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PubMed1999

Role of carotid sonography as a first examination in the evaluation of patients with transient ischemic attacks and strokes: benefit in relation to age.

PURPOSE: We studied the influence of age on the utility of carotid sonography in patients with transient ischemic attacks and strokes. METHODS: The results of Doppler ultrasound examinations of the carotid arteries in 613 consecutive patients with transient ischemic attacks (n = 450) or strokes (n = 163) were analyzed for different age groups. For each patient, the grade of stenosis was scored for the ipsilateral internal carotid artery. The results of the ultrasound examinations were correlated with angiographic findings and findings at endarterectomy. The extent of atherosclerosis for each age group was expressed as the ratio between the number of grade II-IV stenoses (> or = 50%) in the carotid arteries and the number of patients in that group ("atherosclerosis ratio"). RESULTS: Under the age of 40 years, high-grade atherosclerotic stenoses were not found. However, 3 relatively young patients had dissections of the internal carotid arteries. The atherosclerosis ratio exceeded 0.5 for age groups 65-69 years through 80+ years. Among the patients with high-grade stenoses, ischemic heart disease prevented endarterectomy in 63% of patients in age group 80+ years, 44% in age group 75-79 years, and 26% in age group 70-74 years. CONCLUSIONS: Carotid sonography did not detect any significant atherosclerotic changes in young patients but was useful for diagnosing other etiologies of ischemic cerebral disease, eg, carotid dissection. At the other end of the spectrum, the impact of carotid sonography on patient management appears to be limited in patients over the age of 70 years. Carotid sonography seems to be most useful for patients 40-69 years old.

Adult↗
PubMed1991

Disabling cerebral transient ischemic attacks.

The surgical management of an emerging clinical entity, namely disabling transient cerebral ischemic attacks, is described. A series of 19 patients treated in a 2-year period (12 with anterior circulation dysfunction and seven with posterior insufficiency) met the following criteria: 1) stereotypical recurrent episodes of transient neurological dysfunction related to the anterior or posterior circulation distribution; 2) failure of maximum medical therapy to control the transient neurological dysfunction; 3) four-vessel cerebral angiography demonstrating an isolated vascular territory corresponding to patient symptoms; 4) inhalation xenon cerebral blood flow studies with at least three of eight probe-pairs showing significant asymmetries in the initial slope index, localizing an area of relative oligemia to the symptomatic hemisphere (anterior circulation only); and 5) severe restriction of lifestyle due to transient ischemic attacks (TIA's). Seventeen patients underwent surgical bypass therapy: deep sylvian superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in nine; surface STA-MCA bypass in three; STA-superior cerebellar artery bypass in three; STA-posterior cerebral artery bypass in one; and aorta-carotid artery bypass in one. There was one perioperative death and four perioperative strokes (two ipsilateral and two contralateral to the operated side). The average follow-up period was 14 months. Of the 16 surviving surgically treated patients, 13 (81%) have had an excellent to good outcome with complete resolution of TIA's and minimal neurological deficits. Three patients had a poor outcome with either a significant persistent neurological deficit or continued TIA's. The two patients not treated surgically continue to have vertebrobasilar insufficiency episodes while receiving oral anticoagulation medication. The overall mortality rate (5.5%) and stroke morbidity rate (22.2%) of surgical therapy for disabling TIA's are high in this neurologically unstable group of patients, but are associated with an 81% excellent to good response. Although the natural history of disabling TIA's is not known, these patients present with significant to total disability due to their symptoms. It is concluded that disabling TIA's respond to surgical revascularization and may represent an indication for cerebral revascularization surgery.

Cerebral Revascularization↗
PubMedDate not supplied

Prolonged disturbances of regional cerebral blood flow in transient ischemic attacks.

Regional cerebral blood flow (rCBF) was measured over both hemispheres in 20 patients with unilateral transient ischemic attacks (TIA) of the territory of the internal carotid artery on the day of the TIA. rCBF was estimated with the nontraumatic Xenon 133-inhalation technique using the initial slope index. 13 patients experienced their first TIA, 7 had several attacks. In 14 patients the first rCBF-measurement was performed during the presentation of clinical symptoms. The 2nd rCBF-measurement was done on day 2, the last one on day 7. Scans of the 15 patients studied with CT were normal. On day 1 mean rCBF of the TIA-side was significantly lower than that of the contralateral hemispheres. 22% of all areas showed a significant reduction of flow compared to mean rCBF. Mean rCBF of both the TIA- and the contralateral side was significantly reduced compared to the bi-hemispheric mean rCBF of a control group with no history of TIA or completed strokes but at least 2 risk factors for cerebrovascular disease. Whereas mean rCBF did not change in the contralateral side it increased significantly (+6.9%) in the TIA-side from day 1 to day 2 but not from there to day 7. This is reflected by the increase of the total number of ROI with normal flow from day 1 to day 2. Considering the actual flow and the flow course of that tissue which was believed to be responsible for the clinical symptoms the following regional patterns were observed: normal rCBF in 6 patients; early return to normal concomitant to the clinical course (n = 4).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

A prospective reevaluation of transient ischemic attacks as a risk factor for death and fatal or nonfatal cardiovascular events.

BACKGROUND AND PURPOSE: Transient ischemic attack (TIA) is generally considered a risk factor for death and cardiovascular events. This assumption is based on comparisons of the survival of the TIA population with that of the general population. Such comparisons may provide biased estimates of the risk associated with TIA because the general population is usually more healthy than TIA patients. METHODS: Using a prospective case-control study design, we report the comparison of a TIA population (n = 280) and a control group (n = 399) with a comparable cardiovascular risk factor burden. Proportional hazards analysis was used to compare survival time and time to fatal or nonfatal stroke and/or myocardial infarction for the two study groups. Comparisons were made without adjustment for risk factors and after adjustment for age, race, sex, and major cardiovascular risk factors. RESULTS: Before adjustment for age-race-sex or risk factors, TIA proved to be a risk factor for early mortality, stroke, and myocardial infarction (P < .05). Adjustment for age-race-sex disparities between the case and control groups explained much of the differences in mortality, as the hazard ratio was reduced from 2.2 to 1.4. However, adjustment for age-race-sex or age-race-sex and risk factors did not markedly reduce the role of TIA as a risk factor for stroke or myocardial infarction. CONCLUSIONS: Although TIA proved to be a risk factor for stroke or myocardial infarction, it apparently plays a smaller role in the risk of death.

Age Factors↗
PubMed2002

Validation of a weight-based nomogram for the use of intravenous heparin in transient ischemic attack or stroke.

BACKGROUND AND PURPOSE: Intravenous heparin therapy is often used in patients presenting with transient ischemic attack (TIA) or stroke as either bridging therapy for anticoagulation with warfarin or primary therapy in suspected intracranial arterial dissection, crescendo TIAs, or suspected hypercoagulable states. We attempted to validate the use of a weight-based nomogram for heparin-adjusted therapy during hospital admission of patients with TIA or stroke. METHODS: A prospective, single-blinded, randomized, clinical trial was undertaken to compare the use of a specially designed, weight-based heparin nomogram against the traditional method of physician-ordered heparin therapy for patients admitted with TIA or stroke. The trial was not designed to examine the efficacy of heparin therapy but to examine the use of the nomogram for labor requirements, costs of monitoring, safety, length of heparin therapy, and user-friendliness. RESULTS: Pretreatment clinical factors were comparable between those randomized to use of the nomogram (n=101) and to usual care (n=105). Nomogram patients had a significantly lower first activated partial thromboplastin time than nonnomogram patients (60.6 +/- 16.8 versus 69.8 +/- 28.7 seconds). Patients treated by nomogram achieved a therapeutic range of anticoagulation sooner than nonnomogram patients (13.4 +/- 17.0 versus 17.9 +/- 14.1 hours). The fraction of time during which anticoagulation was therapeutic was significantly greater in patients on nomogram therapy (74 +/- 25% versus 67 +/- 26%). Nomogram patients also had significantly fewer supratherapeutic coagulation results, significantly fewer dose adjustment mistakes, significantly fewer calls to house staff regarding anticoagulation, and significantly fewer total complications than nonnomogram patients. The times required for discontinuation of heparin and discharge from hospital were not significantly different. A survey of house staff and nursing staff showed a preference for nomogram use. CONCLUSIONS: The heparin nomogram is a user-friendly method of maintaining heparin infusions and is associated with improved anticoagulation measures, fewer total complications related to heparin therapy, fewer mistakes in heparin dosage adjustment, and decreased labor on the part of house staff and nursing staff.

Aged↗
PubMed1978

Transient ischemic attacks: a prospective study of 225 patients.

Between the years 1964 and 1973, 225 patients with transient ischemic attacks (TIAs) due primarily to atherosclerosis were evaluated and treated. They have now been followed for from 3 to 14 years (average 5.5 years). As of 1976, 82 of the 225 patients were dead, 21 from cerebral infarction, 52 from heart disease and nine from other causes. Of the 56 untreated patients, 11 (19 percent) had cerebral infarctions, four (7 percent) of which were fatal; six (11 percent) were still having TIAs. Of the 45 patients medically treated, 10 (24 percent) had cerebral infarctions, three (7 percent) of which were fatal; 11(25 percent) still experienced TIAs. In the surgical group of 124, 27 (21 percent) had postoperative cerebral infarctions, seven (6 percent) of which were fatal; 23 (18 percent) had cerebral infarctions during follow-up, of which seven (6 percent) were fatal; and 15 (12 percent) were still having TIAs. No statistically significant differences (p less than 0.05) related to cerebral infarction or TIAs developed among the three groups. The majority (23 percent) eventually succumbed to myocardial infarction, leading us to conclude that great emphasis must be placed upon TIAs as a warning for cardiac as well as cerebrovascular disease.

Aged↗
PubMed1988

How transient are transient ischemic attacks?

Information on 1,343 hospitalized patients in the Cornell Neurology Database with final diagnoses of transient ischemic attacks (TIA), reversible ischemic neurologic deficits (RIND), or ischemic stroke was examined in order to determine the duration of ischemic deficits. Episodes resolved within the first 24 hours (classic definition of TIA) in 382 of the patients (28.4%) and between days 1 and 7 (consistent with RIND) in 34 (2.5%). In 191 of the 382 patients with traditionally-defined TIAs (50.0%), episodes lasted less than 30 minutes, and in another 37 (9.7%), from 30 to 60 minutes. Of 1,115 patients with deficits lasting at least 60 minutes, only 154 (13.8%) resolved within 24 hours and could thus be considered to have had a TIA. Resolution within the next hour occurred in only 39 of 1,152 patients (3.4%) with a deficit at 30 minutes, 21 of 1,115 patients (1.9%) with a deficit at 60 minutes, 19 of 1,113 patients (1.7%) with a deficit at 90 minutes, and 16 of 1,094 patients (1.5%) with a deficit at 120 minutes. The data suggest that as currently managed, patients with a deficit persisting at least 60 minutes have less than a 2% chance of resolving spontaneously during any subsequent 1-hour period. Rapid resolution after instituting a new treatment in relatively few additional patients would suggest a therapeutic effect, even in a nonrandomized trial.

Aged↗
PubMedDate not supplied

[Transient ischemic attacks: risk factors, duration and neuroimaging in a series of 173 patients].

INTRODUCTION: The appearance of transient ischemic attacks (TIA) is an important sign of vascular risk. The maximum time the deficit lasts has been set arbitrarily at 24 hours. It is assumed that TIA does not entail permanent vascular lesions. PATIENTS AND METHODS: A retrospective review of the clinical records of patients diagnosed as suffering from TIA in our centre between 1996 and 1997. Analysis of associated risk factors (RF), duration and findings in neuroimaging. RESULTS: The clinical records of 173 patients (106 males) were examined. The RF identified were similar to those described for ischemic strokes. 45.6% of patients with a history of vascular pathologies received no preventative treatment. 58% of the TIA were resolved within the first 30 minutes and 71% within the first hour. Cranial CT was normal in 69%, showed old lesions in 26% and lesions that were compatible with the clinical signs of TIA in 5% (in the latter case the duration of the episodes was greater). CONCLUSIONS: TIA shares the same RF and aetiopathogenic mechanisms as ischemic stroke and should, therefore, be considered as such. There is a need to revise the concept of TIA paying special attention to the findings of neuroimaging or to establish duration limits that are better matched to the practical reality. TIA maintains a practical interest since it provides a simple method of identifying patients with a high vascular risk.

Aged↗
PubMed1992

[Cerebral blood flow distribution and reactivity during the symptom-free stages of transient ischemic attacks--a 99mTc-HMPAO SPECT study].

Even during the symptom-free stages, patients with transient ischemic attacks (TIA) often show cerebral blood flow (CBF) disturbances. For evaluating the factors which cause these abnormalities, we studied CBF and CBF reactivity to acetazolamide (Diamox) using a 99mTc-hexamethylpropyleneamine oxime (HMPAO) single photon emission computed tomography (SPECT). The results from CBF-SPECT were compared with X-ray computed tomography (CT), cerebral arteriogram, clinical characteristics of TIA and cerebrovascular risk factors. The overall sensitivity rates in detecting the lesion were 68% in CBF-SPECT and 9% in CT. The size of the hypoperfused area tended to be wide in patients who had intracranial, severe stenotic or multiple arterial lesions on the ipsilateral side. No such relations were found between CBF and other examinations. Brain hypoperfusion was located in the subcortical region in eight patients; two patients showed a small hypodense lesion on CT which corresponded to the hypoperfusion on SPECT, and three patients showed no arteriographic abnormality. Hypoperfusion in the cortex was seen in seven patients; all patients showed arteriographic abnormality, but no CT abnormality. The severity rating of the vascular stenosis and hypoperfusion, and the incidence of the intracranial lesions were higher in this group than the group with subcotical hypoperfusion. Seven patients showed fixed normoperfusion before and after diamox injection. Two patients with a subcortical small infarction showed fixed hypoperfusion even after diamox injection. Twelve patients showed focal hypoperfusion before diamox with a new filling-in after diamox. Only one patient showed resting hypoperfusion and decreased CBF reactivity to diamox.(ABSTRACT TRUNCATED AT 250 WORDS)

Acetazolamide↗
PubMed1981

A randomized clinical trial of pentoxifylline and antiaggregants in recent transient ischemic attacks (TIA). A one year follow-up.

A multicenter comparative trial was conducted in patients with transient ischemic attacks (TIA) to study the preventive capacity of a combination of acetylsalicylic acid and dipyridamol (1,050 mg + 150 mg/day - group A) and of pentoxifylline (1,200 mg/day - group P) in the reduction of morbidity rates. Sixty-six patients, 36 on A and 30 on P, were evaluated. There was no statistically significant difference between both groups as regards age, sex, blood pressure, localisation of TIA and incidence of risk factors. Incidence of new ischemic events during a one year follow up period in the A-group was 28% compared to 10% in the P-group, this difference being statistically significant in favour of P (p less than 0.05). Stroke incidence was similar in both groups but distinctly lower (4.5%) than the natural frequency in TIA.

Adult↗
PubMed1994

Absence of sex differences in the evaluation of patients hospitalized for transient ischemic attacks.

BACKGROUND: Sex has been shown to affect the extent of evaluation and treatment of patients with coronary artery disease. This study investigates potential differences in the evaluation of hospitalized men and women with transient ischemic attacks to determine whether a similar bias exists. METHODS: The 1989 MedisGroups comparative database was used to analyze a convenience sample consisting of all family and internal medicine patients with the primary admission diagnosis-related group (DRG) of "transient ischemic attack." RESULTS: Women comprised 1933 of the 3165 admissions. The mean age for women was 1.88 years older than for men (P < .01). Women were three times more likely to reside in a nursing home before admission (P < .01), but had a lower prevalence of dementia (P < .05). The 1232 men had a higher severity of illness score at admission (P < .05), and were 5.3% more likely to be admitted to a teaching hospital than women (P < .01). Men were also more likely than women to be admitted to large hospitals (P < .01). There were no differences between sexes in the use of cranial computed tomography, carotid or cardiac Doppler, or carotid arteriography. Adjusted means for hospital charges, morbidity, and mortality did not differ between sexes, but length of stay was longer by 1.5 days for women compared with men (P < .01). CONCLUSIONS: In-hospital evaluation of elderly patients with transient ischemic attacks did not differ significantly between men and women. This finding does not exclude the possibility of a difference in workup for men as compared with women in the ambulatory management of this condition.

Aged↗
PubMed1985

Usefulness of heparin in initial management of patients with recent transient ischemic attacks.

We evaluated the efficacy of short-term intravenous heparin therapy in 74 patients with recent transient ischemic attacks (TIAs). The patients were treated after hospitalization until operation or long-term medical treatment was instituted. Heparin was given in a continuous infusion to maintain an activated partial thromboplastin time of 1 1/2 to 2 1/2 times control values. During the treatment period, 12 patients (16.2%) had recurrent TIAs and five (6.8%) had cerebral infarction. Bleeding complications occurred in nine patients (12.2%). In this limited series, heparin did not prevent recurrent TIAs or cerebral infarction among high-risk patients with recent TIAs.

Adult↗
PubMed2006

Why a polysomnogram should become part of the diagnostic evaluation of stroke and transient ischemic attack.

Neurologists need to recognize, diagnose, and treat obstructive sleep apnea (OSA) in patients with stroke or transient ischemic attack (TIA). Increasing medical evidence suggests that OSA is an independent risk factor for stroke and TIA. Stroke (or TIA) is more likely a cause, rather than a consequence, of OSA because PSG studies have shown: 1) apneas in stroke are typically obstructive, not central or Cheyne-Stokes in type; 2) apneas are just as frequent and severe in patients with either TIA or stroke; 3) OSA severity is not influenced by the acuteness or location of the stroke; 4) untreated OSA patients have more strokes, stroke morbidity, and mortality than those who are treated. OSA alone can induce hypertension, especially in younger men. A causal relationship has recently been demonstrated between OSA and hypertension. A distinctive feature of OSA-induced hypertension is loss of the normal nighttime fall in blood pressure ("nondippers"). Data from the Sleep Heart Health Study showed a dose-response association between OSA severity and the presence of hypertension 4 years later. Hypertension or ischemic heart disease usually develops in untreated patients with OSA over time without particular worsening of OSA. Studies have shown sleep itself is not a risk factor for stroke because most stroke and TIAs begin between 6 am and noon, while the individual is awake. However, OSA promptly be considered in stroke beginning during sleep because 88% of strokes that develop during sleep occur in "nondippers." Premature death in OSA patients is most often cardiovascular, but occurs while the patients are awake. The risk of myocardial infarction is increased 20-fold in untreated OSA. Treating OSA patients with continuous positive airway pressure can prevent or improve hypertension, reduce abnormal elevations of inflammatory cytokines and adhesion molecules, reduce excessive sympathetic tone, avoid increased vascular oxidative stress, reverse coagulation abnormalities, and reduce leptin levels. If all this can be achieved by a polysomnogram, then this test should become part of a neurologist's armamentarium for stroke and TIA.

Humans↗
PubMed1980

The outcome of patients with transient ischemic attacks and stroke treated with anticoagulants.

Long-term anticoagulant treatment was given to 25 patients with transient ischemic attacks (TIA) and 49 stroke patients with reversible ischemic neurological deficit or cerebral embolism. Another 16 TIA patients were observed without anticoagulant treatment. Life table analyses, comparing the observed with the expected frequency, revealed increased mortality in the TIA patients irrespective of whether or not they had received anticoagulants. The stroke patients treated with anticoagulants also had a higher mortality than expected. On the other hand, the incidence of subsequent stroke was not higher than expected in the TIA and stroke patients treated with anticoagulants, while it was significantly increased in the TIA patients not treated with anticoagulants. Thus, the risk of stroke, but not the risk of death, was normalized by the anticoagulant treatment. Unacceptably serious bleeding complications were seen in the group of stroke patients with anticoagulant treatment. Bleeding complications, in both TIA and stroke patients, seemed to be related to lengthy treatment, high blood pressure on admission or insufficient patient compliance.

Aged↗
PubMedDate not supplied

[Lack of correlation between plasma homocysteine levels and cerebral microangiopathy in patients wtih transient ischemic attack].

OBJECTIVE: The aim of this study is to evaluate cerebral MRI findings in patients with atherothrombotic transient ischemic attacks (TIA) and its correlation with plasma homocysteine (Hcy) levels. PATIENTS AND METHODS: A total of 62 consecutive patients with the diagnosis of TIA of atherothrombotic origin were studied. MRI examinations were performed in all patients for the evaluation of the presence of infarct and/or white matter hyperintensities (WMHI). Plasma Hcy levels were determined according to the method described by Smolin and Schneider modified. RESULTS: Plasma Hcy levels were significantly (p < 0.036) higher in patients with MRI-detected infarcts (9.69 +/- 2.06 mumol/l) compared with patients without infarcts (8.65 +/- 1.7 mumol/l. There was no correlation (p < 0.33) between plasma Hcy levels and the presence or absence of WMHI seen on MRI. CONCLUSIONS: In TIA patients, plasma Hcy levels were significantly higher in patients with cerebral infarcts, but did not correlate with the presence of WMHI. Our results suggest that mild hyperhomocysteinemia would be associated with large-medium vessel rather than with small vessel disease.

Adult↗
PubMed2002

Shaking limb transient ischemic attacks: unusual presentation of carotid artery occlusive disease: report of two cases.

OBJECTIVE AND IMPORTANCE: Shaking limb transient ischemic attacks (TIAs) represent a rare clinical syndrome that has been ascribed to focal cerebral ischemia attributable to insufficient brain perfusion, usually resulting from carotid artery occlusive disease. The techniques conventionally used to evaluate this condition are contrast angiography, carotid artery ultrasonography, and magnetic resonance angiography. Treatment consists of internal carotid artery (ICA) endarterectomy or, in the case of complete ICA occlusion, extracranial-intracranial bypass. In this report, two patients with shaking limb TIAs are presented. For one patient, preoperative evaluations included single-photon emission computed tomographic studies with acetazolamide vasodilator challenge; for the second patient, computed tomographic angiography was used to assess vascular anatomic features. CLINICAL PRESENTATION: Two patients with severe carotid artery disease presented with brief, recurrent, shaking limb TIAs. Angiograms obtained for Patient 1 demonstrated complete ICA occlusion in association with severe external carotid artery stenosis, whereas preoperative single-photon emission computed tomographic scans revealed a lack of cerebrovascular reserve in response to acetazolamide challenge. Carotid artery duplex ultrasonography and computed tomographic angiography demonstrated severe stenosis of the ICA for Patient 2. INTERVENTION: Patient 1 underwent a left external carotid artery endarterectomy. Patient 2 underwent a right ICA endarterectomy. CONCLUSION: After surgery, the shaking limb episodes ceased for both patients. Postoperative single-photon emission computed tomographic scans for Patient 1 demonstrated increased cerebral blood flow in response to acetazolamide challenge. These data provide support for the concept that shaking limb TIAs are related to hemodynamic failure and that improvements in cerebral blood flow through conducting vessels can alleviate the condition.

Aged↗
PubMed2002

Combined percutaneous pulmonary valvuloplasty and patent foramen ovale closure in an adult with recurrent transient ischemic attacks.

We report the case of a 60-year-old man with a history of recurrent transient ischemic attacks, effort syncope, cyanosis, erythrocytosis and a systolic murmur. Echocardiography and catheterization showed severe pulmonary stenosis and a patent foramen ovale with a right-to-left shunt. The patient was submitted to combined percutaneous pulmonary valvuloplasty and patent foramen ovale closure using the Amplatzer device.

Cardiac Catheterization↗