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The high risk of stroke immediately after transient ischemic attack: a population-based study.

BACKGROUND: The risk of stroke is elevated in the first 48 hours after TIA. Previous prognostic models suggest that diabetes mellitus, age, and clinical symptomatology predict stroke. The authors evaluated the magnitude of risk of stroke and predictors of stroke after TIA in an entire population over time. METHODS: Administrative data from four different databases were used to define TIA and stroke for the entire province of Alberta for the fiscal year (April 1999-March 2000). The age-adjusted incidence of TIA was estimated using direct standardization to the 1996 Canadian population. The risk of stroke after a diagnosis of TIA in an Alberta emergency room was defined using a Kaplan-Meier survival function. Cox proportional hazards modeling was used to develop adjusted risk estimates. Risk assessment began 24 hours after presentation and therefore the risk of stroke in the first few hours after TIA is not captured by our approach. RESULTS: TIA was reported among 2,285 patients for an emergency room diagnosed, age-adjusted incidence of 68.2 per 100,000 population (95% CI 65.3 to 70.9). The risk of stroke after TIA was 9.5% (95% CI 8.3 to 10.7) at 90 days and 14.5% (95% CI 12.8 to 16.2) at 1 year. The risk of combined stroke, myocardial infarction, or death was 21.8% (95% CI 20.0 to 23.6) at 1 year. Hypertension, diabetes mellitus, and older age predicted stroke at 1 year but not earlier. CONCLUSIONS: Although stroke is common after TIA, the early risk is not predicted by clinical and demographic factors. Validated models to identify which patients require urgent intervention are needed.

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Low yield in the diagnostic evaluation of transient ischemic attacks.

Among 163 patients presenting with the clinical features of a TIA, extensive testing identified only 2 patients with nonatherosclerotic causes. We conclude that most patients with a TIA have atherosclerotic vascular disease and that screening tests for other etiologies have a low yield.

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Prognosis for patients following a transient ischemic attack with and without a cerebral infarction on brain CT. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group.

BACKGROUND: Although cerebral infarctions are commonly observed on brain CTs of patients with TIAs, their prognostic importance is unknown. METHOD: The association between appropriately sited brain infarctions (ie, lesions located in the anterior circulation of the brain and ipsilateral to the symptomatic stenosed carotid artery) visualized on CT and the risk of subsequent stroke was assessed by Cox proportional hazards regression in 164 patients presenting with TIA (and no history of previous stroke) and severe angiographically defined carotid stenosis (70 to 99%) from the North American Symptomatic Carotid Endarterectomy Trial. RESULTS: Patients with a TIA and CT-verified brain lesions were older and were more likely to have higher degrees of carotid stenosis and carotid plaque ulceration, a longer duration of symptoms, and a history of hypertension. With regard to prognosis, after adjusting for all known risk factors (patient characteristics) in a regression analysis, the presence of ischemic lesions observed on CT was not associated with an increased risk of ipsilateral stroke at 2 years (adjusted hazard ratio = 1.00; 95% CI: 0.39 to 2.58; p value = 0.99). CONCLUSION: Considered in combination with other patient characteristics, the mere presence of an appropriately sited cerebral infarction on CT does not alter the prognosis (risk of ipsilateral strokes) of severely stenosed patients with TIA. Therefore, there is no clinical rationale in differentiating patients with TIA on the basis of CT findings alone.

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Vascular lesions in Chinese patients with transient ischemic attacks.

We studied 96 Chinese patients with TIAs using transcranial Doppler and duplex ultrasonography. We found intracranial stenosis or occlusion in 51% of cases and extracranial disease in 19% of cases. The most common intracranial lesion was stenosis of the terminal internal carotid artery or proximal middle cerebral artery, whereas the most common extracranial lesion was stenosis of the carotid bifurcation.

Adolescent↗

The duration of symptoms in transient ischemic attack.

BACKGROUND: The majority of TIAs last from 2 to 15 minutes, although some may be of long duration. OBJECTIVE: We examined factors related to the duration of TIAs to identify the relationship to clinical characteristics. METHODS: We performed brain imaging studies as well as angiographic and cardiac examinations in 81 consecutive patients (64 men and 17 women, age 65.8+/-9.9 years) with carotid TIAs. We evaluated risk factors (hypertension, diabetes mellitus, hyperlipidemia, alcohol consumption, and smoking), potential cardiac sources of emboli, and arterial stenosis > or =50% in diameter in the carotid or middle cerebral arteries. Recent infarcts were assessed with CT or MRI. We correlated duration of symptoms with clinical data. RESULTS: The presence of emboligenic cardiac or arterial diseases was significantly related to the duration of symptoms. With sensitivity-specificity curve analysis for detecting such diseases, the duration of symptoms could be divided into short-duration TIAs (<60 minutes, n = 41) or long-duration TIAs (> or =60 minutes, n = 40). Patients with long-duration TIAs had emboligenic cardiac or arterial diseases more frequently than those with short-duration TIAs (86% versus 46%, p < 0.001). Recent infarcts were also more frequent in patients with long-duration TIAs than they were in patients with short-duration TIAs (45% versus 21%, p < 0.05). CONCLUSIONS: Short-duration and long-duration TIAs can be separated based on symptom duration of < 1 hour or > or = 1 hour. Patients with long-duration TIAs should be examined more closely for the presence of cardiac and arterial diseases than those with short-duration TIAs.

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Suppression of recurrent transient ischemic attacks by a statin agent.

Recent studies of hydroxy-methylglutaryl coenzyme A reductase inhibitors have demonstrated that therapy with statins is associated with a significant decrease in the risk of stroke and TIA in patients with coronary artery disease. The underlying mechanism responsible for this effect is unclear. The author presents two patients who had cessation of TIAs upon institution of statin therapy. A variety of non-lipid-lowering mechanisms may account for this beneficial effect. This initial observation, if confirmed by further study, may suggest a role for statin agents in preventing recurrent TIAs.

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