RESUMO
BACKGROUND/AIMS: Acute posterior multifocal placoid pigment epitheliopathy is a rare but important disease that can be associated with life-threatening complications due to cerebral vasculitis. The primary objective was to determine the incidence of neurological complications and risk factors for stroke and transient ischaemic attack (TIA) associated with acute posterior multifocal placoid pigment epitheliopathy. Secondary objectives included the clinical presentation, visual outcomes and recurrence rates. METHODS: This was a multicentre retrospective case series including 111 eyes from 60 subjects presenting from January 2009 to June 2020. RESULTS: Median age at presentation was 29 years (IQR 24.7-35.1) and 36 subjects (60.0%) were male. 20 subjects (33.3%) reported a viral prodrome. Stroke and TIA were observed in seven subjects (11.7%). Older age was the only significant risk factor for stroke/TIA (p=0.042). Vision loss occurred in seven eyes, with four eyes (3.6%) having final visual acuity 6/15-6/60 and three eyes (2.7%) having visual acuity of 6/60 or worse. Recurrence occurred in 10 subjects (16.7%). CONCLUSIONS: The presence of headache cannot reliably predict those at risk of stroke/TIA. Individuals presenting with acute posterior multifocal pigment epitheliopathy should therefore undergo a clinical neurological review and work-up for cerebral vasculitis as deemed appropriate by the treating ophthalmologist and collaborating neurologist.
Assuntos
Ataque Isquêmico Transitório, Doenças Retinianas, Acidente Vascular Cerebral, Vasculite do Sistema Nervoso Central, Síndrome dos Pontos Brancos, Humanos, Masculino, Feminino, Doenças Retinianas/diagnóstico, Doenças Retinianas/tratamento farmacológico, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/epidemiologia, Ataque Isquêmico Transitório/complicações, Estudos Retrospectivos, Epitélio Pigmentado da Retina, Síndrome dos Pontos Brancos/complicações, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/epidemiologia, Acidente Vascular Cerebral/etiologia, Vasculite do Sistema Nervoso Central/complicações, Doença Aguda, AngiofluoresceinografiaRESUMO
PURPOSE: Detection of ischemic lesions in patients with transient neurovascular symptoms is relevant for the estimation of the risk of a subsequent stroke and etiological classification. To improve detection rates, different technical approaches have been used, such as diffusion-weighted imaging (DWI) with high b-values or higher magnetic field strength. Here, we sought to investigate the value of computed DWI (cDWI) with high b-values in these patients. METHODS: From an MRI report database we identified patients with transient neurovascular symptoms who underwent repeated MRI including DWI. cDWI was calculated with a monoexponential model with high b-values (2000, 3000, and 4000 s/mm2) and compared to the routinely used standard DWI with regard to presence of ischemic lesions and lesion detectability. RESULT: Overall 33 patients with transient neurovascular symptoms (71 [IQR 57-83.5] years; 21 [63.6%] male) were included. On DWI, acute ischemic lesions were observed in 22 (78.6%). Acute ischemic lesions were observed in 17 (51.5%) patients on initial DWI, and in 26 (78.8%) patients on follow-up DWI. Lesion detectability was rated significantly better on cDWI at 2000s/mm2 compared to standard DWI. In 2 (9.1%) patients, cDWI at 2000s/mm2 revealed an acute ischemic lesion proven on follow-up standard DWI which was not detected with certainty on the initial standard DWI. CONCLUSION: cDWI might be a valuable addition to routinely acquired standard DWI in patients with transient neurovascular symptoms since its use might result in improved ischemic lesion detection. A b-value of 2000s/mm2 seems most promising for clinical practice.
Assuntos
Ataque Isquêmico Transitório, Acidente Vascular Cerebral, Humanos, Masculino, Feminino, Imagem de Difusão por Ressonância Magnética/métodos, Infarto, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/patologiaRESUMO
OBJECTIVES: Patients who have recently suffered a transient ischemic attack (TIA) or minor ischemic stroke are at increased risk of cognitive impairment. In the present study, we aimed to investigate the effect of a 1-year exercise intervention on cognitive functioning up to 2 years post intervention. MATERIAL AND METHODS: We conducted a single-blind randomized controlled trial to investigate the effect of an exercise intervention on cognitive functioning, compared with usual care, for up to 2 years. Patients with a TIA or minor stroke were randomly allocated to an intervention group receiving the 1-year exercise intervention (n = 60) or to usual care (n = 59). Outcome measures were assessed at baseline and after 1 and 2 years. We measured cognition with neuropsychological tests on three domains: (1) executive functioning, (2) attention-psychomotor speed, and (3) memory. Linear mixed models were used for longitudinal data to determine the effect of the exercise intervention on cognitive functioning. Statistical analyses were performed using IBM SPSS software 24.0. RESULTS: We found that over the two years study period -and corrected for age, sex, and educational level- the intervention group on average improved significantly more in executive functioning than the control group (ß = 0.13; 95 % CI [0.02 to 0.25]; p = 0.03). No significant intervention effects were found on either memory or attention-psychomotor speed. CONCLUSIONS: Our data show that a 1-year exercise intervention significantly improved executive functioning over time, compared to usual care. We recommend that health care professionals consider broadening standard secondary stroke prevention treatment in patients with TIA/minor stroke by adding exercise and physical activity.
Assuntos
Ataque Isquêmico Transitório, Treinamento Resistido, Acidente Vascular Cerebral, Humanos, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/terapia, Ataque Isquêmico Transitório/complicações, Método Simples-Cego, Acidente Vascular Cerebral/complicações, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/terapia, CogniçãoRESUMO
INTRODUCTION: The aim of this study was to investigate the impact of smoking on dual antiplatelet therapy in patients with minor stroke or transient ischemic attack (TIA) under different glycated albumin (GA) levels. METHODS: We analyzed data from the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial. A subgroup of 3,044 patients with baseline GA levels was included and categorized by smoking status and GA levels. The primary efficacy outcome was a new stroke within 90 days. The safety outcome was any bleeding event at 90 days. The interaction of smoking status with antiplatelet therapy was calculated by Cox proportional hazards regression model. RESULTS: In patients with GA levels ≤15.5%, the proportion of smokers was 37.7% (719/1,908), while in patients with GA levels >15.5%, it was 51.6% (586/1,136). During the 3-month follow-up period, 299 (9.9%) patients had a new stroke occurrence. In patients with elevated GA levels, both smokers and nonsmokers could not benefit from dual antiplatelet therapy (smokers, adjusted hazard ratio [HR] 0.70, 95% confidence interval [CI]: 0.42-1.17; nonsmokers, adjusted HR 0.82, 95% CI: 0.57-1.18). In patients with normal GA levels, dual antiplatelet therapy reduced the risk of stroke recurrence in smokers by 72% (adjusted HR 0.28, 95% CI: 0.14-0.56) and in nonsmokers by 53% (adjusted HR 0.47, 95% CI: 0.26-0.86). However, whether the GA level was elevated or normal, there was no significant interaction between smoking status and antiplatelet therapy. CONCLUSIONS: Smokers with elevated GA levels could not benefit from dual antiplatelet therapy after minor stroke or TIA.
Assuntos
Ataque Isquêmico Transitório, Acidente Vascular Cerebral, Humanos, Inibidores da Agregação Plaquetária/efeitos adversos, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/tratamento farmacológico, Aspirina, Fumantes, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/tratamento farmacológico, Albumina Sérica, Quimioterapia Combinada, Resultado do TratamentoRESUMO
BACKGROUND: Although carotid web (CaW) is increasingly diagnosed as a cause of cryptogenic stroke, data are still limited to monocentric small sample cohort. To broaden knowledge on symptomatic CaW, CAROWEB registry has been recently implemented. AIMS: In a large cohort of symptomatic CaW patients, we described epidemiologic characteristics, admission clinical and imaging features, and the current management including the secondary preventive strategy choice made in comprehensive French Stroke Units. METHODS: CAROWEB is an ongoing French observational multicenter registry enrolling consecutive CaW patients diagnosed after an ipsilateral ischemic stroke (IS) or transient ischemic attack (TIA). Submitted cases were validated by two experienced neurologist and neuroradiologist. Clinical, imaging, and management features were collected for this study. RESULTS: Between June 2019 and December 2021, 244 cases were submitted by 14 centers, 42 rejected, and 202 included (IS, 91.6%; TIA, 7.9%; retinal infarction, 0.5%; mean age, 50.8 ± 12.2 years; female, 62.9%; Caucasian, 47.5%; Afro-Caribbean, 20.3%). IS patients showed median (interquartile range (IQR)) admission National Institutes of Health Stroke Scale (NIHSS) score, 8 (2-15); intracranial artery occlusion, 71.8%; ipsilateral chronic cerebral infarction (CCI), 16.3%; and reperfusion treatment, 57.3%. CaW was not identified during the mechanical thrombectomy procedure in 30 of 85 (35.3%) patients. Secondary prevention was invasive in 55.6% (stenting, n = 80; surgery, n = 30). In multivariable analysis, the invasive therapeutic option was associated with ipsilateral CCI (odds ratio (OR): 4.24 (1.27-14.2), p = 0.019) and inversely associated with risk factors (OR: 0.47 (0.24-0.91), p = 0.025) and admission NIHSS score (OR: 0.93 (0.89-0.97), p = 0.001). CONCLUSION: CaW must be considered in all ethnic groups including Caucasians. Secondary prevention is heterogeneous in large French Stroke Centers. The absence of risk factors, milder severity strokes, and ipsilateral CCI were predictive variables of secondary invasive treatment. The high rate of invasive treatment suggests that medical treatment alone is deemed ineffective to avoid recurrence and emphasize the need of randomized trials.
Assuntos
Isquemia Encefálica, Estenose das Carótidas, Endarterectomia das Carótidas, Ataque Isquêmico Transitório, AVC Isquêmico, Acidente Vascular Cerebral, Adulto, Feminino, Humanos, Pessoa de Meia-Idade, Isquemia Encefálica/complicações, Artérias Carótidas, Estenose das Carótidas/cirurgia, Endarterectomia das Carótidas/efeitos adversos, Ataque Isquêmico Transitório/epidemiologia, Ataque Isquêmico Transitório/terapia, Ataque Isquêmico Transitório/diagnóstico, AVC Isquêmico/complicações, Estudos Retrospectivos, Acidente Vascular Cerebral/diagnóstico por imagem, Acidente Vascular Cerebral/epidemiologia, Acidente Vascular Cerebral/terapia, Resultado do TratamentoRESUMO
PURPOSE OF REVIEW: To explore the differential diagnosis of posterior fossa transient ischemic attacks (TIA) associated with vertigo and/or imbalance.To review the contribution of cerebral small vessel (SVD) disease to balance dysfunction and dizziness in the elderly. MAIN FINDINGS: TIAs involving vestibular structures that mediate the vestibulo-ocular and vestibulospinal reflexes remain a diagnostic challenge because they overlap with causes of benign episodic vertigo. Here, we summarize the results of multidisciplinary specialty efforts to improve timely recognition and intervention of peripheral and central vestibular ischemia. More papers confirm that SVD is a major cause of gait disability, falls and cognitive disorder in the elderly. Recent work shows that early stages of SVD may also be responsible for dizziness in the elderly. The predominant location of the white matter changes, in the frontal deep white matter and genu of the corpus callosum, explains the association between cognitive and balance dysfunction in SVD related symptoms. SUMMARY: The evaluation of patients with intermittent vascular vertigo represent a major diagnostic challenge, recent reviews explore the ideal design approach for a multidisciplinary study to increase early recognition and intervention. Hemispheric white matter microvascular ischemia has been the subject of research progress - advanced stages are known to cause gait disorder and dementia but early stages are associated with "idiopathic" dizziness in the elderly.
Assuntos
Ataque Isquêmico Transitório, Neuro-Otologia, Humanos, Idoso, Tontura/diagnóstico, Tontura/etiologia, Ataque Isquêmico Transitório/complicações, Ataque Isquêmico Transitório/diagnóstico, Vertigem/diagnóstico, Vertigem/etiologia, Isquemia/complicaçõesRESUMO
OBJECTIVES: Transcatheter patent foramen ovale closure lowers recurrent stroke in patients with cryptogenic stroke or transient ischemic attack with an indication for closure. However, the incidence of recurrent stroke is not negligible and underlying pathophysiology remains largely unknown. We sought to evaluate the prevalence of recurrent ischemic neurological events and to assess its predictors after transcatheter patent foramen ovale closure. METHODS: We enrolled consecutive patients who underwent patent foramen ovale closure for secondary prevention of neurological ischemic events at the University Hospital of Parma between 2006 and 2021. Clinical and procedure-related features were collected for each patient. The incidence of recurrent ischemic neurological events was assessed at follow-up. RESULTS: We enrolled a total of 169 patients with mean Risk of Paradoxical Embolism score at hospital admission of 6.4 ± 1.5. The primary indication was previous cryptogenic stroke (94 [55.6 %] subjects), followed by transient ischemic attack (75 [44.4 %]). Among patients with complete outcome data (n= 154), after a median follow-up of 112 months, recurrent cerebral ischemia occurred in 13 [8.4 %], with an annualized rate of 0.92/100 patients. The presence of obesity [OR 5.268, p = 0.018], Risk of Paradoxical Embolism score < 7 [OR 5.991, p = 0.035] and migraine [OR = 5.932 p = 0.012] were independent positive predictors of recurrent stroke/ transient ischemic attack after patent foramen ovale closure. CONCLUSIONS: The presence of obesity, Risk of Paradoxical Embolism score < 7 and migraine were independent positive predictors of recurrent ischemic neurological events after patent foramen ovale closure.
Assuntos
Embolia Paradoxal, Forame Oval Patente, Ataque Isquêmico Transitório, AVC Isquêmico, Transtornos de Enxaqueca, Acidente Vascular Cerebral, Humanos, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/epidemiologia, Ataque Isquêmico Transitório/etiologia, Forame Oval Patente/complicações, Forame Oval Patente/diagnóstico por imagem, Forame Oval Patente/epidemiologia, Embolia Paradoxal/diagnóstico por imagem, Embolia Paradoxal/epidemiologia, Embolia Paradoxal/etiologia, Resultado do Tratamento, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/epidemiologia, Acidente Vascular Cerebral/etiologia, Infarto Cerebral/complicações, AVC Isquêmico/complicações, Prevenção Secundária, Obesidade/complicaçõesRESUMO
CONTEXT: A healthy, 22-year-old, male NCAA Division I baseball shortstop was experiencing confusion, chest pain, and tightness during an off-season intersquad scrimmage. The patient did not have any significant medical history or mechanism of head injury. After initial evaluation from the athletic trainer, the patient's cognitive status began to quickly decline. The emergency action plan was put in place rapidly and referred the patient to the local emergency clinic. CASE PRESENTATION: Upon arrival at the emergency department, an electrocardiogram was performed to rule out myocardial infarction or stroke. The first electrocardiogram results returned negative for any cardiac pathology, but a stroke alert was called. The patient was then transported to a level II trauma center due to continual cognitive decline. The patient was diagnosed with transient ischemic attack (TIA) secondary to an undiagnosed patent foramen ovale (PFO) that would later be diagnosed with further evaluation 2 months after the initial TIA incident. After multiple diagnostic and laboratory tests, the PFO went undetected until a 2D echocardiogram was performed and evaluated by a cardiologist. MANAGEMENT AND OUTCOMES: After the confirmation of the congenital defect, surgical intervention was performed to correct the PFO using catheterization. Despite multiple preparticipation examinations, electrocardiograms, and examination of past family history, the PFO went undetected until the patient experienced symptoms of TIA. The discovery of PFO in this 22-year-old athletic individual is unusual because traditional screening techniques (electrocardiogram and preparticipation examinations) failed to detect the congenital defect. CONCLUSIONS: Due to the emergent and timely actions of the athletic trainer, the patient has made a full recovery and is able to compete fully in athletic events. This case study amplifies the need for athletic trainers at all sporting events, updated and reviewed emergency action plans, rapid recognition of TIA in athletic individuals, and return-to-play protocol for an athletic individual after TIA.
Assuntos
Beisebol, Forame Oval Patente, Ataque Isquêmico Transitório, Acidente Vascular Cerebral, Humanos, Masculino, Adulto Jovem, Adulto, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/etiologia, Ataque Isquêmico Transitório/prevenção & controle, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/etiologia, Acidente Vascular Cerebral/prevenção & controle, Forame Oval Patente/complicações, Forame Oval Patente/diagnóstico, Forame Oval Patente/cirurgia, Atletas, Resultado do TratamentoRESUMO
BACKGROUND: Urine ketone bodies may appear in different states in the acute stage of stroke. We aimed to examine the association between urine ketone bodies and recurrent stroke in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) in this study. METHODS: In Third China National Stroke Registry (CNSR-III), 14,015 patients with AIS or TIA were screened for urine ketone bodies. The outcomes were any stroke, ischemic stroke and combined vascular events within 1 year. The association of urine ketone bodies with recurrent stroke were analyzed by Cox proportional hazards. RESULTS: During 1 year of follow-up, 1,335 (9.53%) participants experienced recurrent stroke. After adjustment for conventional confounding factors, patients with urine ketone bodies test positive had a higher risk of recurrent stroke (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.13-1.82), compared to those were negative. The correlation between positive urine ketone bodies and recurrent stroke were consistent in patient with (HR, 1.45; 95% CI, 1.00-2.12) and without (HR, 1.40; 95% CI, 1.02-1.94) diabetes. No significant interaction between urine ketone bodies and diabetes were observed. CONCLUSIONS: Positive ketone bodies in urine was independently associated with recurrent stroke in patients with AIS or TIA.
Assuntos
Diabetes Mellitus, Ataque Isquêmico Transitório, AVC Isquêmico, Acidente Vascular Cerebral, Humanos, Ataque Isquêmico Transitório/complicações, Ataque Isquêmico Transitório/diagnóstico, Corpos Cetônicos, Acidente Vascular Cerebral/complicações, Acidente Vascular Cerebral/diagnóstico, Infarto Cerebral, Recidiva, Fatores de RiscoRESUMO
Migraine or migraine-like symptoms can contribute to a delayed stroke diagnosis. However, migraine with aura is a common stroke mimic and often the basis for acute thrombolytic therapy. It is probably also the reason why many patients are misdiagnosed with a transient ischemic attack. In this clinical review, we explain the factors that could differentiate a transient ischemic attack from a migraine with aura.
Assuntos
Ataque Isquêmico Transitório, Transtornos de Enxaqueca, Enxaqueca com Aura, Acidente Vascular Cerebral, Humanos, Ataque Isquêmico Transitório/diagnóstico, Enxaqueca com Aura/diagnóstico, Enxaqueca com Aura/tratamento farmacológico, Diagnóstico Diferencial, Transtornos de Enxaqueca/diagnóstico, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/terapiaRESUMO
OBJECTIVES: Guidelines advise cardiac rhythm monitoring for 3 up to 30 days for detecting atrial fibrillation (AF) in patients with ischemic stroke of undetermined cause. However, the optimal monitoring duration is unknown. We aimed to determine the AF detection rate during 7-day outpatient cardiac rhythm monitoring in this patient group. METHODS: Participants from a large tertiary hospital in a prospective observational study (ATTEST) underwent outpatient cardiac rhythm monitoring after a negative standard diagnostic evaluation (i.e., 12-lead electrocardiogram and in-hospital telemetry). Primary outcome was the rate of newly detected AF. RESULTS: We examined 373 patients [age: 67.8±11.6 years; women: 166(44.5%); stroke: 278(74.5%)]. Median monitoring duration was 7 days (Inter Quartile Range (IQR) 7-7), performed after median of 36 days (IQR 27-47). AF was newly detected in 17(4.6%) patients, 5.4% of patients with ischemic stroke and 2.1% of patients with TIA. 53% of AF was detected on day-1, after day-3 73% of new AF was found. First AF episodes were detected up to day-7. Diabetes and increasing age were independent predictors of new AF. CONCLUSION: After ischemic stroke or TIA of undetermined cause, 7-day outpatient cardiac rhythm monitoring detected new AF in 4.6%. Patients with AF had significantly more cardiovascular risk factors. Although about 50% of first AF episodes occurred during the first day of monitoring, new AF was detected up to day-7, implying that the recommended minimum of 3 days cardiac rhythm monitoring after ischemic stroke of undetermined cause is insufficient. Subsequent long-term rhythm monitoring should be considered in selected patients.
Assuntos
Fibrilação Atrial, Ataque Isquêmico Transitório, AVC Isquêmico, Acidente Vascular Cerebral, Idoso, Feminino, Humanos, Pessoa de Meia-Idade, Fibrilação Atrial/complicações, Fibrilação Atrial/diagnóstico, Ataque Isquêmico Transitório/complicações, Ataque Isquêmico Transitório/diagnóstico, AVC Isquêmico/complicações, Pacientes Ambulatoriais, Fatores de Risco, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/etiologia, Estudos ProspectivosRESUMO
TIA is defined as an episode of neurological deficit with sudden onset, caused by focal cerebral or retinal ischemia lasting less than 24 hours. A tissue-based definition has been proposed but its application has been challenging, in part as its use requires magnetic resonance imaging. In most cases the diagnosis is solely based on history as provided by the patient. The diagnosis can therefore be challenging, and interobserver agreement between physicians is only fair. The importance of a TIA is its subsequent substantial risk of stroke, especially within the first weeks. Immediate acute care and treatment has been shown to decrease the risk of stroke substantially and is therefore crucial. Diagnostic procedures include imaging of the brain and neck vessels, ECG and cardiac rhythm monitoring, and blood pressure measuring. Treatment decisions are based on the diagnostic findings and include antithrombotic therapy, statins, blood pressure lowering medications, and carotid surgery if indicated.
Assuntos
Ataque Isquêmico Transitório, Médicos, Acidente Vascular Cerebral, Humanos, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/prevenção & controle, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/etiologia, Acidente Vascular Cerebral/prevenção & controle, Encéfalo, Pressão SanguíneaRESUMO
AIMS: Heart failure (HF) is a risk factor for major adverse events in atrial fibrillation (AF). Whether this risk persists on non-vitamin K antagonist oral anticoagulants (NOACs) and varies according to left ventricular ejection fraction (LVEF) is debated. METHODS AND RESULTS: We investigated the relation of HF in the ETNA-AF-Europe registry, a prospective, multicentre, observational study with an overall 4-year follow-up of edoxaban-treated AF patients. We report 2-year follow-up for ischaemic stroke/transient ischaemic attack (TIA)/systemic embolic events (SEE), major bleeding, and mortality. Of the 13 133 patients, 1854 (14.1%) had HF. Left ventricular ejection fraction was available for 82.4% of HF patients and was <40% in 671 (43.9%) and ≥40% in 857 (56.1%). Patients with HF were older, more often men, and had more comorbidities. Annualized event rates (AnERs) of any stroke/SEE were 0.86%/year and 0.67%/year in patients with and without HF. Compared with patients without HF, those with HF also had higher AnERs for major bleeding (1.73%/year vs. 0.86%/year) and all-cause death (8.30%/year vs. 3.17%/year). Multivariate Cox proportional models confirmed HF as a significant predictor of major bleeding [hazard ratio (HR) 1.65, 95% confidence interval (CI): 1.20-2.26] and all-cause death [HF with LVEF <40% (HR 2.42, 95% CI: 1.95-3.00) and HF with LVEF ≥40% (HR 1.80, 95% CI: 1.45-2.23)] but not of ischaemic stroke/TIA/SEE. CONCLUSION: Anticoagulated patients with HF at baseline featured higher rates of major bleeding and all-cause death, requiring optimized management and novel preventive strategies. NOAC treatment was similarly effective in reducing risk of ischaemic events in patients with or without concomitant HF.
Assuntos
Fibrilação Atrial, Isquemia Encefálica, Embolia, Insuficiência Cardíaca, Ataque Isquêmico Transitório, AVC Isquêmico, Acidente Vascular Cerebral, Masculino, Humanos, Fibrilação Atrial/complicações, Fibrilação Atrial/diagnóstico, Fibrilação Atrial/tratamento farmacológico, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/epidemiologia, Acidente Vascular Cerebral/etiologia, Anticoagulantes/efeitos adversos, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/epidemiologia, Ataque Isquêmico Transitório/prevenção & controle, Estudos Prospectivos, Volume Sistólico/fisiologia, Administração Oral, Função Ventricular Esquerda, Hemorragia/induzido quimicamente, Insuficiência Cardíaca/diagnóstico, Insuficiência Cardíaca/epidemiologia, Sistema de RegistrosRESUMO
INTRODUCTION: Soluble C-type lectin-like receptor 2 (sCLEC-2) is a new biomarker for platelet activation, which can be easily measured by usual blood collection. We conducted the CLECSTRO, a prospective, observational cohort study, to evaluate the clinical implications of sCLEC-2 in patients with acute ischaemic stroke (AIS) and transient ischaemic attack (TIA). METHODS AND ANALYSIS: The participants are patients with AIS/TIA and control patients required for differentiation from AIS/TIA. The target population is 600, including the patients and controls, who would be recruited from eight stroke centres across Japan. The inclusion criteria are AIS within 24 hours of onset and a modified Rankin Scale (mRS) score of 0-2, TIA within 7 days of onset, and contemporary patients required for differentiation from AIS/TIA. Plasma sCLEC-2 will be measured by high-sensitive chemiluminescent enzyme immunoassay using residual blood samples from routine laboratory examinations at the first visit in all patients and 7 days later or at discharge in patients with AIS/TIA. The outcomes include plasma levels of sCLEC-2 in patients with AIS/TIA and controls, sCLEC-2/D-dimer ratio in non-cardioembolic and cardioembolic AIS/TIA, correlation of sCLEC-2 with recurrence or worsening of stroke, severity of stroke, infarct size, ABCD2 score in TIA and outcome (mRS) at 7 days and 3 months. ETHICS AND DISSEMINATION: This study was approved by the Ethical Committee of the University of Yamanashi as the central ethical committee in agreement with the ethical committees of all collaborative stroke centres. Informed consent will be obtained by an opt-out form from the patients at each stroke centre according to the Ethical Guidelines for Medical and Biological Research Involving Human Subjects by the Japanese Ministry of Health, Labour and Welfare. TRIAL REGISTRATION NUMBERS: NCT05579405, UMIN000048954.
Assuntos
Isquemia Encefálica, Ataque Isquêmico Transitório, AVC Isquêmico, Acidente Vascular Cerebral, Humanos, Isquemia Encefálica/diagnóstico, Ataque Isquêmico Transitório/diagnóstico, Lectinas Tipo C, Estudos Multicêntricos como Assunto, Estudos Observacionais como Assunto, Estudos Prospectivos, Acidente Vascular Cerebral/diagnósticoRESUMO
BACKGROUND: Fabry disease (FD) is a rare X-linked lysosomal storage disorder caused by α-galactosidase A (α-Gal A) deficiency. The progressive accumulation of globotriaosylceramide results in life-threatening complications, including renal, cardiac, and cerebrovascular diseases. In order to improve health care of FD-patients, knowledge of its predictors is important. The aim of our study was to evaluate health-related quality of life (HrQol) in FD and to identify its independent determinants by exploring a wide range of demographic, social and clinical parameters. RESULTS: In this cross-sectional multicenter study, 135 adult patients with FD were recruited at three specialized European centers in Germany and Switzerland. Demographics, social status and clinical parameters as well as data on HrQol (EQ5D, EQ VAS) and depression were collected by means of self-reporting questionnaires and confirmed by medical records. HrQol and its predictors were evaluated by univariate and multivariate regression analyses. The study population consisted of 78 female and 57 male FD patients (median age 48 yrs) of whom 80.7% (N = 109) were on enzyme replacement therapy (ERT) and 10.4% (N = 14) were on chaperone treatment. Univariate analysis revealed various factors reducing HrQol such as age > 40 years, classic phenotype, organ involvement (kidney and heart disease, stroke/transient ischemic attack (TIA), gastrointestinal disturbances), depression, and burning limb pain. However, only the following factors were identified as independent predictors of decreased HrQol: classic phenotype, kidney and heart disease, stroke/TIA, depression, and burning limb pain. ERT and chaperone therapy were independent determinants of increased HrQol. CONCLUSIONS: Modifiable factors, such as burning limb pain and depression, identified as independent predictors of HrQol-deterioration should be addressed in programs aiming to improve HrQol in FD. A multidisciplinary approach is essential in FD-patients since diverse organ involvement prominently compromises HrQol in affected patients. Our findings showed that the classic phenotype is a strong predictor of worsening HrQol.
Assuntos
Doença de Fabry, Cardiopatias, Ataque Isquêmico Transitório, Acidente Vascular Cerebral, Adulto, Humanos, Masculino, Feminino, Pessoa de Meia-Idade, Doença de Fabry/diagnóstico, Doença de Fabry/genética, Doença de Fabry/complicações, Qualidade de Vida, Ataque Isquêmico Transitório/complicações, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/tratamento farmacológico, Estudos Transversais, alfa-Galactosidase/genética, alfa-Galactosidase/uso terapêutico, Acidente Vascular Cerebral/complicações, Dor/tratamento farmacológicoRESUMO
Cocaine abuse with its complications is a common problem that presents often in the emergency room. Complications of cocaine use can involve multiple systems. These complications can arise within each system simultaneously or at different times. We treated a patient who presented with symptoms of cerebrovascular accident and was found to have concomitant non-ST segment elevation myocardial infarction (NSTEMI). A 54-year-old male with medical history significant for hypertension and prior MI presented to emergency department with left leg and arm numbness first noticed when he woke up in the morning of presentation. He admitted using cocaine the night prior to presentation. Neurological exam was remarkable for decreased sensation to left extremities. His National Institute of Health Stroke Scale (NHISS) score was 1. Blood work was significant for an elevated troponin I of 1.74 ng/ml, and an elevated Creatinine of 2.34 mg/dl. CT head and MRI brain were negative for acute intracranial hemorrhage or radiological evidence of stroke. He was treated with aspirin, clopidogrel, statin and therapeutic enoxaparin for NSTEMI. His symptoms of left sided numbness resolved over the course of his stay. This case underscores why cocaine abuse should always be considered in the differential for patients presenting with symptoms suggestive of acute coronary syndrome or stroke, especially in young and middle-aged males.
Assuntos
Transtornos Relacionados ao Uso de Cocaína, Cocaína, Ataque Isquêmico Transitório, Infarto do Miocárdio sem Supradesnível do Segmento ST, Infarto do Miocárdio com Supradesnível do Segmento ST, Acidente Vascular Cerebral, Masculino, Pessoa de Meia-Idade, Humanos, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/etiologia, Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico, Transtornos Relacionados ao Uso de Cocaína/complicações, Transtornos Relacionados ao Uso de Cocaína/diagnóstico, Hipestesia, Acidente Vascular Cerebral/diagnóstico por imagem, Acidente Vascular Cerebral/etiologia, HemorragiaRESUMO
BACKGROUND: Identification of visual symptoms as a sign of acute stroke can be challenging for both first line healthcare professionals and lay persons. Failed recognition of visual symptoms by medical dispatchers at the Emergency Medical Dispatch Center (EMDC-112) or personnel at the Out-of-Hours Health Service (OOHS) may delay stroke revascularization. We aimed to identify correct system response to visual symptoms in emergency calls. METHODS: Phone calls from patient or bystander to the EMDC-112 or OOHS, which included visual symptoms on patients later verified with stroke/Transient ischemic attack (TIA) diagnosis, were analyzed. Data were stratified according to hospitalization within and after 4.5 h from symptom onset. Descriptive and multiple logistic regression analysis were performed. RESULTS: Of 517 calls identified, 290 calls fulfilled inclusion criteria. Only 30% of the patients received correct visitation by the medical dispatchers and referral to the hospital by a high-priority ambulance. Correct visitation was associated with early contact (adjusted OR: 2.37, 95% CI: 1.11, 5.03), contact to the EMDC-112 (adjusted OR: 3.18, 95% CI: 1.80, 5.62), and when the medical dispatcher asked additional questions on typical stroke symptoms (adjusted OR: 6.36, 95% CI: 3.01, 13.43). No specific visual symptom was associated with stroke recognition and fast hospitalization. CONCLUSIONS: First line healthcare professionals had significant problems in identifying visual symptoms as a sign of acute stroke and eliciting correct response. This highlights an urgent need to improve knowledge of visual symptoms in acute stroke and emphasize correct response to stroke symptoms in general.
Assuntos
Serviços Médicos de Emergência, Ataque Isquêmico Transitório, Acidente Vascular Cerebral, Humanos, Acidente Vascular Cerebral/complicações, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/terapia, Hospitais, Ataque Isquêmico Transitório/diagnóstico, AmbulânciasRESUMO
BACKGROUND/PURPOSE: Inherited thrombophilia testing in the acute inpatient setting is controversial and expensive, and rarely changes clinical management. We evaluated ordering patterns and results of inpatient inherited thrombophilia testing for patients who presented with an isolated acute ischemic stroke or transient ischemic attack (TIA) without concurrent venous thromboembolism. METHODS: We retrospectively analyzed patients admitted for acute ischemic stroke or TIA between January 1st, 2019 and December 31st, 2021 at Thomas Jefferson University Hospitals in Philadelphia, PA and who underwent inherited thrombophilia testing during the hospital admission. Charts were reviewed to determine stroke risk factors, test results, and clinical management. RESULTS: Among 2108 patients admitted for acute ischemic stroke or TIA (including branch and central retinal artery occlusions) during the study period, the study included 249 patients (median age 49.0 years, 50.2% female) who underwent inpatient testing for factor V Leiden, prothrombin G20210A variant, hyperhomocysteinemia, PAI-1 elevation, and deficiencies of protein C and S and antithrombin. 42.2% of patients had at least one abnormal test, and among the 1035 tests ordered, 14.3% resulted abnormal. However, 28% of abnormal tests were borderline positive antigen or activity assays that likely represented false positives. There was no significant difference in the likelihood of a positive test among patients without stroke risk factors vs those with risk factors (47.1% vs 40.9%, P = .428), nor any significant difference between those under vs over age 50 years (45.7% vs 38.3%, P = .237). No patients with an abnormal result had their clinical management changed as a result. Charges for the tests totaled $468,588 USD. CONCLUSIONS: Inherited thrombophilia testing in the hospital immediately following isolated acute arterial ischemic stroke or TIA was associated with high rates of likely false positive results and was expensive. Positive results did not change clinical management in a single case.
Assuntos
Isquemia Encefálica, Ataque Isquêmico Transitório, AVC Isquêmico, Acidente Vascular Cerebral, Trombofilia, Humanos, Feminino, Pessoa de Meia-Idade, Masculino, Estudos Retrospectivos, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/genética, Ataque Isquêmico Transitório/terapia, Isquemia Encefálica/etiologia, AVC Isquêmico/complicações, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/genética, Acidente Vascular Cerebral/terapia, Trombofilia/complicações, Trombofilia/diagnóstico, Trombofilia/genética, Fatores de RiscoRESUMO
BACKGROUND: The short-term incidence of ischemic stroke after a transient ischemic attack (TIA) is high. However, data on the long-term incidence are not well known but are needed to guide preventive strategies. METHODS: Patients with first-time TIA (index date) in the Danish Stroke Registry (January 2014-December 2020) were included and matched 1:4 with individuals from the background population and 1:1 with patients with a first-time ischemic stroke on the basis of age, sex, and calendar year. The incidences of ischemic stroke and mortality from index date were estimated by Aalen-Johansen and Kaplan-Meier estimators, respectively, and compared between groups using multivariable Cox regression. RESULTS: We included 21 500 patients with TIA, 86 000 patients from the background population, and 21 500 patients with ischemic stroke (median age, 70.8 years [25th-75th percentile, 60.8-78.7]; 53.1% males). Patients with TIA had more comorbidities than the background population, yet less than the control stroke population. The 5-year incidence of ischemic stroke after TIA (6.1% [95% CI, 5.7-6.5]) was higher than the background population (1.5% [95% CI, 1.4-1.6], P<0.01; hazard ratio, 5.14 [95% CI, 4.65-5.69]) but lower than the control stroke population (8.9% [95% CI, 8.4-9.4], P<0.01; hazard ratio, 0.58 [95% CI, 0.53-0.64]). The 5-year mortality for patients with TIA (18.6% [95% CI, 17.9-19.3]) was higher than the background population (14.8% [95% CI, 14.5-15.1], P<0.01; hazard ratio, 1.26 [95% CI, 1.20-1.32]) but lower than the control stroke population (30.1% [95% CI, 29.3-30.9], P<0.01; hazard ratio, 0.41 [95% CI, 0.39-0.44]). CONCLUSIONS: Patients with first-time TIA had an ischemic stroke incidence of 6.1% during the 5-year follow-up period. After adjustment for relevant comorbidities, this incidence was approximately 5-fold higher than what was found for controls in the background population and 40% lower than for patients with recurrent ischemic stroke.
Assuntos
Isquemia Encefálica, Ataque Isquêmico Transitório, AVC Isquêmico, Acidente Vascular Cerebral, Masculino, Humanos, Idoso, Feminino, Ataque Isquêmico Transitório/diagnóstico, Ataque Isquêmico Transitório/epidemiologia, Ataque Isquêmico Transitório/etiologia, Incidência, Isquemia Encefálica/diagnóstico, Isquemia Encefálica/epidemiologia, Isquemia Encefálica/complicações, Acidente Vascular Cerebral/diagnóstico, Acidente Vascular Cerebral/epidemiologia, Acidente Vascular Cerebral/etiologia, Fatores de RiscoRESUMO
BACKGROUND: The use of implantable loop recorder (ILR) to detect atrial fibrillation (AF) in patients with a history of cryptogenic stroke (CS) has seldom been investigated in "real-world" settings. OBJECTIVE: This study aimed to present the results of the Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation (SPIDER-AF) registry. METHOD: SPIDER is a multicentric, observational registry, including 35 facilities all over Germany. It enrolled outpatients without AF history and with CS before ILR implantation. RESULTS: We included 500 patients (mean age 63.1 ± 12.7 years), 304 (60.8%) were males, with previous stroke (72.6%) and TIA (27.4%). After inclusion, all were followed for at least 12 months. AF was detected in 133 (26.8%), 25.3% of patients with previous stroke and 29.9% with TIA (p = 0.30). AF was detected after a median of 121.5 days (IQR 40.5-223.0). AF was primarily paroxysmal (95.7% after stroke, 100% after TIA). In 19.5% (n = 26) anticoagulation was not administered after AF detection. Mean CHA2DS2-VASc score (OR 1.22; CI 1.01-1.49; p = 0.037) and age > 70 years (OR 0.41; CI 0.19-0.88; p = 0.0020) correlated with AF. Repeat cerebrovascular events at follow-up (28; 5.6%) correlated with AF (OR = 2.17; CI 1.00-4.72; p = 0.049). AF (p = 0.91) and recurrent events (p = 0.43) occurred similarly in females and males. CONCLUSIONS: In the context of cryptogenic strokes ILRs are a valuable tool for early detection of AF. In a real-world scenario, the anticoagulation therapy remains inadequate despite diagnosed AF in a relevant subset of patients requiring optimization of patient management.
