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PubMed1989

Current trends in treatment of transient ischemic attacks.

Current trends in treatment of transient ischemic attacks (TIAs) are reviewed. Patients with TIAs should be treated individually, the main goals of therapy being to avoid cerebral infarction and vascular death. Management of risk factors includes control of high blood pressure, dyslipoproteinemias, diabetes mellitus, atrial fibrillation, cardiac arrhythmias, and overweight. A healthy diet, exercising and non-smoking are additional useful measures. The most commonly used antiplatelet drug is aspirin. Doses of 325 mg per day are as effective as doses of 1,300 mg per day but have fewer side effects. Ticlopidine seems the best antiplatelet drug currently available; it is given in doses of 500 mg per day for a month and then 250 mg per day for the rest of the patient's life. Anticoagulants have not shown their advantages over drugs that prevent platelet aggregation. However, when a patient under treatment with warfarin with an adequate dose range suffers recurrent TIAs, warfarin can be used in association with ticlopidine. On the other hand, if patients under treatment with ticlopidine have further TIAs, they should be switched to anticoagulants for 6 months and then back to antiplatelet drugs. With regard to surgery, an effective means of prolonging survival seems to be the treatment of coronary artery disease before carotid endarterectomy is considered. The effectiveness of carotid endarterectomy is being evaluated in ongoing multicentric, randomized, controlled clinical trials.

Anticoagulants↗

PubMed1989

[Chronic subdural hematoma simulating transient ischemic attacks].

Chronic subdural hematoma presenting as transient ischemic attacks (TIA) is very rare. In a 74-year-old man in whom chronic subdural hematoma was responsible for recurrent attacks of local neurological deficiencies, the diagnosis was established by computerized tomographic (CT) scanning. Both TIA and chronic subdural hematoma usually occur in the elderly. Since the prognosis as well as the therapeutic approach are completely different in the 2 conditions, it is advisable to use imaging techniques, such as CT scanning, when there are recurrent TIA.

Aged↗

PubMed1994

Transient ischemic attacks. Rethinking concepts in management.

All transient ischemic attacks are not created equal. However, they are a medical emergency, and all patients should be hospitalized for urgent evaluation of their risk for stroke or myocardial infarction. For optimal management, it must be determined whether an ischemic attack affects the anterior or posterior circulation. In this article, the authors review current medical options for stroke prevention and the indications for carotid endarterectomy.

Cerebrovascular Disorders↗

PubMed1990

Prolonged hypoperfusion and early stroke after transient ischemic attack.

Many patients suffer a stroke early after a transient ischemic attack, but the reason why is often unclear. We studied 12 patients with less than 75% stenosis of the internal carotid artery and a single hemispheric transient ischemic attack lasting less than 1 hour who had a normal neurologic examination 3-13 hours later and a normal computed tomogram 24-36 hours later. Single-photon emission computed tomography using technetium-99m HM-PAO less than or equal to 50 hours after the attack showed no abnormality in eight patients, but in the other four there was an area with 30-50% reduction in perfusion ipsilateral to the transient ischemic attack. Three of these four patients developed an ipsilateral infarct 3-7 days later, but none of the eight patients with normal single-photon emission computed tomograms had a stroke during the following weeks. No difference in therapy, risk factors, severity of internal carotid artery disease, or timing of the technetium-99m study could explain these findings. We suggest that some transient ischemic attacks, though clinically identical to others, may be associated with persisting focal hypoperfusion, which predisposes to early stroke.

Aged↗

PubMed1991

Reevaluation of transient ischemic attacks as a risk factor for early mortality.

The prevailing belief that transient ischemic attack is a risk factor for cardiovascular morbidity and mortality is based primarily on comparisons of survival of patients after transient ischemic attacks to that of an age-, race-, and sex-adjusted general population. Concomitant conditions that carry a high risk of premature mortality or morbidity, such as ischemic heart disease, hypertension, and diabetes, are very prevalent among patients with transient ischemic attacks. Hence, the poor prognosis of such patients may be attributable to these factors rather than their transient ischemic attack per se, which may only serve to bring patients into the medical system. We compared the survival of 336 patients after transient ischemic attack to that of a control group with a similar risk factor profile consisting of 6,710 patients evaluated for cardiac catheterization. Survival estimates, both unadjusted and adjusted for risk factors, did not differ between the two groups. Three-year survival estimates, after adjustment to the mean value of covariates, were 94% for the patients with transient ischemic attacks and 91% for the controls. These results suggest that the transient ischemic attack may not be an independent risk factor for mortality, although it may identify patients already at increased risk from coexisting conditions.

Cardiac Catheterization↗

PubMedDate not supplied

Transient ischemic attacks. Retrospective study of 150 cases of ischemic infarct in the territory of the middle cerebral artery.

Transient ischemic attacks (TIA) are episodes of abrupt beginning, consisting of subjective or objective neurological dysfunction of short duration, with complete recovery of neurological function in the course of 24 hours. With this definition, the authors carried out a retrospective study of 150 patients suffering from ischemic infarct in the brain in the territory of the middle cerebral artery. Thirty-eight percent of the patients had had TIAs before their cerebral infarct. The symptoms, in order of frequency, were motor, sensory deficits, alterations of speech and vision. Most of the patients had a definite cerebral infarct, occurring one month after the last TIA; the symptoms of both processes were remarkably similar. The authors studied the angiographic characteristics, pharmacological and toxic antecedents, and associated diseases in these patients. The study indicates that TIA may be the first manifestation of cerebral vascular disease.

Adult↗

PubMed1979

[Transient ischemic attacks with intracranial tumors (author's transl)].

Transient ischemic attacks are not only the consequence of cerebral atherosclerosis. A woman of 48 years had transient ischemic attacks because of a meningeom narrowing the internal carotid artery. A steal syndrome in tumor vessels of a glioblastoma must be presumed in a man of 67 showing initial hemisyndrome with first transient, later on remaining palsy.

Aged↗

PubMed2004

Higher risk of further vascular events among transient ischemic attack patients with diffusion-weighted imaging acute ischemic lesions.

BACKGROUND AND PURPOSE: Recently, a new definition of transient ischemic attack (TIA) has been proposed based on the duration of symptoms and diffusion-weighted imaging (DWI) findings. We investigate the value of temporal and neuroimaging data on the prognoses of TIA patients. METHODS: Clinical data, symptom duration, DWI, and ultrasonographic findings were collected in 83 consecutive classical TIA patients attended in the emergency department. Stroke recurrence, myocardial infarction, or any vascular event was recorded at follow-up (mean of 389 days). RESULTS: A total of 27 (32.5%) patients revealed focal abnormalities on DWI, whereas 37(44.6%) had symptoms lasting >1 hour. Large-artery disease was detected in 37 (44.6%) patients. Twenty (24.1%) patients experienced an endpoint: 2 (2.4%) myocardial infarctions, 16 (19.3%) cerebral ischemic events, and 2 cases (2.4%) of peripheral arterial disease. Cox proportional hazards multivariate analyses identified the association of symptoms >1 hour with DWI abnormalities as independent predictors of further cerebral ischemic events or any vascular event (hazard ratio [HR], 5.02; CI, 1.37 to 18.30; P=0.015; and HR, 3.77; CI, 1.09 to 13.00; P=0.029). Large-artery occlusive disease also remained an independent predictor of both endpoints (HR, 4.22; CI, 1.17 to 15.22; P=0.028; and HR, 3.60; CI, 1.14 to 11.39; P=0.0293). CONCLUSIONS: TIA patients with DWI abnormalities associated with duration of symptoms >1 hour and those with large-artery occlusive disease have a higher risk of further vascular events. Routine use of DWI and Doppler ultrasonographic examinations will be useful for identifying TIA patients at high risk to plan aggressive prevention therapies.

Aged↗

PubMed2003

A comparative study of hemorheological parameters in transient ischemic attack and acute ischemic stroke patients: possible predictive value.

A complete neurological and laboratory assessment was made of 31 transient ischemic attack (TIA) and 33 acute ischemic stroke patients. Laboratory parameters were compared with 33 age- and sex-matched controls. Erythrocyte deformability was characterised by determining the relative cell transit time (RCTT) with a St. George filtrometer. Plasma viscosity was measured with a Haake microviscosimeter. In comparison with controls, fibrinogen content, erythrocyte sedimentation rate (ESR), platelet and leukocyte count, erythrocyte RCTT and plasma viscosity were found to be significantly higher in stroke patients. In TIA patients the elevation of these values was not significant with the exception of platelet count. Our results suggest that the hemorheological alterations observed in TIA and stroke are largely non-specific findings and associated with the atherosclerotic disease of patients. The significant elevation of leukocytes, fibrinogen and plasma viscosity in acute stroke versus TIA probably reflects the systemic acute phase response of organism to cerebral infarction.

Acute Disease↗

PubMed1994

ST segment depression detected by continuous electrocardiography in patients with acute ischemic stroke or transient ischemic attack.

BACKGROUND AND PURPOSE: Forty percent of patients with a history of ischemic stroke or transient ischemic attack (TIA) have concomitant coronary artery disease. ST segment depression, detected by continuous electrocardiography, is associated with increased cardiac morbidity and mortality in patients with known coronary artery disease. While electrocardiographic changes have been associated with acute stroke, the etiology and significance of these changes remain unclear. In this pilot study we report the prevalence of ST segment depression and ventricular arrhythmias in patients with acute ischemic stroke or TIA monitored by continuous electrocardiography. Clinical predictors of ST segment depression and ventricular arrhythmia are also identified. METHODS: Consecutive patients presenting with acute ischemic stroke or TIA were enrolled within 72 hours of hospital admission and monitored by continuous electrocardiography for 48 hours. The electrocardiographic results were analyzed for periods of ST segment depression and ventricular arrhythmias. RESULTS: Of 51 patients with ischemic stroke or TIA, 15 (29%) had episodes of ST segment depression (95% confidence interval, 15% to 43%), and 18 (35%) had ventricular arrhythmias (95% confidence interval, 21% to 49%). In logistic regression analysis, increasing age (P < .02) and a left-sided neurological event (P < .01) were significant predictors of ST segment depression. Increasing numbers of atherosclerotic risk factors, a history of cardiac disease, and increasing or decreasing mean arterial pressure were not predictive of ST segment depression. CONCLUSIONS: Patients with acute ischemic stroke or TIA have a 29% prevalence of ST segment depression within the first 5 days after their event. In comparison, the prevalence of ST depression is 2.5% to 8% in asymptomatic adults and 43% to 60% in patients with symptomatic coronary artery disease. The association of ST segment depression with left-sided neurological events suggests that the electrocardiographic changes are in part neurologically mediated. Further study is necessary to better define the brain-heart interaction and to determine whether ST segment depression in patients with ischemic stroke or TIA reflects underlying coronary artery disease.

Acute Disease↗

PubMed2003

Epidemiological impact in the United States of a tissue-based definition of transient ischemic attack.

BACKGROUND AND PURPOSE: The traditional definition of transient ischemic attack (TIA), based on an arbitrary time criterion of symptom resolution within 24 hours, is problematic because a large number of patients with traditionally defined TIAs have a relevant cerebral infarction on brain imaging. The objective of this study was to characterize the epidemiological impact of adopting a tissue-based definition of TIA. METHODS: Estimates of the annual US incidence of traditionally defined transient ischemic attacks were abstracted from the literature. Models were then constructed for determining the frequency of brain injury in traditionally defined TIAs, derived from recent human studies of MR diffusion-weighted imaging (DWI) in transient cerebral ischemia. RESULTS: Traditionally defined US TIA annual incidence rates ranged from 37 to 107 per 100,000 per year. Across 5 series, the raw frequency of DWI positivity in traditionally defined TIAs was 44%. Adjusting for an overrepresentation of longer-duration TIAs in MR series yielded an expected frequency of diffusion MRI positivity of 33% in unselected, traditionally defined TIAs. Applying this model to the US population in the year 2000 showed that adopting a tissue-based definition of TIA would decrease the annual number of events classified as TIAs from 179,840 to 120,493 and increase events classified as strokes from 821,181 to 880,520. CONCLUSIONS: Adopting a tissue-based definition of transient ischemic attack would reduce estimates of the annual incidence of TIA by 33% (sensitivity analysis range, 19% to 44%) and increase estimates of the annual incidence of stroke in the United States by 7% (range, 4% to 10%).

Diffusion Magnetic Resonance Imaging↗

PubMed1989

Extracranial carotid atherosclerosis in black and white patients with transient ischemic attacks.

To evaluate the association between extracranial carotid atherosclerosis, race, and transient ischemic attack, we carried out a retrospective hospital chart review and quantified the extent of noninvasively determined extracranial carotid atherosclerosis in 25 black patients greater than 45 years old with transient ischemic attacks. Two sex- and age-matched white patients with transient ischemic attacks were similarly studied for each black patient. Extent of extracranial carotid atherosclerosis (expressed as B-mode score) was similar for blacks and whites. B-mode score was only slightly less in patients with posterior- than in those with anterior-circulation transient ischemic attacks. Fifty-six patients (35 white, 21 black) had unilateral anterior-circulation transient ischemic attacks. Of the 32 patients with more extensive extracranial carotid atherosclerosis ipsilateral to the affected hemisphere, 23 (66% of 35) were white; only nine (43% of 21) were black. In the 35 white patients, the extent of disease in the ipsilateral carotid artery was significantly greater (p less than 0.03) than that in the contralateral carotid artery. When B-mode scores in the left and right carotid arteries were combined for the subgroup of patients with unilateral anterior-circulation transient ischemic attacks, blacks had slightly more atherosclerosis in the extracranial arteries than whites.

Arteriosclerosis↗

PubMed1996

Incidence of transient ischemic attacks and minor ischemic strokes in Segovia, Spain.

BACKGROUND AND PURPOSE: The aim of this study was to determine the incidence of transient ischemic attacks (TIAs) and minor ischemic strokes (MISs) in Segovia, Spain. METHODS: A 2-year prospective community-based register of TIAs and MISs established in Segovia from February 16, 1992, to February 15, 1994. Every patient underwent underwent a complete clinical evaluation and cranial CT scan. Sex- and age-specific incidence rates with 95% confidence intervals (CIs) were calculated for all ages. RESULTS: The total series included 235 patients; 103 suffered TIAs and 132 suffered MISs. Mean age was 70.8 years (range, 29 to 96 years); 92 were women and 143 were men. The crude annual incidence was 0.80/1000 (95% CI, 0.70 to 0.90): 0.35/1000 (95% CI, 0.28 to 0.42) for TIAs and 0.45/1000 (95% CI, 0.37 to 0.53) for MISs. The incidence of TIAs and MISs increased with age. Approximately 78 of TIAs and MISs were in the carotid distribution, 19% were vertebrobasilar, and 3% were considered of uncertain vascular distribution. Cranial CT scan was performed in all patients. CT showed cerebral infarcts in 30.1% (31/103; 95% CI, 21% to 39%) of TIAs and 70% (92/132; 95% CI, 62% to 78%) of MISs (P<.00001). CONCLUSIONS: Our study is the first community-based register that provides sex-and age-specific rates for MISs and in which a CT scan was obtained in all patients. The incidence of TIAs in Segovia is comparable to that in other previous similar studies.

Adolescent↗

PubMed1995

Considerations in the prophylactic treatment of transient ischemic attack or ischemic stroke in the carotid artery territory.

This non-randomized study surveys the prophylactic treatment of 154 patients after transient ischemic attack or ischemic stroke in the carotid artery territory. Clinical presentation and etiologies were compared on the basis of the proposed prophylactic treatment. A surgical intervention or a long-lasting anticoagulation was restricted to only 30 patients (20%) due especially to the gravity of the ischemic cerebral lesions, general deterioration, and the advanced age of most of the patients. The purpose is to emphasize the "down-to-earth" situation in current medical care of non-selected patients as distinguished from the strictly selected patients of randomized studies. More importance should be done to open studies which better reflect the daily medical reality.

Adult↗

PubMed2004

What is the lowest dose of aspirin for maximum suppression of in vivo thromboxane production after a transient ischemic attack or ischemic stroke?

BACKGROUND: There is still worldwide disagreement about the optimal lowest dose of aspirin to be used in patients after a transient ischemic attack (TIA) or nondisabling stroke. We measured the urinary 11-dehydro-thromboxane-B(2) (uTXB(2)) excretion to compare the degree of suppression of in vivo platelet activation by various low doses of aspirin. METHODS: 60 patients were randomly allocated to treatment with either 30, 50, 75 or 325 mg of aspirin. All patients received a 413-mg loading dose of carbasalate calcium (equivalent to 325 mg of aspirin) on day 0. The study population was stratified into a subgroup with acute ischemic stroke (AIS; n = 20; onset of symptoms <48 h) and a subgroup with a recent TIA or minor stroke (TIA/mS; n = 40) with onset of symptoms beyond 30 days, but less than a year previously. Urine samples were collected on day 0, 1, 5, 11 and 28 in patients with AIS, and on day 0, 11 and 28 in the patients with a TIA/mS. RESULTS: On day 28, mean uTXB(2) levels were 241, 130, 217 and 187 pmol/mmol creatinine in the four treatment groups (ANOVA, p = 0.43). In the AIS subgroup, uTXB(2) remained suppressed on days 5 and 11 in all except the patients with the lowest dose (mean uTXB(2) on days 5 and 11: 475 and 392 pmol/mmol creatinine; log-transformed ANOVA, p = 0.05). CONCLUSION: In patients with a TIA or nondisabling stroke, a daily dose of 30 mg of aspirin provides sufficient suppression of thromboxane synthesis. No indication of a dose-effect relationship was found. However, whether such a low dose adequately suppresses thromboxane synthesis in patients with acute stroke is uncertain.

Adult↗

PubMed2000

Can seizures be the only manifestation of transient ischemic attacks? A report of four cases.

Several studies have investigated the frequency of epileptic seizures following ischemic strokes and transient ischemic attacks (TIAs). Little attention has been paid to the possibility that seizures may be precipitated by TIAs. We examined if seizures can be the only symptom of a TIA and how often this might occur. We performed a retrospective analysis of clinical charts and electroencephalograms of 160 consecutive patients evaluated for a first-ever seizure from January 1997 to December 1999 at Belluno General Hospital. From January to May 2000, 19 more first-ever seizure patients were evaluated directly. Four patients (2%) had seizures in the presence of important risk factors for ischemic stroke (atrial fibrillation in two patients, atrial fibrillation and ventricular mural thrombus in one patient, hemodynamically significant left carotid stenosis in one patient). Seizures were not accompanied by other neurological deficits or brain lesions on CT or MRI. As risk factors for brain ischemia are frequent in the general population not developing seizures, our results do not prove that the occurrence of seizures was more than casual in these patients. Yet they indicate that in a small percentage of patients, seizures can occur in a context highly suggestive of TIA, with no other focal deficits.

Aged↗

PubMed2005

Hyperacute diffusion-weighted imaging abnormalities in transient ischemic attack patients signify irreversible ischemic infarction.

BACKGROUND: To characterize the frequency and clinical features of diffusion-weighted imaging (DWI) abnormalities in the hyperacute phase of transient ischemic attacks (TIAs). METHODS: We performed DWI in 21 consecutive patients with TIA (mean age 64 years; 17 men and 4 women) during both the hyperacute phase (within 6 h after onset) and subacute phase (within 2-9 days after onset). RESULTS: DWI abnormalities were present in the hyperacute phase in 11 patients (positive group) and absent in the other 10 patients (negative group). These groups could not be differentiated based on the clinical characteristics. In the subacute phase, all 11 patients from the positive group had abnormalities on MRI including T2-weighted and fluid attenuation inversion recovery images as well as DWI, with lesions being located in regions similar to those observed in the hyperacute phase. Of the 10 patients in the negative group, new DWI abnormalities were noted in 2 during the subacute phase. CONCLUSIONS: Approximately half of TIA patients in whom MRI was performed in the hyperacute phase had DWI abnormalities, all of which persisted in the subacute phase. The findings suggest that essentially all hyperacute DWI abnormalities in TIA patients may indicate irreversibility and signify the presence of brain infarction.

Adult↗

PubMed1993

Risk factors for cervical atherosclerosis in patients with transient ischemic attack or minor ischemic stroke.

BACKGROUND AND PURPOSE: Our purpose was to study potential determinants of the presence and the severity of cervical atherosclerosis in patients with transient ischemic attack or minor ischemic stroke. METHODS: Two hundred ninety-four patients up to 60 years of age were included in this cross-sectional study. The male to female ratio was 171/123. Atherosclerosis was defined as the presence of any visible atherosclerotic lesion in anteroposterior or left oblique views of cervical arteries in aortic arch angiograms. The severity of atherosclerosis was assessed using three scores, which were computed separately for the total thickness and length of all plaques as well as for the percent stenosis of the vessels. RESULTS: Atherosclerosis was present in 180 patients (61.2%). In a multiple stepwise logistic regression analysis, age, serum triglycerides, smoking history for more than 20 years, arterial hypertension (defined as systolic or diastolic blood pressure values at least 150 or 100 mm Hg, respectively, or the use of antihypertensive medication), regular light alcohol consumption (inversely), and body mass index (marginal inverse association) were independent determinants of the presence of atherosclerosis; the respective odds ratios were 1.1/1 y, 1.8/1 mmol/L, 3.3, 2.4, 0.3, and 0.9/1 kg/m2. In multiple linear regression models, age was associated positively and the ratio of high density lipoprotein to total cholesterol was associated negatively with the severity of atherosclerosis regardless of the scoring method, whereas current smoking and female sex were predictors only of the percent stenosis and the length of the lesions. Arterial hypertension showed a significant association only with the length of the lesions. CONCLUSIONS: Age, cigarette smoking, and arterial hypertension contribute substantially to atherosclerosis in cervical arteries, but this study also confirms the independent associations of lipid or lipoprotein variables with atherosclerotic disease. An independent inverse association of regular light consumption of alcohol with cervical atherosclerosis was also observed.

Adult↗