Low risk of vascular events following urgent treatment of transient ischaemic attack: the Aarhus TIA study

Background and purpose: Patients with TIA have a high short‐time risk of stroke and an increased long‐term risk of ischaemic vascular events compared with the general population. Urgent intervention may reduce short‐time stroke risk, but little is known about the effect beyond 3 months. We examined 1‐year outcome and risk factor management in patients with TIA after urgent intervention. Methods: All patients with TIA referred to Aarhus University Hospital 1 March 2007–28 February 2008 were seen by an acute TIA team (ATT), integrating outpatient care and stroke unit facilities. Preventive treatment was initiated immediately, including fast‐track surgery for carotid stenosis. Follow‐up including nurse‐conducted health counseling was carried out after 7, 90, and 365 days. Results: A total of 306 patients were included. Stroke, myocardial infarction, or vascular death occurred in 5.2% during 1 year of follow‐up. The cumulated stroke rate was 1.6%, 2.0%, and 4.4% after 7, 90, and 365 days, respectively, compared to expected 4.5% [relative risk (RR) 0.36, 95% CI 0.13–0.98] and 7.5% (RR 0.26, 95% CI 0.11–0.63) after 7 and 90 days using ABCD² criteria. Recurrent TIA occurred in 10.2% (n = 32). Secondary prevention targets were attained in 47.6% after 1 year. Carotid surgery was performed in 8.1%; median time to operation was 11 days after contact with the ATT. Conclusion: Urgent intervention after TIA by an ATT covering outpatient and stroke unit facilities combined with nurse‐conducted health counseling is associated with a low 1‐year risk of new vascular events and may improve risk factor control.     

A case-control study of transient global amnesia.

To evaluate risk factors and prognosis of transient global amnesia (TGA), three groups of 30 subjects each affected respectively by: (1) first-ever TGA; (2) first-ever transient ischaemic attack (TIA); (3) depressive neurosis, were compared. Prevalence of cerebrovascular risk factors was similar in patients with TGA and TIA, but significantly lower in the third group. CT showed more hypodense lesions in TIA patients than in those with TGA. In a mean follow-up of 36 months, five TGA patients experienced a TIA and three others had recurrence of TGA, but none suffered stroke or myocardial infarction. In the TIA group, four had recurrence of TIA, two suffered a stroke and two others a myocardial infarction, whereas none had TGA attacks. None of the patients of the third group had any ischaemic event during follow-up. The similar prevalence of risk factors, but the different prognosis between TGA and TIA patients, suggest that TGA is an ischaemic event, probably not triggered by thromboembolism but by a different, possibly vasospastic, mechanism.     

Etiology of late cerebrovascular events after carotid endarterectomy

Background: Progressive carotid artery disease has been shown to cause cerebrovascular events years after a patient’s carotid thromboendarterectomy (CEA). Yet, some late cerebrovascular events in CEA patients are attributable to other etiologies. Objective: We sought to determine frequency and characteristics of late cerebrovascular events in post‐CEA patients attributable to etiologies other than progressive carotid disease. Methods: In a post hoc analysis of data from a CEA‐registry with long‐term follow‐up, all patients with transient ischaemic attack (TIA) or stroke occurring >1 month post‐CEA were identified. The etiologies of these events were dichotomized into the groups large‐artery atherosclerosis (LAA) and that non‐large‐artery atherosclerosis (non‐LAA), i.e. all other etiologies (Trial of Org 10172 in Acute Stroke Trial‐criteria). Frequency and characteristics of both groups were compared. Results: Sixty of 361 post‐CEA patients (16.6%; 95%CI 12.9–20.9%) had late cerebrovascular events after 7 years (median). Thirty patients had ischaemic strokes and 30 had TIAs. These events were attributable to LAA in 48% (29/60) and to non‐LAA in 52% (31/60). In the LAA group, contralateral carotid stenosis (62%; 18/29) was more frequent than recurrent ipsilateral stenosis (38%; 11/29). Amongst non‐LAA patients, cardioembolism (29%; 9/31) and small‐artery‐occlusion (23%; 7/31) were the most frequent causes. LAA and non‐LAA patients did not differ in age, time since CEA, risk factor profile, type of event, and baseline medication. Conclusion: In post‐CEA‐patients, half of the late cerebrovascular events were attributable to etiologies other than LAA. Clinical features did not distinguish LAA‐events from non‐LAA events. Thus, stroke prevention in post‐CEA patients should not be confined to screening for progressive carotid disease but includes efforts to optimize the management of risk factor and cardiac diseases.     

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.     

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.     

Carotid stenosis as predictor of stroke after transient ischemic attacks

ABCD2 score identifies high-risk TIAs but its validity in different countries and hospitals is unknown. Doubts remain also about the role of diagnostic work up for patients with TIAs in the emergency department. The present study was undertaken to confirm the usefulness of ABCD2 score in the emergency department of Trento Hospital and to evaluate if other exams (carotid ultrasound or CT scan) commonly performed in TIA patients are helpful. We retrospectively analysed discharge diagnosis of around 120,000 patients seen at the first aid of Trento Hospital over a 28 month period. ABCD2 score, carotid ultrasound and CT scan were recorded and were correlated with recurrence of stroke at different time points (mean follow-up period of 11.4 months) in all patients with TIA. We identified 965 patients with focal neurologic deficit and 502 could be classified as TIA. An ischemic stroke recurred in 30 patients at the end of the follow-up (30% in the first two days). ABCD2 score confirmed its value. A significant carotid stenosis (>70%) was an independent risk factor for stroke at any time point. Our study confirms the role of ABCD2 in a large Italian cohort of TIA patients but also suggests the importance of performing a carotid ultrasound as soon as possible.     

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.     

In‐hospital stroke: a multi‐centre prospective registry

Background: In‐hospital strokes (IHS) are relatively frequent. Avoidable delays in neurological assessment have been demonstrated. We study the clinical characteristics, neurological care and mortality of IHS. Methods: Multi‐centre 1‐year prospective study of IHS in 13 hospitals. Demographic and clinical characteristics, admission diagnosis, quality of care, thrombolytic therapy and mortality were recorded. Results: We included 273 IHS patients [156 men; 210 ischaemic strokes (IS), 37 transient ischaemic attacks (TIA) and 26 cerebral haemorrhages]. Mean age was 72 ± 12 years. Cardiac sources of embolism were present in 138 (50.5%), withdrawal of antithrombotic drugs in 77 (28%) and active cancers in 35 (12.8%). Cardioembolic stroke was the most common subtype of IS (50%). Reasons for admission were programmed or urgent surgery in 70 (25%), cardiac diseases in 50 (18%), TIA or stroke in 30 (11%) and other medical illnesses in 71 (26%). Fifty‐two per cent of patients were evaluated by a neurologist within 3 h of stroke onset. Thirty‐three patients received treatment with tPA (15.7%). Thirty‐one patients (14.7%) could not be treated because of a delay in contacting the neurologist. During hospitalization, 50 patients (18.4%) died, 41 of them because of the stroke or its complications. Conclusions: Cardioembolic IS was the most frequent subtype of stroke. Cardiac sources of embolism, active cancers and withdrawal of antithrombotic drugs constituted special risk factors for IHS. A significant proportion of patients were treated with thrombolysis. However, delays in contacting the neurologist excluded a similar proportion of patients from treatment. IHS mortality was high, mostly because of stroke.     

The cause and prognosis of strokes in people under 50 years

A study of 192 personal cases of completed stroke, reversible ischaemic neurological deficit (RIND) or transient ischaemic attack (TIA) in patients aged 10–49 years seen between 1961 and 1979 inclusive is reported. Three died acutely; 189 were followed for up to 15 years. The main cause of the initial event was atheromatous or hypertensive vascular disease. Of the 90 patients whose initial event was a completed stroke 19 (21%) developed a second stroke, whereas only 4 of the 78 patients with TIA suffered a stroke later. In the entire series there were 6 cardiac deaths and one from mesenteric thrombosis during the follow-up period.The risk of stroke following TIA is less in persons under 50 years than in the older age group. The risk of a second stroke following an initial stroke depends on whether or not there is evidence of vascular disease. In the absence of such evidence the risk is small; in the presence of evidence it is high, being of the order of 20%.     

Cessation of embolic signals after antithrombotic prevention is related to reduced risk of recurrent arterioembolic transient ischaemic attack and stroke

OBJECTIVES: To evaluate the reduction of embolic signals after the initiation of an antithrombotic secondary prevention in patients with recent arterioembolic stroke and to determine the predictive value of decreased microembolism on the risk of early stroke recurrence. METHODS: Eighty six consecutive patients (55 men, 31 women; mean age 60.6 years) with a non-disabling arterioembolic ischaemic event in the anterior circulation within the last 30 days and a medium grade or high grade stenosis (> or =50%) of the ipsilateral carotid or middle cerebral artery underwent 1 hour transcranial Doppler monitoring as part of the admission examinations. Antithrombotic secondary prevention was started after completion of admission. Patients in whom embolic signals were detected underwent a second monitoring within 4 days (mean time 1.8 days). All patients were followed up prospectively to evaluate the relation between presence and persistence of embolic signals and the risk of recurrent transient ischaemic attack (TIA) and stroke within the next 6 weeks. RESULTS: In 44 patients, embolic signals were detected at admission, a mean 5.4 days (range 0 to 21 days) after the initial event. Twenty five were positive for embolic signals also at the second monitoring, in 19 signals had ceased. Forty two patients without embolic signals at admission served as controls. During follow up, six ischaemic events (two stroke, three TIA, one amaurosis fugax) occurred in 25 patients with persisting embolic signals but none in 19 patients in whom signals had ceased by the second monitoring. One patient in the control group had a TIA. The incidence of a recurrent event was 0.45 per 30 patient-days if embolic signals persisted compared with 0.015 if signals could not be detected or had ceased. Persistence of embolic signals was an independent predictor of a recurrent TIA or stroke (adjusted odds ratio 37.0; 95% confidence interval (95% CI) 3.5 to 333; p<0.003). Cessation and decrease of embolic signals was associated with the administration of antiplatelet agents but not with anticoagulation with intravenous heparin (p<0.001). CONCLUSIONS: Rapid cessation of embolic signals detected in patients with recently symptomatic arterial stenosis decreases increased risk of an early ischaemic recurrence. Effect of antithrombotic agents on embolic signals might serve as a marker for their efficacy on preventing stroke recurrence.     

Long‐term follow‐up of patients with asymptomatic occlusion of the internal carotid artery with good and impaired cerebral vasomotor reactivity

Background: Cerebral hemodynamic status might be prognostic for either the symptomatic or asymptomatic course of carotid occlusive disease. It is determined by evaluating cerebral vasomotor reactivity (VMR). We assessed VMR in asymptomatic patients with total occlusion of the internal carotid artery (ICA) and followed them to evaluate the role of impaired VMR in predicting ischaemic stroke (IS). Methods: Thirty‐five patients (21 men, mean age ± SD 68 ± 7.5 years) with unilateral asymptomatic ICA occlusion were studied by transcranial Doppler and the Diamox test (intravenous 1.0 g acetazolamide) and followed for 48 months or until reaching the end‐points of IS, transient ischaemic attack, or vascular death. VMR% was evaluated by recording the percent differences in peak systolic blood flow velocities in each middle cerebral artery at baseline and after Diamox administration. Results: Based on VMR% calculations, 14 (40%) patients had good VMRs and 21 (60%) had impaired VMRs. The global annual risk of ipsilateral ischaemic events was 5.7%. The annual ipsilateral ischaemic event risk was 1.8% in patients with good VMRs, whilst it was 7.1% in patients with impaired VMRs. An impaired VMR was significantly correlated with ipsilateral IS (Kaplan–Meier log rank statistic, P = 0.04). Conclusions: Our results support the value of VMR assessment for identifying asymptomatic patients with carotid occlusion who belong to a high‐risk subgroup for IS. New trials using extracranial‐to‐intracranial bypass surgery in patients with asymptomatic ICA occlusion and impaired VMRs are warranted.     

Plasma homocysteine is a risk factor for recurrent vascular events in young patients with an ischaemic stroke or TIA

Objectives Young patients with an ischaemic stroke or transient ischaemic attack (TIA) often have no vascular risk factors. Hyperhomocysteinaemia is an established risk factor for stroke in elderly patients but it is uncertain whether it is also important for the prognosis of young ischaemic stroke and TIA patients. We examined the possible effect of the plasma homocysteine level on the risk of recurrent vascular events in patients between 18 and 45 years of age. Methods The study population consisted of 161 consecutive patients with a recent cerebral infarction or TIA. Data on the primary event and the homocysteine level were collected retrospectively from hospital records. General practitioners and patients were contacted by telephone to record vascular events and the type of medication used during the follow–up period. Vascular events included cerebral infarction, TIA, pulmonary embolism, venous thrombosis, myocardial infarction and peripheral arterial disease. Results A Kaplan- Meier curve showed a dose effect relationship between event-free survival time and tertiles of the homocysteine level (Log rank statistic 5.91; p = 0.05). The Cox hazard ratio, after adjustment for homocysteine lowering treatment, was 1.7 (95 % CI, 1.1 to 2.8) for any vascular outcome event, 1.9 (95% CI, 1.1 to 3.0) for arterial outcome events and 1.8 (95 % CI, 1.1 to 2.9) for cerebral outcome events. Conclusions In spite of our small number of outcome events we found a significant association at the 95% confidence level between homocysteine level and the risk of recurrent vascular events in young patients with an ischaemic stroke or TIA. The association is of the same magnitude as in elderly people.     

Differential risks of subsequent vascular events for transient ischaemic attack and minor ischaemic stroke.

Using a prospective hospital-based registry, 146 patients with transient ischaemic attack (TIA) were compared with 376 patients with minor first-ever ischaemic stroke with respect to the 3-month risk of subsequent vascular events, in order to clarify the distinctions between the disease entities. All patients were enrolled within 48 h of onset. The risk factor distribution for the two groups was comparable, except that the TIA patients had more previous TIAs. Large artery atherosclerosis (34%) and small vessel occlusion (32%) were the main aetiologies in the TIA group, whereas small vessel occlusion (49%) was the major cause in the stroke group. The 3-month risk of combined endpoints of stroke, myocardial infarction, and vascular death for TIA patients was higher than that for the minor stroke group (15.1% vs. 3.2%; hazard ratio 4.6, 95% confidence interval 2.3-9.3 in multivariate analysis). Large artery atherosclerosis and male sex were the other significant predictors. TIA may demand more urgent management than minor stroke. The fact that aetiology is a predictor, highlights the need for rapid diagnostic tests to establish pathogenesis.     

Could platelet aggregation ratio be an indicator for differential diagnosis of transient ischemic attack and cerebral ischemic stroke?

BACKGROUND: Platelet aggregation plays an important role in the pathogenesis of thromboembolic cerebrovascular disease. Platelet aggregation ratio (PAR) and its derivates have been used successfully to identify the effectiveness of antiplatelet agents and their optimum dosage in patients suffering from stroke. However, we failed to find any study using PAR as a predictive factor in differential diagnosis of ischemic cerebrovascular diseases. In this study, we aimed to investigate PAR in patients with acute ischemic stroke and transient ischemic attack (TIA), comparing their neuroradiological features, and whether PAR values could be an indicator for differential diagnosis of TIA and cerebral ischemic stroke. METHODS: The study consisted of 75 adult patients who were admitted with suspected stroke and 25 control healthy individuals. All patients were diagnosed with acute ischemic stroke or TIA and the diagnoses were confirmed by clinical examination and computed tomography (CT). The stroke group consisted of 45, and the TIA group of 30 consecutive patients. The patients included in this study had noncardioembolic stroke. PAR values were measured on admission in all groups, according to the modified method of Wu and Hoak. The statistical significance of differences was evaluated using one-way ANOVA, the unpaired Student t test and the Bonferroni and Tamhane post hoc tests. RESULTS: Differences in PARs between the control and TIA groups, control and stroke groups and stroke and TIA groups were significant (p < 0.001). Nevertheless, in each group, differences between genders were not statistically significant. Initial CT scan demonstrated early infarction sign in 26 stroke patients (57%); however, in 19 stroke patients, it was not detected. Differences in PARs between TIA and stroke patients, whose initial CT scan findings were negative, were found to be significant. However, differences in PARs between CT negative stroke patients and positive stroke patients were not significant. CONCLUSION: We believe that the use of PAR values in the assessment of acute ischemic stroke and TIA could open up a new perspective in the management of such patients. In differential diagnosis, PAR values have to combine with neurological examination and CT scan signs. The current test is not able to differentiate vascular occlusive diseases in other organs from vascular occlusive problems in the brain. Further study is needed to determine the sensitivity and specificity of this test in all patients and to confirm the prognostic value in stroke patients.     

Prognosis in patients with transient ischaemic attacks and minor stroke associated with a normal angiogram

61 patients with a transient ischaemic attack (TIA) or minor stroke and a normal angiogram and with no other explanation for the ischaemic event were followed up for a mean period of 6.3 years. Of 19 patients with a TIA 5 suffered further TIAs, and 1 of the 5 also an ischaemic stroke. 3 of 42 patients with a minor stroke had a new ischaemic stroke, in 1 case preceded by a TIA. In 2 stroke patients the lesion affected a new arterial region. 3 patients died of cerebral haematoma, in 1 preceded by an ischaemic stroke. 4 patients suffered myocardial infarction, and 1 of these died. The overall incidence of recurrent cerebral and cardiovascular symptoms was 23% (14 of 61 patients). The mean age was significantly higher (p less than 0.01) in patients with recurrent cerebral and cardiovascular lesions. No correlation emerged between risk factors. Patients with a TIA or minor stroke and a normal angiogram and with no other known source of embolism have a better prognosis than patients with a known source of embolism. However, elderly patients in particular run an increased risk of cardiac and cerebral vascular incidents.     

Transient ischaemic attacks in young patients: a thromboembolic or migrainous manifestation? A 10 year follow up study of 46 patients.

Forty six patients aged 18-39 years with transient ischaemic attacks (TIA) were studied; two thirds were women. Twenty five patients had attacks accompanied by headache, and seven gave a history of common migraine. Only four of 27 angiograms were abnormal; no operable carotid lesion was demonstrated. Over a mean follow up period of 10 years stroke or myocardial infarction (AMI) occurred in all four patients who presented major cerebrovascular risk factors, but in only two of the remaining 42 patients. Thus irrespective of age thromboembolic TIA is a harbinger of stroke or AMI. However, most TIAs under the age of 40 years are caused by a non-embolic benign vascular disorder. The clinical characteristics, long-term prognosis, and possible pathogenesis, for such attacks are often indistinguishable from those of classical migraine. In the absence of cardiovascular risk factors, arteriography does not provide much diagnostic and prognostic information.     

Mycoplasma pneumoniae in elderly patients with stroke. a case-control study on the seroprevalence of M. pneumoniae in elderly patients with acute cerebrovascular disease - the M-PEPS Study

BACKGROUND AND PURPOSE: Previous studies have suggested certain infections as potential risk factors for stroke. Chlamydia pneumoniae, an atypical respiratory pathogen, has been linked to atherosclerotic vascular diseases. Mycoplasma pneumoniae, another atypical respiratory micro-organism, can rarely cause stroke. We investigated whether serological markers of M. pneumoniae infection were associated with acute stroke or transient ischaemic attack (TIA) in elderly patients. METHODS: This case-control study was nested within the C-PEPS study - a case-control study on the seroprevalence of C. pneumoniae in elderly stroke and medical patients. Ninety-five incident cases of patients admitted consecutively with acute stroke or TIA, and 82 control subjects admitted concurrently with acute non-cardiopulmonary, non-infective disorders, were included in this study (both groups aged 65 years or older). Using commercial enzyme-linked immunosorbent assay (ELISA) kits, the presence of M. pneumoniae immunoglobulins IgA, IgG and IgM in patients' sera was determined. RESULTS: The seroprevalence of M. pneumoniae IgA, IgG and IgM in the stroke or TIA group (median age = 80) were 79, 61 and 6%, respectively. In the control group (median age = 80), the seroprevalence of respective M. pneumoniae IgA, IgG and IgM were 84, 50 and 11%. Using a logistic regression statistical model, adjusting for history of hypertension, smoking, diabetes mellitus, age and sex, history of ischaemic heart disease, and ischaemic electrocardiogram, the odds ratios of having a stroke or TIA in relation to M. pneumoniae IgA, IgG and IgM were 0.63 (95% confidence interval (CI) = 0.26-1.52, p = 0.31), 1.32 (95% CI = 0.66-2.64, p = 0.43) and 0.52 (95% CI = 0.14-1.92, p = 0.32), respectively. CONCLUSIONS: The study showed a high seroprevalence of M. pneumoniae in an elderly hospital population, using ELISA. Although the study ruled out M. pneumoniae seropositivity as a major risk factor for stroke in this elderly population, a smaller effect could not be excluded due to the small sample size. Future larger studies may be required to determine the precise role of M. pneumoniae infection in the pathogenesis of different subtypes of ischaemic stroke, in all age groups, and in different ethnic populations.     

Intracranial Artery Calcium Burden Predicts Recurrent Cerebrovascular Events in Transient Ischaemic Attack Patients

Background: Patients with initial transient ischaemic attack (TIA) subsequently have a higher risk of recurrent TIA or acute ischemic stroke (AIS). The role of scoring intracranial arterial calcification (IAC) in predicting the prevalence of stroke remains unclear. We aim to evaluate if radiological CT calcium score measuring IAC burden could predict future ischemic events in a cohort of TIA patients. Methods: We studied consecutive patients from July 2014 to December 2015 who presented with first episode of TIA. All patients had noncontrasted CT or CT-angiogram of the brain on admission. CT calcium score (cm3) was quantified by measuring calcium deposition in the bilateral internal carotid arteries, middle cerebral arteries, and vertebrobasilar system. Patients were followed up for 2 years and ischemic events for either recurrent TIA or AIS were recorded. We compared patients in terms of clinical profile at presentation and CT calcium score using appropriate univariate and multivariable analyses. Results: Of 156 TIA patients studied, 22% (n = 35) had recurrent TIA or AIS within 2 years of follow-up. On univariate analyses, recurrent TIA/AIS was associated with gender (OR 0.61; 95%CI 0.40-0.95; P = .038), hypertension (mean difference 2.49; 95%CI 1.08-5.75; P = .030) and higher CT calcium score (mean difference 0.84 95%CI 0.16-1.52 P = .016). On multivariable logistic regression, a higher CT calcium score was significantly associated with recurrent TIA/AIS (adjusted OR 1.25 95%CI 1.01-1.55 P = .042). Conclusions: In TIA patients, higher IAC burden by measurement of a quantitative CT calcium score may be associated with recurrent ischemic events.     

Epidemiología y características del ictus isquémico en el adulto joven en Aragón

IntroductionStroke affects around 15 million people per year, with 10%-15% occurring in individuals under 50 years old (stroke in young adults). The prevalence of different vascular risk factors and healthcare strategies for stroke management vary worldwide, making the epidemiology and specific characteristics of stroke in each region an important area of research.This study aimed to determine the prevalence of different vascular risk factors and the aetiology and characteristics of ischaemic stroke in young adults in the autonomous community of Aragon, Spain.MethodsA cross-sectional, multi-centre study was conducted by the neurology departments of all hospitals in the Aragonese Health Service. We identified all patients aged between 18 and 50 years who were admitted to any of these hospitals with a diagnosis of ischaemic stroke or TIA between January 2005 and December 2015. Data were collected on demographic variables, vascular risk factors, and type of stroke, among other variables.ResultsDuring the study period, 786 patients between 18 and 50 years old were admitted with a diagnosis of ischaemic stroke or TIA to any hospital of Aragon, at a mean annual rate of 12.3 per 100 000 population. The median age was 45 years (IQR: 40-48 years). The most prevalent vascular risk factor was tobacco use, in 404 patients (51.4%). The majority of strokes were of undetermined cause (36.2%), followed by other causes (26.5%). The median NIHSS score was 3.5 (IQR: 2.0-7.0). In total, 211 patients (26.8%) presented TIA. Fifty-nine per cent of the patients admitted with a diagnosis of ischaemic stroke (10.3%) were treated with fibrinolysis.ConclusionsIschaemic stroke in young adults is not uncommon in Aragon, and is of undetermined aetiology in a considerable number of cases; it is therefore necessary to implement measures to improve study of the condition, to reduce its incidence, and to prevent its recurrence.     

Clustering of risk factors increases the incidence of echolucent carotid plaque in stroke patients

BACKGROUND: The purpose of this study was to assess the influence of clusters of risk factors on the incidence of echolucent carotid plaque in stroke patients. METHODS: A retrospective analysis of 413 stroke patients who had undergone carotid ultrasonography was performed. High-resolution B-mode ultrasonography was used to evaluate the characteristics of carotid plaque. We investigated the relationships between the incidence of echolucent carotid plaque and clustering of risk factors (hypertension, diabetes mellitus and hyperlipidemia) and stroke subtypes and transient ischemic attack (TIA). RESULTS: Echolucent plaques were present in 10.5% of patients free of risk factors, in 18.8% with a single risk factor (NS), in 27.7% with two risk factors (p <0.01) and in 50.0% with three risk factors (p <0.001), and were significantly more common in patients with multiple risk factors (odds ratio 1.79; 95% CI, 1.05-3.06; p = 0.045). Echolucent plaques were observed in 41.2% of patients with atherothrombotic infarction, in 17.6% with lacunar infarction, in 11.5% with cardioembolic stroke, and in 25.0% with TIA, and were significantly more common in patients with atherothrombotic infarction than in those with lacunar infarction or cardioembolic stroke (p<0.001), or in those with TIA (p <0.05). CONCLUSIONS: The clustering of risk factors increased the incidence of echolucent carotid plaque. Patients with multiple risk factors were at increased risk of echolucent plaque, and these had a significant relationship with atherothrombotic infarction compared with other stroke subtypes and TIA.