Long-term mortality and risk of stroke after transient ischemic attack

Background   Stroke and mortality rates in patients with transient ischemic attack (TIA) differ widely between community-based studies and research cohorts. Our aim therefore was to provide a reliable estimate for TIA patients treated in German neurology departments with an acute stroke unit. Methods   A total of 1951 consecutively admitted TIA patients were prospectively documented in 13 centers and 1480 (75.9 %) gave consent for long-term follow-up. During a mean follow-up of 23.4 months, we assessed recurrent cerebrovascular events and cause of death in 1448 patients via standardized telephone interview including confirmation of endpoint events by the treating physician. Results   Overall 94 patients (6.5 %) suffered a stroke and 118 patients (8.1 %) died, 21 due to stroke. The Kaplan-Meier estimate for stroke during the first year was 4.4 % (95 % CI 3.2–5.6 %) which corresponds to a relative risk of 9.5 (95 % CI 7.4–12.3) compared to the population-based stroke incidence in Germany. The annual rates after the first year were 2.2 % (95 % CI 1.7–2.7 %) for stroke and 3.2 % (95 % CI 2.7–3.8 %) for death. Independent predictors for stroke during follow-up were age and previous cerebrovascular events. The ABCD₂ score did not provide any meaningful prediction of stroke risk at 90 days. Conclusion   While the in-hospital risk of stroke was low, long-term stroke rates in our well-defined multicenter hospital-based cohort were comparable to a large randomized trial. In patients with a well-established diagnosis of TIA, only age and previous cerebrovascular events seem to constitute independent predictors for stroke during long-term follow-up. Participating Departments of Neurology (investigator): Ostalbklinikum Aalen (M. Heyden, MD), Klinikum Bernburg (M. Muller, MD), Krankenanstalten Gilead Bielefeld (C. Hagemeister, MD), Krankenhaus Buchholz (K. Luckner, MD), University of Essen (C. Weimar, MD), University of Freiburg (C. Fritzsch, MD), University of Greifswald (A. Khaw, MD), University of Hannover (K. Weissenborn, MC), Klinikum Heidenheim (S. Kaendler, MD), University of Jena (C. Terborg, MD), Krankenhaus Koln-Mehrheim (U. Frost, MD), University of Leipzig (D. Michalski, MD), Landesklinik Lubben (C. Rohrig, MD), University of Magdeburg (M. Goertler, MD), Ruppiner Kliniken Neuruppin (G. Zindler, MD), University of Rostock (A. Kloth, MD), Burgerhospital Stuttgart (T. Mieck, MD), University of Ulm (R. Huber, MD), Heinrich- Braun-Krankenhaus Zwickau (S. Grieshammer MD).     

缺血性脑卒中/短暂性脑缺血发作患者脑动脉病变分布相关危险因素分析

目的 探讨缺血性脑卒中(ischemic stroke,IS)/短暂性脑缺血发作(transient ischemic attack,TIA)脑动脉病变分布的相关危险因素.方法 对169例IS/TIA患者行颈部及颅内脑血管检查,记录血管病变危险因素如年龄、性别、高血压、糖尿病、长期吸烟、长期饮酒等病史,同时记录实验室、心电图、超声心动图、腹部B超、胸X片等检查结果.确定单变量与不同狭窄模式的相关性采用单变量Logistic回归分析,确定不同颅内外大动脉狭窄模式的独立危险因素采用多元逐步和多变量多项分类Logistic回归分析.结果 高龄、长期吸烟及高低密度脂蛋白(LDL-C)是颅内外大动脉狭窄的独立危险因素,发生颅内外大动脉狭窄的风险分别增加了1.83、6.918、1.656倍;脑卒中史(OR=4.816)、长期吸烟(OR=121.608)、高LDL-C(OR=3.067)是单纯颅内大动脉狭窄的独立危险因素;高龄(OR =2.486)、长期吸烟(OR=25.072)、高LDL-C(OR=5.160)是颅内外大动脉狭窄并存的独立危险因素;而高纤维蛋白原(OR =4.790)是单纯颅外大动脉狭窄的独立危险因素.结论 不同类型颅内外大动脉狭窄病变的独立危险因素不同.     

Prognosis of dolichoectasia in non-cardioembolic transient ischemic attack and minor stroke

Objectives This study aimed to estimate the prognosis of dolichoectasia in non-cardioembolic transient ischemic attack (TIA) and minor stroke patients.

Methods Data were derived from the imaging subgroup of patients in the Clopidogrel in High-risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial. Dolichoectasia was defined as ectasia (basilar artery diameter >4.5 mm) and dolichosis (either basilar artery bifurcation above the suprasellar cistern or lateral to the margin of the clivus or dorsum sellae). The prognosis included ischemic stroke recurrence and poor functional outcome (modified Rankin scale 2–6) at 12-month follow-up. The association of dolichoectasia with risk factors and prognosis of patients were assessed using multivariable Cox regression models.

Results Overall, 1089 patients with magnetic resonance images in the CHANCE trial were included in this subanalysis. A total of 98 (9.0%) patients were detected with dolichoectasia, and 106 (9.7%) patients had a recurrent ischemic stroke at 12 months. Small artery occlusion (SAO) was more prevalent in patients with dolichoectasia compared with those without dolichoectasia (29.6% vs. 22.7%, hazard ratio [HR] 2.87, 95% confidence interval [CI] 1.59–5.17, p < 0.001). However, multivariate analysis showed no association of dolichoectasia with 12-month recurrent stroke (9.2% vs. 9.8%, HR, 1.15; 95%CI, 0.32–4.12; p = 0.83) and poor functional outcome (7.6% vs. 8.4%, odds ratio, 1.22; 95%CI, 0.24–6.08; p = 0.81) in the current subgroup analysis.

Conclusions Dolichoectasia was significantly associated with SAO. There was no relationship between dolichoectasia and 12-month prognosis of patients with non-cardioembolic TIA or minor stroke.     

Expression of platelet glycoprotein VI is associated with transient ischemic attack and stroke

Background and purpose: Platelet collagen receptor glycoprotein VI (GPVI) contributes significantly to platelet adhesion and thrombus formation. We aimed to investigate GPVI in patients presenting with symptoms of acute cerebrovascular disease and to define GPVI as biomarker for acute stroke. Methods: We consecutively evaluated 205 patients, who admitted the stroke unit with symptoms for stroke. Surface expression of the platelet activation markers (GPVI, CD62P, GPIb) was determined by two‐color whole blood flow cytometry. Results: Patients with transient ischemic attack (TIA) (n = 18; 8.8%) as well as with stroke (n = 133; 64.9%) showed a significantly enhanced GPVI expression (mean fluorescence intensity ± SD) on admission compared to patients with non‐ischemic (NI) events (n = 54; 26.3%) (TIA: 20.9 ± 7.1 vs. NI: 16.2 ± 3.9; P = 0.002; stroke: 20.4 ± 5.7 vs. NI; P = 0.002). Neither CD62P nor GPIb surface expression showed a significant difference. Logistic regression analysis revealed that on admission GPVI was associated with stroke independent of conventional laboratory markers such as C‐reactive protein, blood glucose, and creatine kinase. Using a receiver operating characteristic curve on GPVI, we have determined the cut off value of 18.2 for stroke. Thus, patients with enhanced GPVI expression levels (≥18.2) had a 2.4‐fold relative risk for stroke. Patients with elevated platelet GPVI expression level had a poorer clinical outcome in cumulative event‐free survival for stroke, myocardial infarction, and cerebro‐/cardiovascular death at 3‐month follow‐up (log rank; P = 0.045). Conclusions: These findings indicate that platelet GPVI surface expression is significantly enhanced in patients with TIA and stroke compared to patients with NI events. Determination of platelet‐specific GPVI may be useful as an early biomarker for cerebral ischemia.     

Prognostic indicators for mortality in transient ischemic attack and minor stroke

In a prospective study, 129 consecutive patients with transient ischemic attacks (TIAs) and 80 consecutive patients with minor ischemic stroke, involving the carotid artery territory in both cases, were followed-up for six years from their inclusion during the period from January 1984 to October 1985. All patients were 40–80 years old at inclusion, the median age being 74 years in the TIA group and 76 years in the minor stroke group. Overall mortality in the TIA group was significantly higher than in the minor stroke group, [44%, (57/129) vs 20% (16/80), p<0.0006 after correction for age], and that in the general population of Malmö. Pre-existing vascular disease was slightly more prevalent in the TIA than in the minor stroke group [27% (35/129 vs 21% (17/80), NS]. Of the 19 patients with intermittent claudication, who all died [12 (63%) of them due to myocardial infarction (MI)], 18 belonged to the TIA group and only one to the minor stroke group. The respective frequencies of the putative risk factors in the TIA and minor stroke groups were 28% (36/129) vs 9% (7/80) for hypertension (p = 0.016), 9% (12/129) vs 6% (5/80) for diabetes mellitus (NS), and 8% (10/129) vs 9% (7/80) for cardiac arrhythmia (NS). Mortality due to MI was higher in the TIA than in the minor stroke group[24% (31/129) vs 6% (5/80), p = 0.001]. Of the minor stroke patients, none without vascular disease died of MI. Regarding the risk of death in the study population as a whole (i.e., both groups), mortality was greater among those with vascular disease than among those without [81% (42/52) vs 20% (31/157), p = 0.0001], the corresponding figures for death due to MI being 56% (29/52) vs 4% (7/157), p = 0.0001. All six patients with both vascular disease and hypertension died, five of them due to MI. Thus, both in the TIA and minor stroke groups, mortality was greatest among those with preexisting vascular disease. To significantly reduce mortality among TIA and minor stroke patients, it is suggested that very active measures need to be taken against cardiovascular disease.     

短暂性脑缺血发作发展至脑梗死危险因素的分析

目的探讨短暂性脑缺血发作(TIA)发展至脑梗死的危险因素。方法对144例TIA患者的临床资料进行分析。结果144例患者中50例(34.7%)发生了脑梗死;其中椎基底动脉系统TIA20例中11例(55.0%)发生脑梗死;颈内动脉系统TIA118例中37例(31.4%)发生脑梗死;两个系统脑梗死的发生率差异有显著性(P<0.05)。78%的脑梗死发生在TIA后1个月内,5例死于脑梗死。TIA发作持续>30min、24h内>3次发作以及首次发作后>24h或发作>5次开始治疗的患者发生脑梗死的危险性显著增高(P<0.05～0.01)。发生脑梗死的TIA患者血压、血糖、血胆固醇显著增高(均P<0.05)。结论患者TIA发作持续久、次数多、未及时治疗,尤其伴有高血压、高血糖、高脂血症者短期内发生脑梗死的危险性较高。     

Factors associated with medication persistence among ischemic stroke patients: a systematic review

ABSTRACT

Objective

An investigation of the prevalence of medication persistence and associated factors in order to inform effective strategies for improving medication persistence.     

经导管封堵治疗卵圆孔未闭并发隐匿性脑卒中或短暂性脑缺血发作的临床效果

目的 探讨经导管封堵治疗卵圆孔未闭并发隐匿性脑卒中或短暂性脑缺血发作的临床效果。方法 选取本院2016年2月-2018年8月收治的120例卵圆孔未闭并发隐匿性脑卒中或短暂性脑缺血发作患者为研究对象,分为对照组和实验组,每组各60例,对照组患者采用阿司匹林进行治疗,实验组患者进行经导管封堵治疗,观察2组患者的治疗效果、治疗前、治疗6个月后的临床指标水平变化、治疗前、治疗6个月后的血栓弹力图(TEG)指标水平变化以及治疗6个月后的并发症发生率和脑缺血事件复发率。结果 实验组的治疗效果明显好于对照组(P<0.05); 治疗6个月后实验组的射血分数、左室舒张末内径、心率和左室收缩末内径均高于对照组(P<0.05); 治疗6个月后实验组的α-角和MA值明显低于对照组,AA途径诱导的血小板控制率明显高于对照组(P<0.05); 治疗6个月后实验组的并发症发生率和脑缺血事件复发率明显低于对照组(P<0.05)。结论 经导管封堵对卵圆孔未闭并发隐匿性脑卒中或短暂性脑缺血发作的临床效果较好,可以提高患者的心功能,明显降低血小板聚集,降低患者的脑缺血事件复发率和并发症发生率     

Effects of an individualized multimedia computer program for health education in patients with a recent minor stroke or transient ischemic attack - a randomized controlled trial

BACKGROUND: Transient ischemic attack (TIA) and stroke patients often show a striking lack of knowledge about their disease. We developed a computer program that provided health education fitting the educational level, risk profile and symptoms of patients and evaluated it in a randomized controlled trial. METHODS: Transient ischemic attack or minor stroke patients were allocated to health education by a physician (n = 32) or to a combination of education by a physician and the computer program (n = 33). Knowledge was tested by means of a questionnaire at 1 and 12 weeks after inclusion. The maximum possible score was 71 points. RESULTS: Overall knowledge was low - the mean score was 43.6 at 1 week and 42.0 points at 12 weeks for both the groups. The intervention group had slightly better scores at 1 week after using the computer program, 45.4 vs 41.5 (P = 0.09), with the difference increasing to 4.3 points after (post-hoc) adjustment for age and level of education (P = 0.06). After 12 weeks, the score in the intervention group dropped significantly to 42.0 points (P = 0.05), and was no longer different from the standard group. CONCLUSION: This study did not show a lasting effect of health education by an individualized computer program on the knowledge of TIA and minor stroke patients.     

糖尿病合并短暂性脑缺血发作患者发展为脑梗死的独立预测因素

目的 评估糖尿病合并短暂性脑缺血发作患者发展为脑梗死的独立预测因素。方法 入选2013年1月-2015年6月就诊于航天中心医院卒中中心的短暂性脑缺血发作合并糖尿病的患者,收集临床资料(常规、生化、凝血功能、糖化血红蛋白、心脏超声),行核磁共振造影检查,并随访30个月,记录脑梗死事件和较差的功能结局(改良的Rankin量表2～6分)。结果 最终235例患者入选,其中有70例(29.8%)在随访期内发生脑梗死,59例患者被发现Rankin量表达到2～6分,14例患者6月内发生脑梗死,cox多因素回归分析发现,基底动脉动脉延长扩张和高龄是30个月内发生脑梗死的独立预测因素。基底动脉延长扩张能够独立预测随访期内2～6分的改良Rankin量表评分。基底动脉动脉延长扩张和高水平糖化血红蛋白能够预测6个月内脑梗死的发生,而且生存曲线提示基底动脉延长扩张者6个月内及30个月内发展为脑梗死风险明显高于其余患者,糖化血红蛋白水平高于中位数者(6.2%)6个月内发展为脑梗死风险明显高于糖化血红蛋白水平相对低的患者。结论 血管畸形和血糖控制差的患者容易由短暂性脑缺血发作进展为脑梗死,远期生活质量也受到影响。     

改良ABCD2评分与头颈部CTA对TIA后脑梗死的预测价值

目的 探讨应用改良ABCD2 评分及头颈部CT血管造影（CTA）对短暂性脑缺血发作（TIA）后7 d内脑梗死发生率的预测价值,并分析改良ABCD2评分及CTA的相关性。方法 回顾性分析698例TIA的临床资料及CTA资料。采用ABCD2评分法进行评分的同时,附加人血浆脂蛋白相关磷脂酶A2（Lp-PLA2）检测结果进行评分,分为低危组、中危组、高危组;根据头颈CTA血管狭窄程度分为正常或轻度狭窄、中度狭窄及重度狭窄。结果 698例TIA中,7 d内166例发生脑梗死;低危组、中危组及高危组脑梗死发生率呈现递增趋势（P<0.05）。责任血管重度狭窄组7 d内脑梗死发生率明显高于中度狭窄组（P<0.05）,而中度狭窄组明显高于正常或轻度狭窄组（>P<0.05）。低危组、中危组及高危组责任血管重度狭窄率、多支血管病变比例均呈现递增趋势（>P<0.05）,而3组病变血管位于前循环比例无统计学差异（>P>0.05）。结论 应用改良后ABCD2评分及CTA检查对TIA的脑梗死风险预测均有重要意义。     

联合评分评估 TIA 后早期卒中风险的应用研究

目的：探讨联合评分方法对短暂性脑缺血发作（transient is chemic attack ,TIA）后早期卒中风险进行评估的效能。方法收集120例TIA患者,通过头DWI明确有无新鲜梗死。入院后对患者进行ABCD2评分,检测患者血清超敏C反应蛋白（hypersensitive C-reactive protein ,hs-CRP）、血浆纤维蛋白原（fibrinogen ,FIB）的含量。在ABCD2评分基础上,结合血清hs-CRP、FIB结果形成联合评分,对比分析 TIA后1周内ABCD2评分与联合评分两种方法的评估效能。结果120例T IA患者中,39例（32.5％）在发病1周内发生脑梗死。ABCD2评分与联合评分两种方法结果一致,脑梗死发病率由高到低顺序为：高危＞中危＞低危。联合评分低、中危组人数减少,高危组人数增加。与ABCD2评分比较,联合评分低、中危组脑梗死发病率降低,高危组脑梗死发病率升高。联合评分的ROC曲线下面积显著大于ABCD2评分（P＜0.001）。结论结合临床生化检验结果的联合评分效能高于单纯的ABCD2评分,联合评分能更好预测高危人群T IA后早期进展为脑梗死的风险,可用于临床指导T IA危险分层和治疗。     

Neurobrucellosis as an exceptional cause of transient ischemic attacks

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

应用ABCD^2评分法和纤维蛋白原预测TIA后短期脑卒中风险

目的探讨ABCD^2＋纤维蛋白原评分法对短暂性脑缺血发作后7d内发生脑梗死的预测价值。方法用ABCD^2评分法和ABCD^2＋纤维蛋白原评分法分别测定135例TIA患者的评分,并观察TIA后7d内脑梗死的发生率。结果ABCD^2＋纤维蛋白原评分法和ABCIY评分法的曲线下面积（95％CI）分别为0．755（0．668-0．842）和0．711（0．618-0．804）。135例TIA患者中42分者13例,脑梗死的发生率为零;评分为3分者12例,脑梗死的发生率为8％;评分为4分者30例,脑梗死的发生率为17％;评分为5分者40例,脑梗死的发生率为25％;评分为6分者28例,脑梗死的发生率54％;评分≥7分者12例,脑梗死的发生率为58％。低危（0～3分）、中危（4-5分）和高危（6～8分）组TIA后7d内发生脑梗死的比例分别为4％、21％和55％（P〈0．05）。结论ABCD^2＋纤维蛋白原评分法的预测价值高于ABCD^2评分法。ABCD^2＋纤维蛋白原评分标准是临床上预测TIA短期进展为脑梗死的一种比较有效的方法。     

短暂性脑缺血发作与颅内外血管狭窄的关系

目的探讨短暂性脑缺血发作(TIA)与颅内外血管狭窄的关系。方法给68例TIA患者进行颈部B超、经颅多普勒(TCD)以及心脏超声检查,对其中56例有明显脑血管狭窄的患者进一步行数字减影血管造影(DSA)检查。结果56例行DSA检查的患者中,显示大脑中动脉狭窄(或闭塞)6例,颈内动脉狭窄(或闭塞)21例,锁骨下动脉狭窄8例,椎基底动脉狭窄(或闭塞)28例。大动脉狭窄性TIA44例,其中颈内动脉系统16例,椎基底动脉系统28例;栓塞性TIA18例,其中颈内动脉系统15例,椎基底动脉系统3例;腔隙性TIA4例;血管痉挛性TIA2例。结论TIA患者大多存在颅内外血管狭窄,其与TIA有密切关系。