1
|
Giles MF, Rothwell PM. Prognosis and Management in the First Few Days after a Transient Ischemic Attack or Minor Ischaemic Stroke. Int J Stroke 2016; 1:65-73. [DOI: 10.1111/j.1747-4949.2006.00013.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The risk of recurrent stroke during the first few days after a transient ischaemic attack (TIA) or minor stroke is very much higher than previously estimated. However, there is considerable international variation in how patients with suspected TIA or minor stroke are managed in the acute phase, some healthcare systems providing immediate emergency inpatient care and others providing non-emergency outpatient clinic assessment. This review considers what is known about the early prognosis after TIA 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.
Collapse
Affiliation(s)
- Matthew F. Giles
- Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Woodstock Road, Oxford OX2 6HE, UK
| | - Peter M. Rothwell
- Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Woodstock Road, Oxford OX2 6HE, UK
| |
Collapse
|
2
|
Malek AM, Adams RJ, Debenham E, Boan AD, Kazley AS, Hyacinth HI, Voeks JH, Lackland DT. Patient awareness and perception of stroke symptoms and the use of 911. J Stroke Cerebrovasc Dis 2014; 23:2362-71. [PMID: 25213451 DOI: 10.1016/j.jstrokecerebrovasdis.2014.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/29/2014] [Accepted: 05/09/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Response to stroke symptoms and the use of 911 can vary by race/ethnicity. The quickness with which a patient responds to such symptoms has implications for the outcome and treatment. We sought to examine a sample of patients receiving a Remote Evaluation of Acute isCHemic stroke (REACH) telestroke consult in South Carolina regarding their awareness and perception of stroke symptoms related to the use of 911 and to assess possible racial/ethnic disparities. METHODS As of September 2013, 2325 REACH telestroke consults were conducted in 13 centers throughout South Carolina. Telephone surveys assessing use of 911 were administered from March 2012-January 2013 among 197 patients receiving REACH consults. Univariate and multivariate logistic regression was performed to assess factors associated with use of 911. RESULTS Most participants (73%) were Caucasian (27% were African-American) and male (54%). The mean age was 66 ± 14.3 years. Factors associated with use of 911 included National Institutes of Health Stroke Scale scores >4 (odds ratio [OR], 5.4; 95% confidence interval [CI], 2.63-11.25), unknown insurance which includes self-pay or not charged (OR, 2.90; 95% CI, 1.15-7.28), and perception of stroke-like symptoms as an emergency (OR, 4.58; 95% CI, 1.65-12.67). African-Americans were significantly more likely than Caucasians to call 911 (62% vs. 43%, P = .02). CONCLUSIONS African-Americans used 911 at a significantly higher rate. Use of 911 may be related to access to transportation, lack of insurance, or proximity to the hospital although this information was not available. Interventions are needed to improve patient arrival times to telemedicine equipped emergency departments after stroke.
Collapse
Affiliation(s)
- Angela M Malek
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina.
| | - Robert J Adams
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Ellen Debenham
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Andrea D Boan
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Abby S Kazley
- Department of Healthcare Leadership & Management, Medical University of South Carolina, Charleston, South Carolina
| | - Hyacinth I Hyacinth
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Jenifer H Voeks
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel T Lackland
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
3
|
Giles MF, Rothwell PM. The need for emergency treatment of transient ischemic attack and minor stroke. Expert Rev Neurother 2014; 5:203-10. [PMID: 15853490 DOI: 10.1586/14737175.5.2.203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The risk of recurrent stroke following transient ischemic attack or minor stroke has recently been shown to be 5-10% at 1 week and 10-20% at 3 months, depending on study population and methods. This is considerably higher than previously estimated and current clinical guidelines reflect the need for rapid assessment although a wide variation in practice exists. Effective management of patients with transient ischemic attack or minor stroke, therefore, requires identification of individuals at the highest (and lowest) risk and initiation of appropriate secondary prevention. Risk can be stratified at initial presentation by the presence or absence of simple clinical features and following subsequent investigation. For transient ischemic attack patients, older age, diabetes, longer duration of symptoms and weakness or speech disturbance identify patients at highest risk, as does the presence of large artery atherosclerosis (mainly internal carotid artery stenosis) and lesions on diffusion-weighted magnetic resonance imaging. Strong evidence exists for the benefit of some early interventions (carotid endarterectomy and antiplatelet agents), but is circumstantial or awaited for others (statins and antihypertensives). In order for the public health challenge posed by transient ischemic attack and minor stroke to be met, considerable change is required in both public education (to ensure correct recognition of symptoms and swift presentation to medical attention) and the provision of clinical services to ensure the timely initiation of effective treatment.
Collapse
Affiliation(s)
- Matthew F Giles
- Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Woodstock Road, Oxford, OX2 6HE, UK.
| | | |
Collapse
|
4
|
Wait times among patients with symptomatic carotid artery stenosis requiring carotid endarterectomy for stroke prevention. J Vasc Surg 2012; 56:661-7.e1-2. [DOI: 10.1016/j.jvs.2012.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 02/19/2012] [Accepted: 03/07/2012] [Indexed: 11/30/2022]
|
5
|
Chandratheva A, Lasserson DS, Geraghty OC, Rothwell PM. Population-Based Study of Behavior Immediately After Transient Ischemic Attack and Minor Stroke in 1000 Consecutive Patients. Stroke 2010; 41:1108-14. [DOI: 10.1161/strokeaha.109.576611] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Most guidelines now recommend that patients with minor stroke or high-risk transient ischemic attack (TIA) are assessed within 24 hours of their event, but the feasibility of this depends on patients’ behavior. We studied behavior immediately after TIA and minor stroke according to clinical characteristics, patients’ perception of the nature of the event, and their predicted stroke risk.
Methods—
In a population-based study in Oxfordshire, UK, with face-to-face interview of 1000 consecutive patients with TIA and minor stroke (National Institutes of Health Stroke Scale ≤5) from 2002 to 2007 (Oxford Vascular Study), we studied delay in seeking medical attention and identified patients who did not seek attention after an initial event and only presented after a recurrent stroke.
Results—
Of 1000 patients (459 TIAs, 541 minor strokes), 300 (67%) with TIA and 400 (74%) with minor stroke sought medical attention within 24 hours and 208 (47%) and 234 (46%), respectively, sought attention within 3 hours. Most patients (77%) first sought attention through their primary care physician. In patients with TIA, incorrect recognition of symptoms, absence of motor or speech symptoms, shorter duration of event, lower ABCD
2
score, no history of stroke or atrial fibrillation, and weekend presentation were associated with significantly longer delays. However, age, sex, social class, and educational level were all unrelated to either correct recognition of symptoms or to delay in seeking attention. Of 129 patients with TIA or minor stroke who had a recurrent stroke within 90 days, 41 (31%) did not seek medical attention after their initial event. These patients were more likely to have had a TIA (
P
=0.003), shorter duration of event (
P
=0.02), and a history of TIA (
P
=0.09) and less likely to have had motor (
P
=0.004) or speech symptoms (
P
=0.04) compared with those patients who sought medical attention for their initial event.
Conclusion—
Approximately 70% of patients do not correctly recognize their TIA or minor stroke, 30% delay seeking medical attention for >24 hours, regardless of age, sex, social class, or educational level, and approximately 30% of early recurrent strokes occur before seeking attention. Without more effective public education of all demographic groups, the full potential of acute prevention will not be realized.
Collapse
Affiliation(s)
- Arvind Chandratheva
- From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Department of Clinical Neurology, University of Oxford, John Radcliffe Hospital, Oxford, UK; and the Department of Primary Health Care (D.S.L.), University of Oxford, Oxford, UK
| | - Daniel S. Lasserson
- From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Department of Clinical Neurology, University of Oxford, John Radcliffe Hospital, Oxford, UK; and the Department of Primary Health Care (D.S.L.), University of Oxford, Oxford, UK
| | - Olivia C. Geraghty
- From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Department of Clinical Neurology, University of Oxford, John Radcliffe Hospital, Oxford, UK; and the Department of Primary Health Care (D.S.L.), University of Oxford, Oxford, UK
| | - Peter M. Rothwell
- From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Department of Clinical Neurology, University of Oxford, John Radcliffe Hospital, Oxford, UK; and the Department of Primary Health Care (D.S.L.), University of Oxford, Oxford, UK
| |
Collapse
|
6
|
Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low Risk of Ipsilateral Stroke in Patients With Asymptomatic Carotid Stenosis on Best Medical Treatment. Stroke 2010; 41:e11-7. [PMID: 19926843 DOI: 10.1161/strokeaha.109.561837] [Citation(s) in RCA: 298] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lars Marquardt
- From the Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford, Oxford, UK
| | - Olivia C. Geraghty
- From the Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford, Oxford, UK
| | - Ziyah Mehta
- From the Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford, Oxford, UK
| | - Peter M. Rothwell
- From the Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford, Oxford, UK
| |
Collapse
|
7
|
Kulkarni SR, Gohel MS, Bulbulia RA, Whyman MR, Poskitt KR. The importance of early carotid endarterectomy in symptomatic patients. Ann R Coll Surg Engl 2009; 91:210-3. [PMID: 19220938 DOI: 10.1308/003588409x359312] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Early carotid endarterectomy (CEA) in symptomatic patients may prevent repeat cerebral events. This study investigates the relationship between waiting time for CEA and the incidence of repeat cerebral events prior to surgery in symptomatic patients. PATIENTS AND METHODS A prospective database of consecutive patients undergoing CEA between January 2002 and December 2006 was reviewed. Repeat event rates prior to surgery were calculated using Kaplan-Meier analysis and predictive factors identified using Cox regression analysis. RESULTS A total of 118 patients underwent CEA for non-disabling stroke, TIA and amaurosis fugax. Repeat cerebral events occurred in 34 of 118 (29%) patients at a median 51 days (range, 2-360 days) after the first event. The estimated risk of repeat events was 2% at 7 days and 9% at 1 month after first event (Kaplan-Meier survival analysis). Age (HR 1.059; 95% CI 1.014-1.106; P = 0.009] was identified as a predictor of repeat events. Patients underwent surgery at median 97 days (range, 7-621 days) after the first event. Eleven of 60 (18%) patients waiting < or = 97 days for surgery and 23 of 58 (40%) patients waiting > 97 days had repeat events. (P = 0.011, chi-squared test). CONCLUSIONS Delays in surgery should be reduced in order to minimise repeat cerebral events in patients with symptomatic carotid stenosis, particularly in the elderly population.
Collapse
Affiliation(s)
- S R Kulkarni
- Department of Vascular Surgery, Cheltenham General Hospital, UK
| | | | | | | | | |
Collapse
|
8
|
Jagoda A, Chan YFY. Transient Ischemic Attack Overview: Defining the Challenges for Improving Outcomes. Ann Emerg Med 2008; 52:S3-6. [DOI: 10.1016/j.annemergmed.2008.04.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Revised: 03/25/2008] [Accepted: 04/29/2008] [Indexed: 10/21/2022]
|
9
|
Howard VJ, Lackland DT, Lichtman JH, McClure LA, Howard G, Wagner L, Pulley L, Gomez CR. Care seeking after stroke symptoms. Ann Neurol 2008; 63:466-72. [PMID: 18360830 PMCID: PMC3727632 DOI: 10.1002/ana.21357] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess risk factors associated with care for stroke symptoms. METHODS Using data from the population-based national cohort study (REasons for Geographic And Racial Differences in Stroke) conducted January 25, 2003-February 28, 2007 (N = 23,664), we assessed care-seeking behavior among 3,668 participants who reported a physician diagnosis of stroke/transient ischemic attack (n = 647) or stroke symptoms (n = 3,021) during follow-up. Care seeking was defined as seeking medical attention after stroke symptoms or a physician diagnosis. RESULTS Overall, 58.5% of participants (2,146/3,668) sought medical care. In multivariable models, higher income was associated with greater likelihood of seeking care (p = 0.02): participants with income of > or = $75,000 had odds 1.43 times (95% confidence interval [CI], 1.02-2.02) greater than those with income of less than $20,000. Diabetes and previous heart disease were associated with increased care seeking: odds ratio (OR) of 1.23 (95% CI, 1.04-1.47) and OR of 1.26 (95% CI, 1.06-1.49), respectively. Participants with previous stroke symptoms but no stroke history were less likely to seek care than those with stroke history or without previous symptoms (OR, 0.80; 95% CI, 0.67-0.96). Past smoking was associated with lower likelihood (OR, 0.71; 95% CI, 0.59-0.85; p = 0.0003) of seeking care relative to nonsmokers. INTERPRETATION Only approximately half of participants with stroke symptoms sought care. This is despite the encouragement of advocacy groups to seek prompt attention for stroke symptoms. Our results highlight the importance of identifying characteristics associated with care-seeking behavior. Recognizing factors that contribute to delays provides opportunities to enhance education on the importance of seeking care for stroke symptoms.
Collapse
Affiliation(s)
- Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0022, USA
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Giles MF, Flossman E, Rothwell PM. Patient Behavior Immediately After Transient Ischemic Attack According to Clinical Characteristics, Perception of the Event, and Predicted Risk of Stroke. Stroke 2006; 37:1254-60. [PMID: 16574923 DOI: 10.1161/01.str.0000217388.57851.62] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Little research has been done on patients’ behavior after transient ischemic attack (TIA). Recent data on the high early risk of stroke after TIA mean that emergency action after TIA is essential for effective secondary prevention. We therefore studied patients’ behavior immediately after TIA according to their perceptions, clinical characteristics, and predicted stroke risk.
Methods—
Consecutive patients with TIA participating in the Oxford Vascular Study or attending dedicated hospital clinics in Oxfordshire, UK, were interviewed. Predicted stroke risk was calculated using 2 validated scores.
Results—
Of 241 patients, 107 (44.4%) sought medical attention within hours of the event, although only 24 of these attended the emergency department. A total of 107 (44.4%) delayed seeking medical attention for ≥1 day. Correct recognition of symptoms (42.2% of patients) was not associated with less delay. However, patients with motor symptoms or duration of symptoms ≥1 hour were more likely to seek emergency attention (hazard ratio, 2.1; 95% CI, 1.4 to 3.2;
P
=0.00005), as were those at higher predicted stroke risk (
P
=0.001). The other main correlate with delay was the day of the week on which the TIA occurred (
P
<0.001), with greater delays at the weekend. Delay was unrelated to age, sex, or other vascular risk factors.
Conclusions—
Many patients delay seeking medical attention after a TIA irrespective of correct recognition of symptoms, although patients at higher predicted risk of stroke do act more quickly. Public education about both the urgency and nature of TIA is required.
Collapse
Affiliation(s)
- Matthew F Giles
- Department of Clinical Neurology, Oxford University, London, UK
| | | | | |
Collapse
|
11
|
Rothwell PM, Buchan A, Johnston SC. Recent advances in management of transient ischaemic attacks and minor ischaemic strokes. Lancet Neurol 2006; 5:323-31. [PMID: 16545749 DOI: 10.1016/s1474-4422(06)70408-2] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Peter M Rothwell
- Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK.
| | | | | |
Collapse
|
12
|
Graham CA. Editorial Comment—Transient Cerebral Ischemia Demands Urgent Evaluation. Stroke 2003; 34:2451-2. [PMID: 14500925 DOI: 10.1161/01.str.0000094581.18411.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
13
|
Lovett JK, Dennis MS, Sandercock PAG, Bamford J, Warlow CP, Rothwell PM. Very early risk of stroke after a first transient ischemic attack. Stroke 2003; 34:e138-40. [PMID: 12855835 DOI: 10.1161/01.str.0000080935.01264.91] [Citation(s) in RCA: 235] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE The commonly quoted early risks of stroke after a first transient ischemic attack (TIA)-1% to 2% at 7 days and 2% to 4% at 1 month-are likely to be underestimates because of the delay before inclusion into previous studies and the exclusion of patients who had a stroke during this time. Therefore, it is uncertain how urgently TIA patients should be assessed. We used data from the Oxford Community Stroke Project (OCSP) to estimate the very early stroke risk after a TIA and investigated the potential effects of the delays before specialist assessment. METHODS All OCSP patients who had a first-ever definite TIA during the study period (n=209) were included. Three analyses were used to estimate the early stroke risk after a first TIA starting from 3 different dates: assessment by a neurologist, referral to the TIA service, and onset of first TIA. RESULTS The stroke risk from assessment by a neurologist was 1.9% [95% confidence interval (CI), 0.1 to 3.8] at 7 days and 4.4% (95% CI, 1.6 to 7.2) at 30 days. The 7- and 30-day stroke risks from referral were 2.4% (95% CI, 0.3 to 4.5) and 4.9% (95% CI, 1.9 to 7.8), respectively, and from onset of first-ever TIA were 8.6% (95% CI, 4.8 to 12.4) and 12.0% (95% CI, 7.6 to 16.4), respectively. CONCLUSIONS The early risk of stroke from date of first-ever TIA is likely to be higher than commonly quoted. Public education about the symptoms of TIA is needed so that medical attention is sought more urgently and stroke prevention strategies are implemented sooner.
Collapse
Affiliation(s)
- J K Lovett
- Stroke Prevention Research Unit, Department of Clinical Neurology, Radcliffe Infirmary, Woodstock Rd, Oxford OX2 6HE UK
| | | | | | | | | | | |
Collapse
|
14
|
|