRI score is simple and its components are commonly available during the time of admission.

Background—Patients with a patent foramen ovale (PFO) and paradoxical embolism are at risk for recurrent thromboembolic events. This study investigated the long-term risk of recurrent thromboembolic events in patients with PFO and paradoxical embolism after percutaneous PFO closure. Methods and Results—Since 1994, a total of 80 patients with PFO and at least 1 paradoxical embolic event (transient ischemic attack (TIA),

Background and Purpose—The purpose of this study was to investigate the possibility of obtaining prognostic indications in patients with internal carotid occlusion on the basis of intracranial hemodynamic status, presence of previous symptoms of cerebrovascular failure, and baseline characteristics. Methods—Cerebral hemodynamics were studied with transcranial Doppler ultrasonography. Cerebrovascular reactivity to apnea was calculated by means of the breath-holding index (BHI)

Background
There is only scarce information on the incidence and costs of stroke in Belgium. Knowledge of these figures permits targeted allocation of resources and aids cost efficacy estimates.

Methods
We analysed a nationwide administrative database used for reimbursement of hospitals in Belgium. This database allows analysis of the rate of all hospital admissions for TIA, acute ischemic stroke, intracranial hemorrhage and carotid surgery or angioplasty. We compared the costs of hospitalization for stroke and related disorders with the costs of hospitalization for coronary artery disease.

Results
There were 32970 admissions for stroke related disorders in 2007 at a cost of 191.6 million EUROS. There was a decline of 4.7% of the rate of hospitalization for stroke and associated disorders over the period 2002-2007. Despite this decline the total costs did not diminish substantially. In 2007 stroke and related disorders accounted for 2.0% of all Belgian hospitalizations, whereas coronary artery disease hospitalization accounted for 4.4%. The length of stay was longer for stroke and associated disorders. The average cost of hospitalizations in 2007 for stroke related disorders was 6188 EURO and the average cost of coronary artery related disorders was 5026 EURO.

Conclusion
The cost of hospitalization for stroke and related disorders is high. Although coronary artery disease is more frequent and has a larger impact on the health care expenditures, the average cost per hospitalization is higher for stroke and related diseases. This is mainly due to the longer hospitalization duration for stroke.

Vascular recurrence occurs in 11% of patients during the first year after ischemic stroke (IS) or transient ischemic attack. Clinical scores do not predict the whole vascular recurrence risk; therefore, we aimed to find genetic variants associated with recurrence that might improve the clinical predictive models in IS. We analyzed 256 polymorphisms from 115 candidate genes in 3 patient cohorts comprising 4482 IS or transient ischemic attack patients. The discovery cohort was prospectively recruited and included 1494 patients, 6.2% of them developed a new IS during the first year of follow-up. Replication analysis was performed in 2988 patients using SNPlex or HumanOmni1-Quad technology. We generated a predictive model using Cox regression (GRECOS score [Genotyping Reurrence Risk of Stroke]) and generated risk groups using a classification tree method. The analyses revealed that rs1800801 in the MGP gene (hazard ratio, 1.33; P=9×10(-)(03)), a gene related to artery calcification, was...