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PubMed1994

Transient ischemic attacks: diagnosis, and medical and surgical management.

Patients experiencing transient ischemic attacks (TIAs) may have a 2-year stroke rate as high as 57%, and carotid endarterectomy has been shown in prospective randomized studies to be highly effective in reducing this rate. Therefore, it is crucial to correctly identify patients with TIAs, treat underlying causes appropriately, and identify those most likely to benefit from endarterectomy. Whether in the anterior or posterior circulation, TIAs are focal neurologic events that usually last 5 to 30 minutes and are characterized by an abrupt onset followed by gradual resolution. They may be caused by artery-to-artery thromboembolism, cardiogenic embolism, or thrombosis of a small penetrating cerebral vessel (threatened lacunar infarction). A number of contributing disorders must be considered, including migraine, arterial dissection, vasculitis, thrombotic diatheses, blood dyscrasias, infections, and drug abuse. Carotid endarterectomy should be considered only for patients with hemispheric TIAs in whom lacunar events, cardiogenic embolism, and other underlying causes of stroke have been excluded and ipsilateral carotid stenosis of greater than 70% has been demonstrated. The value of endarterectomy increases: if the patient is relatively willing to take immediate risks in order to avoid future morbid events (low risk aversion) and believes stroke is a serious event, nearly tantamount to death; if the morbidity and mortality of the operation, as determined by institutional audits, is low; and if the degree of carotid stenosis is high. The value of endarterectomy declines rapidly with time elapsed from the TIA. Endarterectomy is of marginal value in patients with amaurosis fugax, of uncertain value in patients with stroke, and unlikely to be of any value in patients with asymptomatic carotid stenosis. Long-term anticoagulation has been shown to be beneficial only in patients at risk for cardiogenic embolism. Others, including those undergoing endarterectomy, should receive aspirin. In all patients, there should be an aggressive effort to control risk factors for cardiovascular and cerebrovascular disease.

Endarterectomy, Carotid↗

PubMedDate not supplied

[Indication for transcranial Doppler studies in transient ischemic attack].

UNLABELLED: The diagnostic procedures for the assessment of transient ischemic attacks (TIA) include both brain imaging (computed tomography, nuclear magnetic resonance) and cerebrovascular investigation by means of ultrasound studies and angiography. Transcranial Doppler sonography (TCD) has not yet become a widely used diagnostic tool, although it allows noninvasive investigation of the intracranial cerebral circulation. The aim of this study was to assess the value of TCD investigation in patients who suffered from TIA. Eighty-one consecutive patients admitted to our General Medicine Department with a diagnosis of TIA underwent cranial computed tomography, ultrasound investigation of the extracranial cerebral arteries, and TCD. RESULTS: 39% of the TCD findings were not significant; TCD findings were highly significant in 18% of the patients with TIA, mainly for intracranial arterial stenoses and symptomatic subclavian steal; the other abnormal TCD findings were nonspecific, but in all these cases TCD yielded information on the efficiency of intracranial collateralization and the mechanisms regulating cerebral hemodynamics. These results suggest that TCD is a useful tool for the assessment of TIA.

Adult↗

PubMedDate not supplied

Bruits, ophthalmodynamometry and rectilinear scanning on transient ischemic attacks.

One hundred seventeen patients with clinical signs and symptoms of transient ischemic attacks (TIAs) were evaluated. All underwent clinical evaluation for bruit, ophthalmodynamometry, rapid sequence scintiphotography with rectilinear scanning and four-vessel cerebral angiography. The results of these tests were compared for reliability in predicting location of lesions causing transient ischemic attacks. Angiography remains the most accurate procedure in evaluating extracranial vascular lesions. When determination of bruits, ophthalmodynamometry and brain scanning are done together, accuracy is greater than when any one of the procedures is done alone.

Auscultation↗

PubMed1991

[Cerebral ischemic infarct in computer tomography imaging in the diagnosis of transient ischemic attacks].

The term transient ischaemic attack (TIA) does not correspond to findings of new examination methods and is rather a matter of convention. The authors examined 19 patients with the diagnosis of TIA by CT and found in five a cerebral infarction. The dependence of cerebral infarction in TIA on age, sex, risk factors (hypertension, diabetes) and the duration of clinical symptomatology was not significant.

Cerebral Infarction↗

PubMedDate not supplied

[Transient ischemic attacks as the only manifestation of a dural arteriovenous fistula].

INTRODUCTION: Transient ischemic attacks (TIA), as the only clinical manifestation of a dural arteriovenous malformation, are very seldom seen in clinical practice. CASE REPORT: We describe the case of a 68 year old male with recurring bouts of right hemiparesis, due to haemodynamic alterations stemming from a dural arteriovenous malformation located in the right middle fossa, with cortical venous drainage towards the superior longitudinal sinus, which hampers the drainage of the left parietal cortical veins. Computerized tomography and magnetic resonance scans performed on admission to hospital revealed blood in the left parietal sulcus, with no parenchymatous lesions. This dural arteriovenous fistula was initially treated by the endovascular administration of polyvinyl alcohol in 150 250 mm particles, but after 11 days the patient again presented symptoms of right hemiparesis which became increasingly frequent and intense. This led to the search for a definitive treatment for the dural arteriovenous fistula with cyanoacrylates. No similar symptoms have been observed in the five years follow up carried out after the embolization. CONCLUSIONS: In cases of dural arteriovenous fistulas the arterialized cortical vein can impede the drainage of other veins towards the common venous sinus. On very rare occasions this can lead to the appearance of symptoms of transient ischemic attacks in territories that are a long way from the location of the abovementioned arteriovenous malformation.

Aged↗

PubMed1999

The prognosis of amaurosis fugax and hemispheric transient ischemic attacks.

BACKGROUND: The natural history of amaurosis fugax and of hemispheric transient ischemic attacks (TIAs) may be different. We analysed the ischemic risk factors, carotid status and prognosis with respect to future ischemic events in a cohort of patients who presented with either of these transient ischemic episodes. METHODS: The charts of patients who presented to our institution between February 1983 and April 1995 with amaurosis fugax or hemispheric TIAs were reviewed. Patients under the age of 45 years with a history of migraine or previous carotid surgery were excluded. Follow-up by a clinical visit or telephone interview was performed. Information was obtained regarding demographic features, presenting symptoms, ischemic risk factors, carotid status (as measured by duplex ultrasonography), type of medical treatment prescribed and occurrence of subsequent ischemic events. Outcome ischemic events were graded as major (myocardial infarction, cerebrovascular accident or death due to either of these) or minor (recurrent amaurosis fugax or hemispheric TIA). RESULTS: A total of 141 patients were followed for a mean of 47 months. Risk factors were more prevalent in patients with hemispheric TIAs than in those with amaurosis fugax. Most patients had a low degree of carotid stenosis. There was no statistically significant difference in the occurrence of major outcome events between the two groups. Kaplan-Meier survival curves were similar for the two groups. INTERPRETATION: Amaurosis fugax and hemispheric TIA both carry a risk for future ischemic events. However, we did not find a statistically significant difference in prognosis between the two groups.

Aged↗

PubMed1991

A comparison of two doses of aspirin (30 mg vs. 283 mg a day) in patients after a transient ischemic attack or minor ischemic stroke.

BACKGROUND: Aspirin is known to improve the outcome of patients who have had a cerebral transient ischemic attack, but the optimal dose of aspirin remains uncertain. Experimental evidence indicates that 30 mg of aspirin daily alters platelet aggregation more favorably than the 300-mg dose currently used in patients after transient ischemic attack or minor ischemic stroke. METHODS: We assessed the effects of two doses of a water-soluble preparation of acetylsalicylic acid, or aspirin (30 mg vs. 283 mg a day), on the occurrence of death from all vascular causes, nonfatal stroke, or nonfatal myocardial infarction in a double-blind, randomized, controlled clinical trial in patients who had had a transient ischemic attack or minor stroke. A total of 3131 patients participated in the study. The mean follow-up was 2.6 years. RESULTS: In the group assigned to receive 30 mg of aspirin, the frequency of death from vascular causes, nonfatal stroke, or nonfatal myocardial infarction was 228 of 1555 (14.7 percent), as compared with 240 of 1576 (15.2 percent) in the group assigned to receive 283 mg. The age- and sex-adjusted hazard ratio for the group receiving the lower dose was 0.91 (95 percent confidence interval, 0.76 to 1.09). There were slightly fewer major bleeding complications in the 30-mg group than in the 283-mg group (40 vs. 53), and significantly fewer reports of minor bleeding (49 vs. 84). Fewer patients receiving 30 mg of aspirin reported gastrointestinal symptoms (164 vs. 179) and other adverse effects (73 vs. 90). CONCLUSIONS: Our data indicate that 30 mg of aspirin daily is no less effective in the prevention of vascular events than a 283-mg dose in patients with a transient ischemic attack or minor stroke, and has fewer adverse effects.

Aged↗

PubMed1983

Transient ischemic attacks with external carotid artery stenosis and a normal internal carotid artery.

Transient ischemic attacks have been attributed to emboli from the external carotid artery in patients with complete occlusion of the internal carotid artery. We report a patient with an external carotid stenosis and normal internal carotid who developed ipsilateral transient ischemic attacks. Real time B-mode ultrasonography demonstrated that the plaque obstructing the external carotid artery extended into the carotid sinus. This may have served as a source of emboli into the internal carotid circulation.

Aged↗

PubMed2000

Anticoagulants versus antiplatelet therapy for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attacks.

BACKGROUND: People with nonrheumatic atrial fibrillation who have had a transient ischemic attack or minor ischemic stroke are at risk of recurrent stroke. OBJECTIVES: The objective of this review was to compare the effect of anticoagulants with antiplatelet therapy, for secondary prevention, in people with nonrheumatic atrial fibrillation and previous cerebral ischaemia. SEARCH STRATEGY: The reviewer searched the Cochrane Stroke Group trials register and contacted trialists. SELECTION CRITERIA: Randomised trials comparing oral anticoagulants with aspirin in patients with non-rheumatic atrial fibrillation and a previous transient ischaemic attack or minor ischaemic stroke. DATA COLLECTION AND ANALYSIS: One reviewer extracted the data. MAIN RESULTS: One trial was included, involving 455 patients. They received either anticoagulants (International Normalised Ratio 2.5 to 4.0), or 300 milligrams of aspirin per day. People joined the trial within three months of transient ischaemic attack or minor stroke. The mean follow-up was 2.3 years. Anticoagulant therapy approximately halved the odds of serious vascular events (odds ratio 0.55, 95% confidence interval 0.36 to 0. 83). This equates to preventing an extra 50 vascular events per year for every 1000 patients treated. Anticoagulant therapy decreased the odds of recurrent stroke by two-thirds (odds ratio 0.35, 95% confidence interval 0.22 to 0.59). This translates to preventing an extra 60 strokes for every 1000 patients treated per year. Major extracranial bleeds occurred more often in patients given anticoagulants (odds ratio 4.65, 95% confidence interval 1.66 to 12.99). The absolute difference was 2.8% versus 0.9% bleeds per year. None of the patients on anticoagulants and one on aspirin had an intracerebral bleed. REVIEWER'S CONCLUSIONS: The evidence from one trial suggests that anticoagulant therapy can benefit people with nonrheumatic atrial fibrillation and recent cerebral ischaemia. Aspirin may be a useful alternative if there is a contraindication to anticoagulant therapy. The risk of adverse events appears to be higher with anticoagulant therapy than aspirin.

Anticoagulants↗

PubMed1984

Late survival after carotid endarterectomy for transient ischemic attacks.

Two hundred sixty-six consecutive patients with carotid transient ischemic attacks were treated by 310 carotid endarterectomies. The patients were followed up from 30 months to 12 years, and survival was charted by the life-table method. Comparison with an age- and sex-matched population from the same geographic region showed that survival after operation was not impaired unless there were risk factors from disease that was progressive or could not be well controlled. Hypertension and cardiac disease did not adversely affect survival-probably because they were generally well controlled and included the use of nonsynchronous coronary artery grafting when necessary. Those with impaired cardiac function severe enough to threaten perioperative myocardial infarction or acute irreversible cardiac failure during anesthesia were not recommended for operation.

Adult↗

PubMed2006

Neurobrucellosis as an exceptional cause of transient ischemic attacks.

We report a series of four cases presented with transient ischemic attacks (TIA) or ischemic stroke as the predominant manifestation of neurobrucellosis (NB). Three of the patients were 20-28 years of age, and one patient was 53 years old. They all used to consume unpasteurized milk or its products. Two patients had systemic brucellosis in the past and received antibiotic treatment. Other causes of TIA including cardiac embolism, hypercoagulability, vascular malformations, systemic vasculitis, and infective endocarditis were excluded. NB was diagnosed with serological tests or cultures for Brucella in the cerebrospinal fluid. None of the patients had any further TIA after the initiation of specific treatment. NB should always be sought in young patients with TIA or ischemic stroke, especially if they have no risk factors for stroke and live in an endemic area for brucellosis, even if they do not have other systemic signs of brucellosis.

Adult↗

PubMed1976

The problem of dizziness and syncope in old age: transient ischemic attacks versus hypersensitive carotid sinus reflex.

In the elderly, a transient ischemic attack (TIA) and a hypersensitive carotid sinus reflex (HCSR) often co-exist and can pose a diagnostic challenge. Seven cases are presented. HCSR is a relative condition; besides increased irritability of the receptor or target organs, susceptibility of the nerve center to ischemia probably is induced by a slow heart rate or low blood pressure in any patient with pre-existing occlusive cerebrovascular disease. Dizziness and syncope of this type represent hemodynamic TIA in contrast to thromboembolic TIA. The carotid sinus massage test is recommended for differentiating the two types of TIA; the treatments differ. At present there is no uniform management that can be applied to either TIA or HCSR routinely. Therefore, treatment should be approached on an individual basis, keeping in mind the different pathophysiologic factors operating in the specific patient.

Aged↗

PubMed1990

Transient ischemic attacks: their frequency in the Lehigh Valley.

The incidence of transient ischemic attacks (TIAs) in the Lehigh Valley was analyzed using the Lehigh Valley Stroke Register based on data collected between July 1, 1982, and June 30, 1986. The overall average annual incidence rate was 22.9 per 100,000 population, and 23.2 and 22.5 per 100,000 population in men and women, respectively. Men had a statistically significant higher age-specific rate of TIAs than women. Our incidence appears to be lower than that reported in earlier studies but, because of methodologic differences, only continued observations in our population and in similar populations using a standardized methodology will resolve the question of whether TIA frequency is, in fact, declining.

Adult↗

PubMed1982

Cranial computerized tomography in carotid artery transient ischemic attacks.

32 of 45 (71.1%) patients with carotid artery distribution transient ischemic attacks had normal cranial computerized tomography (CCT). 9 (20%) had cerebral atrophy. Incidental abnormalities were found in 3 (6.6%) patients, while a hypodense lesion corresponding to the site of neurological dysfunction was seen in only 1 (2.2%) patient. The latter showed a persistent abnormality in follow-up studies on the 8th and the 23rd day after the initial event. Our clinical CCT correlation did not demonstrate the frequency of hypodense lesions reported by some authors. Furthermore an increased incidence of cerebral atrophy was found compared to the one reported previously.

Aged↗

PubMedDate not supplied

Effect of stenosis on wall motion. A possible mechanism of stroke and transient ischemic attack.

The mechanism by which atherosclerotic plaque causes stroke and transient ischemic attack is not fully understood. One possibility is that the plaque stenosis may set up hemodynamic conditions causing local arterial wall collapse. Arterial wall collapse may, in turn, affect the integrity of the plaque. This study was designed to define the effects of stenosis on the production of arterial wall collapse using a latex tube model. Stenoses ranging up to 81% by diameter were tested in a Starling resistor chamber under pulsatile pressure conditions upstream of the tube. Increasing the degree of stenosis progressively decreased the external pressure necessary to produce collapse, from 37 mm Hg with the 0% stenosis to 24 mm Hg for the 81% stenosis. The stenoses greater than 70% produced a new phenomenon of "systolic wall collapse" just distal to the stenosis. The maximum diameter decrease was 2.83 mm from the baseline diameter of 6.41 mm. Cyclic wall motion just downstream of the stenosis increased with the increased degree of stenosis from 0.34 mm at 0% stenosis to -1.28 mm at 75% stenosis. The phenomena are discussed in terms of simplified Bernoulli pressure drops. We conclude that local arterial stenosis can produce conditions favorable for wall collapse and increased wall motion at physiologic pressure and flow. This collapse may be important in the development of atherosclerotic plaque fracture and subsequent thrombosis or distal embolization.

Arteriosclerosis↗

PubMed2004

Diffusion-weighted MRI in 300 patients presenting late with subacute transient ischemic attack or minor stroke.

BACKGROUND AND PURPOSE: Many patients with transient ischemic attack (TIA) or minor stroke present to medical attention after a delay of several days or weeks, at which time it may be more difficult to obtain a clear history and clinical signs may have resolved. Because ischemic lesions on diffusion-weighted MRI (DWI) often persist for several weeks, we hypothesized that adding DWI to a standard protocol with T2-weighted imaging might be useful in the management of patients presenting late. METHODS: We studied consecutive patients with TIA or minor stroke presenting > or =3 days after the event. Two independent observers recorded the presence or absence of recent ischemic lesions on 2 different occasions, first with the T2 scan only, and second with T2 and DWI. Each time, with the aid of a written clinical summary, the observers recorded their diagnosis and proposed management. RESULTS: 300 patients (159 men) were scanned at a median of 17 (interquartile range=10 to 23) days after symptom onset. DWI showed a high signal lesion in 114/164 (70%) minor strokes versus 17/136 (13%) TIAs (P<0.0001). The presence of high-signal lesions on DWI decreased nonlinearly with time since symptom onset (P<0.0001) and increased with National Institutes of Health Stroke Score (P=0.038) and with age (P=0.01). In 90/206 (43.7%) patients with 1 or multiple lesions on T2, DWI helped to clarify whether these were related to a recent ischemic event (79 [48%] strokes; 11 [31%] TIAs). Compared with T2 alone, DWI provided additional information in 108 (36%) patients (91 [56%] strokes and 17 [13%] TIAs), such as clarification of clinical diagnosis (18 patients, 6%) or vascular territory (28 patients, 9.3%), which was considered likely to influence management in 42 (14%) patients (32 [19%] strokes; 10 [7.4%] TIAs). CONCLUSIONS: The clinically useful information available from DWI provides a further justification for an MRI-based imaging protocol in patients with subacute TIA or minor stroke.

Aged↗

PubMed2005

Incidence and short-term prognosis of transient ischemic attack in a population-based study.

BACKGROUND AND PURPOSE: Transient ischemic attacks (TIAs) have been shown to be a strong predictor of subsequent stroke and death. We present the incidence and short-term prognosis of TIA within a large population with a significant proportion of minorities with out-of-hospital TIA. METHODS: TIA cases were identified between July 1, 1993 and June 30, 1994 from the Greater Cincinnati/Northern Kentucky population of 1.3 million inhabitants by previously published surveillance methods, including inpatient and out-of-hospital events. Incidence rates were adjusted to the 1990 population, and life-table analyses were used for prognosis. RESULTS: The overall race, age, and gender-adjusted incidence rate for TIA within our population was 83 per 100,000, with age, race, and gender adjusted to the 1990 US population. Blacks and men had significantly higher rates of TIA than whites and women. Risk of stroke after TIA was 14.6% at 3 months, and risk of TIA/stroke/death was 25.2%. Age, race, and sex were not associated with recurrent TIA or subsequent stroke in our population, but age was associated with mortality. CONCLUSIONS: Using our incidence rates for TIA in blacks and whites, we conservatively estimate that approximately 240 000 TIAs occurred in 2002 in the United States. Our incidence rate of TIA is slightly higher than previously reported, which may be related to the inclusion of blacks and out-of-hospital events. There are racial and gender-related differences in the incidence of TIA. We found a striking risk of adverse events after TIA; however, there were no racial or gender differences predicting these events. Further study is warranted in interventions to prevent these adverse events after TIA.

Adult↗

PubMedDate not supplied

Interobserver agreement for the diagnosis of transient ischemic attacks.

The interobserver agreement for the diagnosis of a cerebral transient ischemic attack (TIA) was investigated in a pool of eight senior and interested neurologists from the same department. They interviewed 56 patients in alternating pairs. The diagnosis was based on internationally accepted criteria. The agreement rates were corrected for chance (kappa statistics). Both neurologists agreed that 36 patients had a TIA and 12 had not, but they disagreed about 8 patients (kappa = 0.65; for perfect agreement kappa would be 1.0). The vascular territory (carotid or vertebrobasilar) was agreed upon in only 24 of the 36 patients in whom both diagnosed TIA's (kappa = 0.31). We concluded that currently the diagnosis of a TIA, made by a single neurologist, is a poorly defined entity.

Female↗