Intellectual function in patients with transient ischaemic attacks (TIA) or minor stroke

Psychological testing was performed in 25 patients (mean age 56 years) with transient ischaemic attacks and/or minor strokes and with angiographically verified internal carotid artery stenosis. The effects of carotid endarterectomy on intellectual functions were evaluated postoperatively at 2 weeks and 8 months respectively. Preoperatively the mean test values were below the normal level for all tests indicating a general intellectual impairment for the group as a whole. This may reflect multiinfarct dementia in statu nascendi . At the early postoperative test session some test results were statistically significantly worse than the preoperative. 8 months postoperatively the mean values for all tests had improved as compared with the preoperative values. This improvement reached a statistically significant level in 6 tests. When the side of operation was considered a pattern emerged: in the 12 patients with left-sided endarterectomies improvement was significant for tests mainly related to left-hemisphere function (Word Pairs Test, Story Recall, Trail Making B, Similarities) and in the 13 patients with right-sided endarterectomies significant improvement occurred in the functions mainly related to the right hemisphere (Visual Gestalts, Block Design, Digit Span backwards). This relationship between side of operation and improvement in lateralized functions cannot be explained by retest effects.
It is concluded that TIA's and minor strokes per se may impair intellectual function, and that reversal of deterioration and even improved mental state may follow carotid endarterectomy.     

Computed tomography in patients with transient ischaemic attacks: when is a transient ischaemic attack not a transient ischaemic attack but a stroke?

Summary In a prospective community-based study, 184 patients with transient ischaemic attacks (TIAs) were identified from a study population of about 105,000 between 1981 and 1986. Computed tomography (CT) was attempted in all those with cerebral ischaemic attacks (n=152, 83%); patients with amaurosis fugax only (n=32, 27%) were not scanned routinely. Scans were obtained in 120 (79%) of those with cerebral attacks and 12 (38%) of those with amaurosis fugax. The scans were reported by a neuroradiologist who was blinded to the patients' clinical features. Of 120 (27% :95% confidence interval 19–35) scans in patients with cerebral attacks, 32 showed a focal area of hypodensity or cortical loss, but in only 14 (12% :95% confidence interval 6–18) was this in an area of the brain appropriate to the patients' symptoms. There were no significant differences in the clinical features, the duration of attacks or the prognosis (i.e, risk of death, stroke or myocardial infarction) of patients with and without ischaemic lesions on CT. It is concluded that patients with clinically definite TIAs who have a presumed ischaemic and appropriately sited lesion on CT should not be re-classified as having had a stroke.     

Recent advances in management of transient ischaemic attacks and minor ischaemic strokes

The risk of recurrent stroke during the first few days after a transient ischaemic attack or minor stroke is much higher than previously estimated. However, there is substantial variation worldwide in how patients with suspected transient ischaemic attack or minor stroke are investigated and treated in the acute phase: some health-care systems provide immediate emergency inpatient care and others provide non-emergency outpatient clinical assessment. This review considers what is known about the early prognosis after transient ischaemic attack and minor ischaemic stroke, what factors identify individuals at particularly high early risk of stroke, and what evidence there is that urgent preventive treatment is likely to be effective in reducing the early risk of stroke.     

Neuropsychological evaluation in transient ischaemic attack and minor stroke

Summary Two groups of patients with transient ischaemic attack and minor stroke without detectable haemodynamic stenotic lesions were evaluated by neuropsychological tests and compared with a control group. The mean values of the scores adjusted for age and educational background demonstrated that (a) the patients with transient ischaemic attack did not have a worse performance than normal subjects in any of the tests, (b) the patients with minor stroke had a worse performance than normals, particularly in Rey's figure-copying test (P<0.025), and (c) the latter test was not affected by educational background or age of the subjects. The results are discussed with reference to other case series, and the importance of age and cerebral damage in causing intellectual impairment evaluated by neurophysiological tests is stressed.     

Apolipoproteins as predictors of ischaemic stroke in patients with a previous transient ischaemic attack

BACKGROUND: Weak associations between total and LDL cholesterol and ischaemic stroke compared with coronary heart disease (CHD) are at odds with the similar effectiveness of statin drugs in preventing ischaemic stroke and CHD, suggesting that other lipid sub-fractions that are affected by statins might be better predictors of ischaemic stroke. Apolipoprotein B levels are reduced by statins and are a stronger predictor of CHD than total and LDL cholesterol in patients both on and off statins. However, there are very few published data on apolipoproteins and stroke risk and no studies in patients with previous transient ischaemic attack (TIA). METHODS: We performed a prospective cohort study of the associations of baseline total cholesterol, LDL, HDL, apolipoproteins A1 and B (apo A1; apo B) and risk of ischaemic stroke in 261 patients with previous TIA. Cox proportional hazards models were used to determine crude and multivariate-adjusted hazard ratios (HR) above versus below median values at 10-years follow-up. RESULTS: The apo B/apo A1 ratio was the strongest independent predictor of ischaemic stroke (HR=2.94, 95% CI 1.43-5.88, p=0.003) followed by apo B (HR=2.26, 95% CI 1.16-4.38, p=0.02). The associations between total cholesterol, LDL, HDL, LDL/HDL ratio and apo A1 and ischaemic stroke risk did not reach statistical significance. CONCLUSIONS: Apo B and the apo B/apo A1 ratio are predictive of ischaemic stroke in patients with previous TIA. Further studies are required to determine whether the prognostic value of apolipoprotein levels is maintained in patients on statins.     

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.