Diffusion‐weighted imaging in transient neurological attacks

Transient ischemic attack (TIA) can be difficult to diagnose. Episodes of acute atypical or nonfocal neurological symptoms, referred to as transient neurological attack (TNA), are as prevalent as TIAs. Diffusion‐weighted imaging (DWI) provides evidence of acute cerebral ischemia in a third of TIA patients. We now report that DWI shows acute ischemia in 23% of patients clinically diagnosed as TNA by experienced stroke neurologists. This questions the accuracy of clinically diagnosing TIA and suggests added value for early magnetic resonance imaging after an episode of acute onset atypical or nonfocal neurological symptoms. Ann Neurol 2015;78:1005–1010     

The neuroprotection of prodromal transient ischaemic attack on cerebral infarction

Background and purpose:  To evaluate the potential neuroprotection against subsequent cerebral infarction conferred by a prodromal transient ischaemic attack (TIA).
Methods:  Various measures, including blood pressure, blood serum glucose, serum lipids, cardiovascular imaging and changes to NIHSS scores were evaluated upon admission and discharge for patients presenting with ischaemic stroke with or without prodromal TIA ( n  = 60 per group).
Results:  When all patients from each group were considered together, no significant group effects emerged. However, when the NIHSS difference scores from the prodromal TIA group were subdivided based on (i) prodromal TIA lasting up to 4 min; (ii) two prodromal TIA attacks and/or; (iii) prodromal TIA-stroke interval within 7 days separately, patients in subgroups 1 and 2 exhibited significantly better outcome on discharge. There was no significant effect found in subgroup three although this TIA group did show better outcome in considering the NIHSS changes.
Conclusions:  Prodromal TIA prior to cerebral infarction may result in an ischaemic tolerance effect. Moreover, the neuroprotection conferred by the TIA may be associated with the duration and the frequency of the TIA, although the relationship between the TIA-stroke interval and prognosis is not clear.     

Patterns of diffusion‐weighted magnetic resonance imaging associated with etiology improve the accuracy of prognosis after transient ischaemic attack

Objective: Diffusion‐weighted magnetic resonance imaging (DWI) is a sensitive diagnostic tool for detecting acute ischaemic lesions in patients with transient ischaemic attacks (TIAs). The additional predictive value of DWI lesion patterns is not well known. Methods: Two hundred and fifty‐four consecutive patients with TIA underwent DWI within 7 days of symptom onset. The presence and pattern of acute ischaemic lesions were related to clinical features, etiology, and stroke recurrence at seven‐ and 90‐day follow‐up. Results: Diffusion‐weighted images abnormalities were identified in 117 (46.1%) patients. The distribution of DWI lesions was cortical, 31; subcortical, 32; scattered lesions in one arterial territory (SPOT) 42; and in multiple areas, 12. SPOT were significantly associated with motor weakness, large‐artery atherosclerosis (LAA), and the cardioembolic subtype of TIA. Single cortical lesions were also associated with cardioembolism, whereas subcortical acute lesions were associated with recurrent episodes, dysarthria, and motor weakness. During follow‐up, seven patients had a stroke within 7 days (2.8%, 95% CI 2.9–6.4%), and 12 had a stroke within 3 months (4.7%%, 95% CI 2.9–6.4%). In the Cox logistic regression model, the combination of LAA and positive DWI remained as independent predictors of stroke recurrence at 90‐day follow‐up (HR 5.78, 95 CI 1.74–19.21, P = 0.004). Conclusion: According to our results, MRI, including DWI, should be considered a preferred diagnostic test when investigating patients with potential TIAs. The combination of neuroimaging and vascular information could improve prognostic accuracy in patients with TIA.     

Pre-existing White Matter Hyperintensity Lesion Burden and Diagnostic Certainty of Transient Ischemic Attack

Goals: There are no validated biomarkers that allow for reliable distinction between TIA and other transient neurological symptoms that mimic TIA. We sought to determine whether the degree of pre-existing white matter hyperintensity (WMH) lesion burden relates to the diagnostic certainty of TIA in a cohort of patients presenting with transient neurological symptoms. Materials and Methods: We retrospectively analyzed 144 consecutive patients with available brain MRI to quantify and normalize the WMH volume for brain atrophy (adjusted white matter hyperintensity [aWMHV]). We first stratified subjects to probable (n?=?62) versus possible (n?=?82) TIA as per existing guidelines. Receiver-operating characteristic curves were used to determine a critical aWMHV-threshold (7.8 mL) that best differentiated probable from possible TIA. We then further stratified patients with possible TIA to likely (n?=?52) versus unlikely (n?=?30) TIA after independent chart review and adjudication. Finally, multivariable logistic and multinomial regression was used to determine whether the defined aWMHV independently related to probable and likely TIA after adjustment for pertinent confounders. Findings: With the exception of age (P < .001) and use of antiplatelets (P?=?.017), baseline characteristics were similar between patients with probable, likely, and unlikely TIA. In the fully adjusted multinomial model, the aWMHV cut-off greater than 7.8 mL (odds ratio 3.8, 95% confidence interval 1.3-10.9, P?=?.012) was significantly more frequent in patients with a probable TIA as compared to those with an unlikely TIA diagnosis. Conclusions: We provide proof-of-principle that WMH may serve as a neuroimaging marker of diagnostic certainty of TIA after neurological workup has been completed.     

Comparative study of pentoxifylline vs antiaggregants in patients with transient ischaemic attacks

Abstract– Out of 235 patients with recent cerebral transient ischaemic attacks, 208 subjects were available for final evaluation after 6 months'randomised treatment with either pentoxifylline (PTX 1200 mg/day) or a combination (ASAD) of acetylsalicylic acid (ASA, 1050 mg/day) and dipyridamole (D, 150 mg/day). Prevention of TIA, stroke or death attributable to previous events were endpoint criteria. The pentoxifylline group ( n = 100) exhibited no recurrent episodes in 86 patients (86%). TIA occurred in 9 patients, stroke in 5 patients and there was 1 death. In the ASAD group ( n = 108) no recurrence of ischaemic episodes was recorded in 82 cases (75.9%). TIA occurred in 20 patients, stroke in 6 patients and there were 3 deaths of vascular origin. Side effects were recorded in 4 ASAD and 1 PTX patients. The total rate of recurrence was 14% with PTX as compared to 24.1% with ASAD treatment.     

Cranial CT scan in transient global amnesia

The occurrence of cerebral infarction in patients with transient global amnesia (n = 43) was evaluated by CT scan and compared to that of patients with transient ischemic attacks (TIA) (n = 58) and with no neurological disease (n = 52). Significant differences were demonstrated between TGA and TIA patients in relation to the control group, but no differences were found between patients with TGA and TIA. Our study suggests a vascular mechanism for TGA and that TGA could be considered a low risk TIA in most cases.     

Optimizing the risk estimation after a transient ischaemic attack – the ABCDE⊕ score

Background and purpose: The risk of stroke after a transient ischaemic attack (TIA) can be predicted by scores incorporating age, blood pressure, clinical features, duration (ABCD‐score), and diabetes (ABCD2‐score). However, some patients have strokes despite a low predicted risk according to these scores. We designed the ABCDE+ score by adding the variables ‘etiology’ and ischaemic lesion visible on diffusion‐weighted imaging (DWI) –‘DWI‐positivity’– to the ABCD‐score. We hypothesized that this refinement increases the predictability of recurrent ischaemic events. Methods: We performed a prospective cohort study amongst all consecutive TIA patients in a university hospital emergency department. Area under the computed receiver‐operating curves (AUCs) were used to compare the predictive values of the scores with regard to the outcome stroke or recurrent TIA within 90 days. Results: Amongst 248 patients, 33 (13.3%, 95%‐CI 9.3–18.2%) had a stroke (n = 13) or a recurrent TIA (n = 20). Patients with recurrent ischaemic events more often had large‐artery atherosclerosis as the cause for TIA (46% vs. 14%, P < 0.001) and positive DWI (61% vs. 35%; P = 0.01) compared with patients without recurrent events. Patients with and those without events did not differ with regard to age, clinical symptoms, duration, blood pressure, risk factors, and stroke preventive treatment. The comparison of AUCs [95%CI] showed superiority of the ABCDE+ score (0.67[0.55–0.75]) compared to the ABCD²‐score (0.48[0.37–0.58]; P = 0.04) and a trend toward superiority compared to the ABCD‐score (0.50[0.40–0.61]; P = 0.07). Conclusion: In TIA patients, the addition of the variables ‘etiology’ and ‘DWI‐positivity’ to the ABCD‐score seems to enhance the predictability of subsequent cerebral ischaemic events.     

Significance of microbleeds in patients with transient ischaemic attack

Background and purpose: The aim of this study was to determine the prognostic significance of microbleeds in TIA‐patients. In patients with a transient ischaemic attack (TIA), the prognostic value of microbleeds is unknown. Methods: In 176 consecutive TIA patients, the number, size, and location of microbleeds with or without acute ischaemic lesions were assessed. We compared microbleed‐positive and microbleed‐negative patients with regard to the end‐point stroke within 3 months. Results: Four of the seven patients with subsequent stroke had microbleeds. Microbleed‐positive patients had a higher risk for stroke [odds ratios (OR) 8.91, 95% CI 1.87–42.51, P < 0.01] than those without microbleeds. Microbleed‐positive patients with accompanying acute ischaemic lesions had a higher stroke risk than those with neither an acute ischaemia nor a microbleed (OR 6.20, 95% CI 1.10–35.12; P = 0.04). Conclusion: Microbleeds alone or in combination with acute ischaemic lesions may increase the risk for subsequent ischaemic stroke after TIA within 3 months.     

Computed tomography in reversible ischaemic attacks: clinical and prognostic correlations in a prospective study

Summary Two hundred and nineteen patients admitted with reversible atherothrombotic ischaemic attacks were prospectively evaluated by computed tomography. Of these patients, 122 were diagnosed as suffering from transient ischaemic attacks, 58 from reversible ischaemic neurological deficits and 39 from reversible ischaemic neurological deficits with incomplete resolution. In 133 cases the ischaemic event affected the carotid system, in 63 the vertebrobasilar system and in 23 cases the system could not be determined. Brain infarctions were observed in 64 patients (29.2%), cerebral atrophy in 96 (44.4%) and dilatation of a ventricle in 17 (7.8%). The frequency of brain infarction was related to the duration of the neurological deficit, being 20.5% in those with transient ischaemic attacks, 37.9% in those with reversible ischaemic neurological deficits and 43.6% in patients with reversible ischaemic neurological deficits with incomplete resolution (P=0.005). Ischaemic lesions were closely correlated with abnormalities on supra-aortic trunk angiography or Doppler ultrasonography. During an average follow-up period of 21 months, a higher percentage of recurrence was found in those patients with CT infarctions, but the difference was not significant.     

Clinical and cerebral angiographic evolutions of idiopathic progressive occlusive disease of the circle of Willis ("moyamoya" disease) in children

In 33 pediatric cases of idiopathic progressive occlusive disease of the circle of Willis (so-called moyamoya disease), clinical features and CAG findings were studied with emphasis on their evolutionary aspects. The subjects were clinically classified as follows; 23 cases of pure transient ischemic attacks (TIA), one presenting purely with infarct, one mixed TIA and epileptic, two mixed TIA + infarct, and 6 mixed epileptic and infarct. The core symptom of the TIA type is a recurrent unilateral or alternating unilateral paresis persisting for minutes or hours. Frequently hyperpnea provoked a TIA. Follow-up observation of the TIA type patients for an average of 6 yrs 11 mos shows that about half the subjects became completely free of symptoms and the other half mostly improved considerably. In contrast, all patients not presenting purely with TIA ("non-TIA" type) still had persistent neurological deficits after a mean interval of 6 yrs 4 mos from the onset. The CAG findings in most cases belonged to stage III according to Suzuki's classification. Therefore the authors subdivided stage III into 3 substages, IIIa, IIIb and IIIc. The longer the duration of the disease up to the CAG examination, the more advanced was the CAG stage. Repeat CAGs examined after a mean interval of 2 yrs 11 mos demonstrated the same stage in 32%, and progress by one or two stages in 55% and 14% of the sides examined, respectively.     

Comparison between induced platelet aggregation and circulating platelet aggregates as platelet function tests in patients with transient ischemic attacks

Routine blood analysis, platelet counts, number of circulating platelet aggregates (CPA) and platelet aggregation in vitro against adenosine-diphosphate (ADP), epinephrine and collagene were studied in 45 healthy controls, in 10 hospitalized patients with other neurological diseases than stroke and in 12 patients with transient ischemic attacks (TIA) before and after prophylactive treatment with anticoagulants (AC) or anti-platelet drugs (APD).
Except for lower hemoglobin and hematocrit levels in women, sex, smoking, oral contraceptives or pregnancy did not significantly influence the routine blood parameter. Smoking females taking oral contraceptives had an increased number of CPA and the most easily induced aggregation in vitro .
Patients with TIA had no significant differences in blood or platelet findings versus the healthy controls (except smoking females on oral contraceptives) or the non-stroke patients, even though individual patients could have high numbers of CPA and an easily induced platelet aggregation in vitro . Treatment with AC did not influence platelet function, whereas APD therapy decreased the number of CPA and inhibited the secondary platelet aggregation in vitro .     

No evidence that severity of stroke in internal carotid occlusion is related to collateral arteries

Background/Aim

The neurological effects of internal carotid artery (ICA) occlusion vary between patients. The authors investigated whether the severity of symptoms in a large group of patients with ipsilateral or/and contralateral ICA occlusion at presentation with ocular or cerebral ischaemic symptoms could be explained by patency of other extra or intracranial arteries to act as collateral pathways.

Methods

The authors prospectively identified all patients (n = 2881) with stroke, cerebral transient ischaemic attack (TIA), retinal artery occlusion (RAO), and amaurosis fugax (AFx) presenting to our hospital over five years, obtained detailed history and examination, and examined the intra and extracranial arteries with carotid and colour‐power transcranial Doppler ultrasound. For this analysis, all those with intracranial haemorrhage on brain imaging and cerebral events without brain imaging were excluded.

Results

Among 2228/2397 patients with brain imaging (1713 ischaemic strokes, 401 cerebral TIAs, 193 AFx, and 90 RAO) who underwent carotid Doppler, 195 (9%) had ICA occlusion. Among those patients with cortical events, disease in potential collateral arteries (contralateral ICA, external carotid, ipsilateral or contralateral vertebral or intracranial arteries) was equally distributed among patients with severe and mild ischaemic presenting symptoms.

Conclusion

The authors found no evidence that the clinical presentation associated with an ICA occlusion was related to patency of other extra or intracranial arteries to act as collateral pathways. Further work is required to investigate what determines the clinical effects of ICA occlusion.     

Ventriculomegaly and balance disturbances in patients with TIA

Israelsson H, Birgander R, Ambarki K, Eklund A, Malm J. Ventriculomegaly and balance disturbances in patients with TIA.
Acta Neurol Scand: 2012: 125: 163–170.
© 2011 John Wiley & Sons A/S. Objectives – Dilated ventricles and gait disturbances are common in the elderly, and these are also features of the treatable syndrome idiopathic normal pressure hydrocephalus (INPH). Many studies report an association between hypertension, vascular disease and INPH. The objective of this study was to study the frequency of ventriculomegaly, with or without hydrocephalic symptoms, in patients who had suffered from a transitory ischaemic attack (TIA). Methods – Gait, Romberg sign, tandem standing and one‐leg stance were consecutively evaluated in elderly >24 h after a TIA. Ventricular size, white matter lesions and atrophy were assessed on computed tomography scans. Exclusion criteria were conditions possibly influencing the balance tests. Results – Seventy‐six patients with TIA out of 105 were included. Ventriculomegaly [Evans Index (EI) > 0.30] was observed in 19.7% and very large ventricles (EI > 0.33) in 7.9%. Ventriculomegaly was found in 58% of the patients with a previous ‘history of balance or gait disturbance’, but only in 12% of those without any prior disturbance (chi‐square test; P = 0.0009). Three out of 76 patients with TIA (3.9%) fulfilled both radiological and clinical criteria for ‘possible INPH’. Conclusion – Ventriculomegaly is a common finding in elderly. One out of 20 patients with TIA may suffer from INPH, existing before and independent of the TIA diagnosis. Therefore, patients presenting with ventriculomegaly and gait/balance disturbances not attributable to other causes should be referred to a hydrocephalus centre or a neurologist with special interest in INPH.     

低血糖脑病和短暂性脑缺血发作的临床和影像特征分析

目的探讨低血糖脑病(HE)和短暂性脑缺血发作(TIA)的临床和影像特征。方法比较HE组(29例)和TIA组(43例)的临床症状、生化和影像学结果。结果 HE组在半球神经功能损害症状包括意识障碍(69.0%)和反应迟钝(24.1%)高于TIA组(27.9%和16.3%)。TIA组局灶神经功能缺损症状包括肢体无力(62.8%)和感觉障碍(69.7%)高于HE组(24.1%和13.8%)。HE组糖化血红蛋白、总胆固醇和低密度脂蛋白较TIA组高,差异有统计学意义(P0.05或P0.01)。HE组颈动脉内膜增厚、轻度狭窄和中度狭窄比例较TIA组高;HE组内-中膜厚度和斑块总积分较TIA组高,差异有统计学意义(P0.05)。头颅CT血管造影显示HE组较TIA组血管狭窄受累多(82.8%vs.51.2%);中度狭窄(24.1%vs.14.0%)、重度狭窄(17.2%vs.7.0%)和闭塞(13.8%vs.7.0%)比例高;累及2支血管(24.1%vs.11.6%)和3支以上血管(24.1%vs.11.6%)比例高,差异有统计学意义(P0.05或P0.01)。结论HE以半球神经功能损害为主,TIA以局灶神经功能缺损为主,HE患者代谢紊乱更严重,颅内血管狭窄受累多,中度、重度狭窄和闭塞比例高。     

Chronic subdural hematoma and transient neurologic deficits

Three cases of chronic subdural hematoma (CSDH) revealed by transient neurological accidents are reported. Although well-known this condition is rare: 1 to 9 p. 100 of CSDHs. Questioning may bring out a history of cranial injury and headache, even minor ones, which are unusual in transient ischemic accidents (TIA). Transient phenomena, such as motor aphasia or speech interruption, point to the diagnosis, especially in male patients over 60 years of age. The finding at electroencephalography of a delta activity more than 48 hours after a TND should exclude the diagnosis of TIA until a CT scan is performed. Since the causes of neurological deficits regressing within less than 24 hours may be ischemia as well a hemorrhage or tumour, the term of transient neurological accident (TNA) should preferably be used, and an emergency CT scan should be performed for diagnostic and therapeutic purposes. Owing to the possibility of another concomitant cause of TNA, the finding of a subdural haematoma should not deter from pursuing cardiovascular examinations. The mechanism of TNA probably involves a vascular factor, as suggested by I-123 IMP cerebral SPECT which shows an intercritical decrease in cerebral blood flow and/or an epileptic factor.     

Plasma brain natriuretic peptide predicts death during hospitalization in acute ischaemic stroke and transient ischaemic attack patients with atrial fibrillation

Background and purpose: Atrial fibrillation (AF) is the most powerful predictor of early death in patients with acute ischaemic stroke. We investigated whether the plasma brain natriuretic peptide (BNP) level on admission can serve as a biological marker of in‐hospital death in acute ischaemic stroke and transient ischaemic attack (TIA) patients with AF. Methods: We prospectively enrolled ischaemic stroke and TIA patients with AF within 24 h of onset and measured plasma BNP on admission. Patients were divided into two groups: the deceased group, who died during hospitalization, and the survival group. The factors associated with in‐hospital death were investigated by multivariate logistic regression analysis. Results: A total of 221 patients with AF were enrolled. Death occurred in 24 (10.9%) patients. The mean ± SD of the plasma BNP level of the deceased group was significantly higher than that of the survival group (714.1 ± 716.3 vs. 320.0 ± 380.7 pg/ml, P < 0.0001). The optimal cutoff level, sensitivity, and specificity of BNP levels to distinguish the deceased group from the survival group were 320 pg/ml, 79.2, and 69.0%, respectively. Multivariate logistic regression analysis demonstrated that age per 10 years increase (OR, 3.56; 95% CI, 1.728–7.346, P = 0.0006), internal carotid artery occlusion (OR, 10.20; 95% CI, 2.525–41.177, P = 0.0011), NIHSS score of >17 (OR, 4.68; 95% CI, 1.137–19.286, P = 0.0325), and plasma BNP level of >320 pg/ml (OR, 4.74; 95% CI, 1.260–17.800, P = 0.0213) were independent factors associated with in‐hospital death. Conclusion: The plasma BNP level on admission can predict in‐hospital death in acute ischaemic stroke and TIA patients with AF.     

Clinical features, risk factors, and prognosis in transient global amnesia: a follow-up study

We previously observed a high frequency of psychopathological features in transient global amnesia (TGA). We aimed at assessing differences in risk factor profile and prognosis between TGA and transient ischemic attack (TIA) patients with a focus on aspects with possible psychopathological relevance. We studied 51 TGA patients (mean age +/- SD, 62.7 +/- 6.7 years; M/F = 24/27) and 51 control patients with TIA (mean age +/- SD, 63.8 +/- 6.7 years; M/F = 41/10) and followed them up for about 7 years. Compared with TIA controls, TGA patients more frequently had a history of psychiatric diseases (age and sex-corrected OR = 2.86, 95% CI: 1.01-8.05) and alcohol use (OR = 3.26, 95% CI: 1.10-9.66) and less frequently a history of cardiac (OR = 0.29, 95% CI: 0.11-0.76) or peripheral artery disease (OR = 0.11, 95% CI: 0.01-0.96). A family history of psychiatric diseases was reported more frequently by TGA than TIA patients (OR = 2.99, 95% CI: 1.04-8.59). On follow-up, in comparison with TIA patients, TGA patients had a significantly lower risk of combined stroke, myocardial infarct, and death (log-rank test, P = 0.0059). In the multivariate analysis, the dissimilar baseline risk factor profile explained most of the difference in prognosis between the two groups. In comparison with TIA patients, patients with TGA have more frequently a personal or family history of psychiatric diseases and a more favorable vascular risk factor profile and prognosis. These results have therapeutic implications and reinforce the hypothesis that TGA is a benign disorder.     

Transient ischaemic attack: a common initial manifestation of cardiac myxomas

BACKGROUND AND AIMS: Cardiac myxomas may present clinically with many different features. Since highly effective treatments exist, it is important that they are diagnosed quickly in order to avoid further complications. Our aim was to determine the influence of neurological presentation in diagnosis and prognosis of cardiac myxomas. METHODS: We have reviewed the clinical charts of 28 patients diagnosed with cardiac myxomas seen at our centre in the last 20 years. RESULTS: Mean age at diagnosis in patients with neurological events was 49.22 years and 60.84 years in those without neurological manifestations (p = 0.0325). Most frequent presentations were: cardiac manifestations (92.8%), general manifestations (71.4%) and embolic events (39.3%). Nine patients (32.1%) presented with cerebral embolism; 7 of whom presented with transient ischaemic attacks (TIA), which was the first manifestation in 6 of them; 3 of them later suffered complete cerebral infarction with sequelae. Echocardiography confirmed diagnosis in 26 out of 27 patients in which it was performed. None of the patients presented neurological symptoms after surgery. CONCLUSION: The most frequent initial neurological manifestation in our series was TIA. Nevertheless, none of the patients were diagnosed after the first neurological symptom. Although the contribution of cardiac myxomas to the total amount of TIA is low, since surgery is highly effective and of low risk, and patients with neurological manifestations are younger, it is vital to consider the possibility of cardiac myxoma after a TIA of unknown origin.     

Transient global amnesia as a manifestation of transient cerebral ischemia

Ten patients with transient global amnesia (TGA) associated with symptoms of transient focal cerebral ischemia were seen at the University Department of Neurology, Århus Kommunehospital in the period 1966–1978. All had either prior to or following the amnesic attack transient ischemic attacks (TIA) in the territory of the posterior cerebral circulation. On admission minor neurological deficits were noted in three and normal findings in the remaining seven. There was no evidence of epilepsy in any case.
We studied the course (average, 77 months) and found that three had recurrent amnesic episodes. Four patients had only further transient focal cerebral ischemic attacks, while six developed a completed stroke, in five located in the distribution of the basilar artery. Seven patients had persistent memory impairment.
TGA is one manifestation of TIA in the vertebrobasilar arterial system.
When TGA appears in connection with other transient cerebral ischemic attacks, the prognosis is apparently grave with a great risk of a subsequent completed stroke or a permanent memory impairment.