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Discriminative Utility of Transcranial Magnetic Stimulation-Derived Markers of Cortical Excitability for Transient Ischemic Attack. Can J Neurol Sci 2021; 49:218-224. [PMID: 33843526 DOI: 10.1017/cjn.2021.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Several guidelines currently recommend acute diffusion weighted imaging (DWI) for the detection of ischemia in transient ischemic attack (TIA). However, DWI hyperintensities resolve early and only 30%-50% with clinically defined TIA show acute DWI positivity. A recent meta-analysis reported an unexplained 7-fold variation in DWI positivity in TIA across studies, concluding that DWI does not provide a consistent basis for defining ischemia. Intracortical excitability, measured using transcranial magnetic stimulation (TMS), has previously been shown to be altered after TIA and associated with ABCD2 scores; however, whether altered cortical excitability is associated with clinical and DWI-based definitions of TIA remains unclear. METHODS Individuals with TIA symptoms (N = 23; mean age = 61 ± 12) were prospectively recruited and underwent DWI and paired-pulse TMS. Multivariate linear regression was used to estimate associations between TMS-derived excitability thresholds, and clinical TIA diagnosis, and imaging-based evidence of cerebral ischemia (DWI positivity). Area under the curve (AUC) analyses was used to compare the discriminability of TMS-derived thresholds and clinical TIA diagnoses. RESULTS Thresholds for intracortical inhibition in the TIA-unaffected hemisphere were significantly associated with the clinical diagnosis of TIA. No associations between TMS-derived thresholds and DWI positivity were observed. TMS thresholds showed low-moderate discriminability and values differed by age (65+) and sex. CONCLUSIONS In this small sample, TMS-derived markers of intracortical excitability were associated with clinical TIA diagnoses but not DWI positivity. Our results provide preliminary evidence for the potential discriminative utility of TMS for the diagnosis of TIA and highlight the need for future work in larger cohorts.
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Scott IU, Campochiaro PA, Newman NJ, Biousse V. Retinal vascular occlusions. Lancet 2020; 396:1927-1940. [PMID: 33308475 PMCID: PMC9546635 DOI: 10.1016/s0140-6736(20)31559-2] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/29/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022]
Abstract
Acute retinal vascular occlusions are common causes of visual impairment. Although both retinal artery occlusions and retinal vein occlusions are associated with increased age and cardiovascular risk factors, their pathophysiology, systemic implications, and management differ substantially. Acute management of retinal artery occlusions involves a multidisciplinary approach including neurologists with stroke expertise, whereas treatment of retinal vein occlusions is provided by ophthalmologists. Optimisation of systemic risk factors by patients' primary care providers is an important component of the management of these two disorders.
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Affiliation(s)
- Ingrid U Scott
- Department of Ophthalmology and Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Peter A Campochiaro
- Department of Ophthalmology and Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
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Bridgwood BM, Wilson A, Clarke D, Eborall H. Understanding TIA: an ethnographic study of TIA consultations. Fam Pract 2020; 37:530-534. [PMID: 32016372 DOI: 10.1093/fampra/cmaa004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Transient ischaemic attack (TIA) is a transient episode of neurological dysfunction. Rapid access TIA clinics have been set up as integrated 'one-stop' clinics that aim to investigate, diagnose, educate and implement treatment to reduce the risk of further TIA/stroke. OBJECTIVE This study aimed to examine how TIA consultations were conducted by observing the consultations and then interviewing patients. METHODS This ethnographic study observed fifteen patient-clinician consultations where a diagnosis of TIA was made within three different TIA outpatient clinics in the East Midlands. All fifteen patients, their accompanying family-members/carers and three stroke clinicians were interviewed. Data analysis was informed by the constant comparative approach. RESULTS There was considerable variation in the conduct of these consultations across sites and clinicians. This resulted in variation in patient experience and knowledge after the consultation including the ability to recognize TIA-associated risk factors and their management. As TIA symptoms resolve, patients may reduce their need to seek health care services in addition to demonstrating reduced concordance with secondary stroke prevention. Health professionals recognize that this single appointment provides patients with a large amount of information which may be difficult to process. Importantly, there was little discussion about future symptoms and how to respond. A management plan, which considered a patient's health belief, knowledge and encouraged the involvement of family members, improved information recall. CONCLUSIONS TIA is a complex medical diagnosis with multiple risk factors that may make the management complex and hence difficult for patients to undertake. Our findings found variability in the conduct, provision of information and patient understanding. Guidance on nationally agreed consultation framework may prove useful. Improved patient education may include individualized/sustained education utilizing multidisciplinary team members across family/primary and secondary care, video or greater online education and improved general public education.
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Affiliation(s)
| | - Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - David Clarke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Helen Eborall
- Department of Health Sciences, University of Leicester, Leicester, UK
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Bhagat R, Narayanan S, Karki BJ, Liu W, Remmel K. A Case of Isolated Dysarthria in a COVID-19 Infected Stroke Patient: A Nondisabling Neurological Symptom With Grave Prognosis. Cureus 2020; 12:e9921. [PMID: 32968582 PMCID: PMC7505622 DOI: 10.7759/cureus.9921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Isolated dysarthria is a speech abnormality characterized by slurring without any language dysfunction, or other neurological deficits. In an acute setting, it is commonly associated with stroke. In the context of social distancing during the current corona virus disease 2019 (COVID-19) pandemic, nondisabling symptoms such as isolated dysarthria can delay a patient's perception to seek immediate medical care. We present a rare case of isolated dysarthria in a COVID-19 infected stroke patient with a grave prognosis. A 79-year-old African American male presented with isolated dysarthria that manifested two days prior to his hospital visit. The dysarthria assessment showed impaired articulation, phonation, and prosody. Other neurological examinations were normal. He tested positive for the COVID-19 infection. His pulmonary CT scan showed bilateral ground glass opacities. An electrocardiogram showed atrial fibrillation (AF). Brain MRI revealed a punctate acute infarction in the left frontal lobe. Initially, he was treated with IV anticoagulation, oral beta-blocker, azithromycin and hydroxychloroquine, but he dramatically deteriorated within a week exhibiting a highly elevated cytokine level eventually resulting in multi-system organ failure. Despite aggressive treatment with steroids, tocilizumab and other supportive measures, the patient died of cardiac arrest. Our case highlights that acute stroke could manifest as an isolated dysarthria, which is an indicator of increased severity and high mortality with COVID-19 infection. Public awareness about the stroke symptom awareness should be emphasized.
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Affiliation(s)
- Riwaj Bhagat
- Neurology, University of Louisville, Louisville, USA
| | | | - Bibodh J Karki
- Infectious Disease, University of Louisville, Louisville, USA
| | - Wei Liu
- Neurology, University of Louisville, Louisville, USA
| | - Kerri Remmel
- Neurology, University of Louisville, Louisville, USA
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Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature. J Neurol 2020; 268:2723-2734. [PMID: 32206899 DOI: 10.1007/s00415-020-09803-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery. METHODS A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy. RESULTS One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model. CONCLUSION Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
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Dolmans LS, Kappelle LJ, Bartelink MLE, Hoes AW, Rutten FH. Delay in patients suspected of transient ischaemic attack: a cross-sectional study. BMJ Open 2019; 9:e027161. [PMID: 30819716 PMCID: PMC6398704 DOI: 10.1136/bmjopen-2018-027161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Suspected transient ischaemic attack (TIA) necessitates an urgent neurological consultation and a rapid start of antiplatelet therapy to reduce the risk of early ischaemic stroke following a TIA. Guidelines for general practitioners (GPs) emphasise the urgency to install preventive treatment as soon as possible. We aimed to give a contemporary overview of both patient and physician delay. METHODS A survey at two rapid-access TIA outpatient clinics in Utrecht, the Netherlands. All patients suspected of TIA were interviewed to assess time delay to diagnosis and treatment, including the time from symptom onset to (1) the first contact with a medical service (patient delay), (2) consultation of the GP and (3) assessment at the TIA outpatient clinic. We used the diagnosis of the consulting neurologist as reference. RESULTS Of 93 included patients, 43 (46.2%) received a definite, 13 (14.0%) a probable, 11 (11.8%) a possible and 26 (28.0%) no diagnosis of TIA. The median time from symptom onset to the visit to the TIA service was 114.5 (IQR 44.0-316.6) hours. Median patient delay was 17.5 (IQR 0.8-66.4) hours, with a delay of more than 24 hours in 36 (38.7%) patients. The GP was first contacted in 76 (81.7%) patients, and median time from first contact with the GP practice to the actual GP consultation was 2.8 (0.5-18.5) hours. Median time from GP consultation to TIA service visit was 40.8 (IQR 23.1-140.7) hours. Of the 62 patients naïve to antithrombotic medication who consulted their GP, 27 (43.5%) received antiplatelet therapy. CONCLUSIONS There is substantial patient and physician delay in the process of getting a confirmed TIA diagnosis, resulting in suboptimal prevention of an early ischaemic stroke.
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Affiliation(s)
- L Servaas Dolmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marie-Louise El Bartelink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Dolmans LS, Hoes AW, Bartelink MLEL, Koenen NCT, Kappelle LJ, Rutten FH. Patient delay in TIA: a systematic review. J Neurol 2018; 266:1051-1058. [PMID: 30027321 PMCID: PMC6469675 DOI: 10.1007/s00415-018-8977-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/27/2018] [Accepted: 07/14/2018] [Indexed: 11/29/2022]
Abstract
Background Patients who suffer a transient ischemic attack (TIA) have a high short-term risk of developing ischemic stroke, notably within the first 48 h. Timely diagnosis and urgent preventive treatment substantially reduce this risk. We conducted a systemic review to quantify patient delay in patients with (suspected) TIA, and assess determinants related to such delay. Methods A systematic review using MEDLINE and EMBASE databases up to March 2017 to identify studies reporting the time from onset of TIA symptoms to seeking medical help. Results We identified nine studies providing data on patient delay, published between 2006 and 2016, with 7/9 studies originating from the United Kingdom (UK). In total 1103 time-defined TIA patients (no remaining symptoms > 24 h), and 896 patients with a minor stroke (i.e., mild remaining symptoms > 24 h) were included (49.1% men, mean age 72.2 years). Patient’s delay of more than 24 h was reported in 33.1–44.4% of TIA patients, with comparable proportions for minor stroke patients. Delays were on average shorter in patients interviewed at the emergency department than among patients seen at TIA outpatient clinics. Univariably associated with a shorter delay were (1) a longer duration of symptoms, (2) motor symptoms, (3) a higher ABCD2 score, and (4) correct patient’s recognition as possible ischemic cerebrovascular event. Conclusions More than a third of patients experiencing a TIA delays medical attention for more than a day, thus critically extending the initiation of stroke preventive treatment. There still seems to be insufficient awareness among lay people that symptoms suggestive of TIA should be considered as an emergency. Additional data and multivariable analyses are needed to define main determinants of patient delay.
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Affiliation(s)
- L Servaas Dolmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marie-Louise E L Bartelink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Niels C T Koenen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Biousse V, Nahab F, Newman NJ. Management of Acute Retinal Ischemia: Follow the Guidelines! Ophthalmology 2018; 125:1597-1607. [PMID: 29716787 DOI: 10.1016/j.ophtha.2018.03.054] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/25/2018] [Accepted: 03/27/2018] [Indexed: 11/24/2022] Open
Abstract
Acute retinal arterial ischemia, including vascular transient monocular vision loss (TMVL) and branch (BRAO) and central retinal arterial occlusions (CRAO), are ocular and systemic emergencies requiring immediate diagnosis and treatment. Guidelines recommend the combination of urgent brain magnetic resonance imaging with diffusion-weighted imaging, vascular imaging, and clinical assessment to identify TMVL, BRAO, and CRAO patients at highest risk for recurrent stroke, facilitating early preventive treatments to reduce the risk of subsequent stroke and cardiovascular events. Because the risk of stroke is maximum within the first few days after the onset of visual loss, prompt diagnosis and triage are mandatory. Eye care professionals must make a rapid and accurate diagnosis and recognize the need for timely expert intervention by immediately referring patients with acute retinal arterial ischemia to specialized stroke centers without attempting to perform any further testing themselves. The development of local networks prompting collaboration among optometrists, ophthalmologists, and stroke neurologists should facilitate such evaluations, whether in a rapid-access transient ischemic attack clinic, in an emergency department-observation unit, or with hospitalization, depending on local resources.
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Affiliation(s)
- Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
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