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Lim A, Ma H, Johnston SC, Singhal S, Muthusamy S, Wang Y, Pan Y, Coutts SB, Hill MD, Ois A, Kapral MK, Knoflach M, Woodhouse LJ, Bath PM, Phan TG. Ninety-Day Stroke Recurrence in Minor Stroke: Systematic Review and Meta-Analysis of Trials and Observational Studies. J Am Heart Assoc 2024; 13:e032471. [PMID: 38641856 DOI: 10.1161/jaha.123.032471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/18/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Risk of recurrence after minor ischemic stroke is usually reported with transient ischemic attack. No previous meta-analysis has focused on minor ischemic stroke alone. The objective was to evaluate the pooled proportion of 90-day stroke recurrence for minor ischemic stroke, defined as a National Institutes of Health Stroke Scale severity score of ≤5. METHODS AND RESULTS Published papers found on PubMed from 2000 to January 12, 2021, reference lists of relevant articles, and experts in the field were involved in identifying relevant studies. Randomized controlled trials and observational studies describing minor stroke cohort with reported 90-day stroke recurrence were selected by 2 independent reviewers. Altogether 14 of 432 (3.2%) studies met inclusion criteria. Multilevel random-effects meta-analysis was performed. A total of 6 randomized controlled trials and 8 observational studies totaling 45 462 patients were included. The pooled 90-day stroke recurrence was 8.6% (95% CI, 6.5-10.7), reducing by 0.60% (95% CI, 0.09-1.1; P=0.02) with each subsequent year of publication. Recurrence was lowest in dual antiplatelet trial arms (6.3%, 95% CI, 4.5-8.0) when compared with non-dual antiplatelet trial arms (7.2%, 95% CI, 4.7-9.6) and observational studies 10.6% (95% CI, 7.0-14.2). Age, hypertension, diabetes, ischemic heart disease, or known atrial fibrillation had no significant association with outcome. Defining minor stroke with a lower National Institutes of Health Stroke Scale threshold made no difference - score ≤3: 8.6% (95% CI, 6.0-11.1), score ≤4: 8.4% (95% CI, 6.1-10.6), as did excluding studies with n<500%-7.3% (95% CI, 5.5-9.0). CONCLUSIONS The risk of recurrence after minor ischemic stroke is declining over time but remains important.
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Affiliation(s)
- Andy Lim
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Emergency Medicine Monash Health Melbourne Victoria Australia
| | - Henry Ma
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | | | - Shaloo Singhal
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | - Subramanian Muthusamy
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Centre for Neurological Diseases Beijing China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Centre for Neurological Diseases Beijing China
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology and Community Health Sciences Hotchkiss Brain Institute, University of Calgary Alberta Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Radiology and Community Health Sciences Hotchkiss Brain Institute, University of Calgary Alberta Canada
| | - Angel Ois
- Servicio de Neurologı'a, Hospital del Mar Barcelona Spain
| | - Moira K Kapral
- Department of Medicine University of Toronto Ontario Canada
| | - Michael Knoflach
- Department of Neurology Innsbruck Medical University Innsbruck Austria
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neuroscience University of Nottingham, Queen's Medical Centre Nottingham United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience University of Nottingham, Queen's Medical Centre Nottingham United Kingdom
| | - Thanh G Phan
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
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Shahjouei S, Li J, Koza E, Abedi V, Sadr AV, Chen Q, Mowla A, Griffin P, Ranta A, Zand R. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2136644. [PMID: 34985520 PMCID: PMC8733831 DOI: 10.1001/jamanetworkopen.2021.36644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome. OBJECTIVE To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting. DATA SOURCES MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020. STUDY SELECTION Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer. DATA EXTRACTION AND SYNTHESIS The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models. MAIN OUTCOMES AND MEASURES Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days). RESULTS The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.
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Affiliation(s)
- Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
- Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Alireza Vafaei Sadr
- Department de Physique Theorique and Center for Astroparticle Physics, University Geneva, Geneva, Switzerland
| | - Qiushi Chen
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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Determinants of Physical Activity at 90 Days After Acute Stroke or Transient Ischemic Attack in Patients With Home Discharge: A Pilot Study. J Aging Phys Act 2021; 30:646-652. [PMID: 34615739 DOI: 10.1123/japa.2021-0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/02/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022]
Abstract
The aim was to identify the barriers to achieving premorbid physical activity in patients with home discharge after acute minor stroke or transient ischemic attack. Fifty-six patients (median age, 72 years) were analyzed. We assessed total physical activity in the premorbid condition and at 90 days after onset using the International Physical Activity Questionnaire. The patients were divided into two groups according to changes in total physical activity until 90 days after onset: decreased activity (n = 16) and nondecreased activity (n = 40) groups. Outcome measures were examined at discharge. The decreased activity group took significantly longer to perform the timed up and go test (median, 7.19 vs. 6.52 s) and contained more apathetic patients (44% vs. 15%). Apathy at discharge (relative risk 6.05, 95% confidence interval [1.33, 27.6]) was a significant determinant of decreased physical activity. Apathy is a barrier to the restoration of premorbid physical activity in stroke survivors.
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Heron N, Kee F, Mant J, Cupples ME, Donnelly M. Infographic. Developing home-based cardiac rehabilitation for people post-transient ischaemic attack (TIA) and ischaemic stroke. Br J Sports Med 2019; 54:487-488. [PMID: 31649020 DOI: 10.1136/bjsports-2019-100864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Neil Heron
- Primary Care, Keele University, Keele, Staffordshire, UK .,Department of Public Health, Queen's University, Belfast, UK
| | - Frank Kee
- Department of Public Health, Queen's University, Belfast, UK
| | - Jonathan Mant
- Department of Medicine, University of Cambridge Department of Engineering, Cambridge, UK
| | | | - Michael Donnelly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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Heron N, Kee F, Mant J, Cupples ME, Donnelly M. Rehabilitation of patients after transient ischaemic attack or minor stroke: pilot feasibility randomised trial of a home-based prevention programme. Br J Gen Pract 2019; 69:e706-e714. [PMID: 31501165 PMCID: PMC6733604 DOI: 10.3399/bjgp19x705509] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/11/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Although the importance of secondary prevention after transient ischaemic attack (TIA) or minor stroke is recognised, research is sparse regarding novel, effective ways in which to intervene in a primary care context. AIM To pilot a randomised controlled trial (RCT) of a novel home-based prevention programme (The Healthy Brain Rehabilitation Manual) for patients with TIA or 'minor' stroke. DESIGN AND SETTING Pilot RCT, home-based, undertaken in Northern Ireland between May 2017 and March 2018. METHOD Patients within 4 weeks of a first TIA or 'minor' stroke received study information from clinicians in four hospitals. Participants were randomly allocated to one of three groups: standard care (control group) (n = 12); standard care with manual and GP follow-up (n = 14); or standard care with manual and stroke nurse follow-up (n = 14). Patients in all groups received telephone follow-up at 1, 4, and 9 weeks. Eligibility, recruitment, and retention were assessed; stroke/cardiovascular risk factors measured at baseline and 12 weeks; and participants' views were elicited about the study via focus groups. RESULTS Over a 32-week period, 28.2% of clinic attendees (125/443) were eligible; 35.2% of whom (44/125) consented to research contact; 90.9% of these patients (40/44) participated, of whom 97.5% (39/40) completed the study. After 12 weeks, stroke risk factors [cardiovascular risk factors, including blood pressure and measures of physical activity] improved in both intervention groups. The research methods and the programme were acceptable to patients and health professionals, who commented that the programme 'filled a gap' in current post-TIA management. CONCLUSION Findings indicate that implementation of this novel cardiac rehabilitation programme, and of a trial to evaluate its effectiveness, is feasible, with potential for clinically important benefits and improved secondary prevention after TIA or 'minor' stroke.
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Affiliation(s)
- Neil Heron
- Department of Primary Care, Keele University, Keele; Centre for Public Health, Queen's University Belfast, Belfast
| | | | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Margaret E Cupples
- Department of General Practice and Primary Care; Centre for Public Health
| | - Michael Donnelly
- Centre for Public Health, Queen's University Belfast, Belfast; UKCRC Centre of Excellence for Public Health Research, Belfast
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Heron N. Cardiac rehabilitation for the transient ischaemic attack (TIA) and stroke population? Using the Medical Research Council (MRC) guidelines for developing complex health service interventions to develop home-based cardiac rehabilitation for TIA and 'minor' stroke patients. Br J Sports Med 2018; 53:839-840. [PMID: 30181325 PMCID: PMC6585273 DOI: 10.1136/bjsports-2018-099593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Neil Heron
- Department of General Practice and Primary Care, Queen’s University, Belfast, UK
- Centre for Public Health Research, Queen’s University, Belfast, UK
- Centre for Public Health, UKCRC Centre of Excellence for Public Health Research (NI), Belfast, UK
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Heron N, Kee F, Mant J, Reilly PM, Cupples M, Tully M, Donnelly M. Stroke Prevention Rehabilitation Intervention Trial of Exercise (SPRITE) - a randomised feasibility study. BMC Cardiovasc Disord 2017; 17:290. [PMID: 29233087 PMCID: PMC5727948 DOI: 10.1186/s12872-017-0717-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/21/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The value of cardiac rehabilitation (CR) after a transient ischaemic attack (TIA) or minor stroke is untested despite these conditions sharing similar pathology and risk factors to coronary heart disease. We aimed to evaluate the feasibility of conducting a trial of an adapted home-based CR programme, 'The Healthy Brain Rehabilitation Manual', for patients following a TIA/minor stroke, participants' views on the intervention and, to identify the behaviour change techniques (BCTs) used. METHODS Clinicians were asked to identify patients attending the Ulster Hospital, Belfast within 4 weeks of a first TIA or minor stroke. Those who agreed to participate underwent assessments of physical fitness, cardiovascular risk, quality of life and mental health, before random allocation to: Group (1) standard/usual care; (2) rehabilitation manual or (3) manual plus pedometer. All participants received telephone support at 1 and 4 weeks, reassessment at 6 weeks and an invitation to a focus group exploring views regarding the study. Two trained review authors independently assessed the manual to identify the BCTs used. RESULTS Twenty-eight patients were invited to participate, with 15 (10 men, 5 women; 9 TIA, 6 minor stroke; mean age 69 years) consenting and completing the study. Mean time to enrolment from the TIA/stroke was 20.5 days. Participants completed all assessment measures except VO2max testing, which all declined. The manual and telephone contact were viewed positively, as credible sources of advice. Pedometers were valued highly, particularly for goal-setting. Overall, 36 individual BCTs were used, the commonest being centred around setting goals and planning as well as social support. CONCLUSION Recruitment and retention rates suggest that a trial to evaluate the effectiveness of a novel home-based CR programme, implemented within 4 weeks of a first TIA/minor stroke is feasible. The commonest BCTs used within the manual revolve around goals, planning and social support, in keeping with UK national guidelines. The findings from this feasibility work have been used to further refine the next stage of the intervention's development, a pilot study. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02712385 . This study was registered prospectively on 18/03/2016.
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Affiliation(s)
- Neil Heron
- Department of General Practice and Primary Care, Queen’s University, Belfast, UK
- Centre for Public Health Research, Queen’s University, Belfast, UK
- UKCRC Centre of Excellence for Public Health Research (NI), Belfast, Northern Ireland
- Department of General Practice, Queen’s University, Dunluce Health Centre, Level 4, 1 Dunluce Avenue, Belfast, BT9 7HR UK
| | - Frank Kee
- Department of General Practice and Primary Care, Queen’s University, Belfast, UK
- Centre for Public Health Research, Queen’s University, Belfast, UK
- UKCRC Centre of Excellence for Public Health Research (NI), Belfast, Northern Ireland
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Philip M. Reilly
- Patient and Public Involvement (PPI) Representative for SPRITE Studies, Belfast, Northern Ireland
| | - Margaret Cupples
- Department of General Practice and Primary Care, Queen’s University, Belfast, UK
- Centre for Public Health Research, Queen’s University, Belfast, UK
- UKCRC Centre of Excellence for Public Health Research (NI), Belfast, Northern Ireland
| | - Mark Tully
- Department of General Practice and Primary Care, Queen’s University, Belfast, UK
- Centre for Public Health Research, Queen’s University, Belfast, UK
- UKCRC Centre of Excellence for Public Health Research (NI), Belfast, Northern Ireland
| | - Michael Donnelly
- Department of General Practice and Primary Care, Queen’s University, Belfast, UK
- Centre for Public Health Research, Queen’s University, Belfast, UK
- UKCRC Centre of Excellence for Public Health Research (NI), Belfast, Northern Ireland
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Park HK, Kim BJ, Han MK, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Nah HW, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Lee BC, Yu KH, Oh MS, Kim JT, Choi KH, Kim DE, Ryu WS, Choi JC, Johansson S, Lee SJ, Lee WH, Lee JS, Lee J, Bae HJ. One-Year Outcomes After Minor Stroke or High-Risk Transient Ischemic Attack. Stroke 2017; 48:2991-2998. [DOI: 10.1161/strokeaha.117.018045] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/16/2017] [Accepted: 09/01/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Hong-Kyun Park
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Beom Joon Kim
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Moon-Ku Han
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Jong-Moo Park
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Kyusik Kang
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Soo Joo Lee
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Jae Guk Kim
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Jae-Kwan Cha
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Dae-Hyun Kim
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Hyun-Wook Nah
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Tai Hwan Park
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Sang-Soon Park
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Kyung Bok Lee
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Jun Lee
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Keun-Sik Hong
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Yong-Jin Cho
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Byung-Chul Lee
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Kyung-Ho Yu
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Mi-Sun Oh
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Joon-Tae Kim
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Kang-Ho Choi
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Dong-Eog Kim
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Wi-Sun Ryu
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Jay Chol Choi
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Saga Johansson
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Su Jin Lee
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Won Hee Lee
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Ji Sung Lee
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Juneyoung Lee
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
| | - Hee-Joon Bae
- From the Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (H.-K.P., B.J.K., M.-K.H., H.-J.B.); Department of Neurology, Eulji General Hospital (J.-M.P., K.K.) and Department of Neurology, Eulji University Hospital (S.J.L., J.G.K.), Eulji University, Daejeon, Korea; Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K., H.-W.N.); Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.); Department
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Secondary prevention lifestyle interventions initiated within 90 days after TIA or 'minor' stroke: a systematic review and meta-analysis of rehabilitation programmes. Br J Gen Pract 2016; 67:e57-e66. [PMID: 27919935 PMCID: PMC5198618 DOI: 10.3399/bjgp16x688369] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/09/2016] [Indexed: 01/17/2023] Open
Abstract
Background Strokes are often preceded by a transient ischaemic attack (TIA) or ‘minor’ stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear. Aim To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used. Design and setting The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO. Method Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results. Results A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours. Conclusion There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed.
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Shrestha S, Poudel RS, Khatiwada D, Thapa L. Stroke subtype, age, and baseline NIHSS score predict ischemic stroke outcomes at 3 months: a preliminary study from Central Nepal. J Multidiscip Healthc 2015; 8:443-8. [PMID: 26491342 PMCID: PMC4598209 DOI: 10.2147/jmdh.s90554] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The combined medications practice of using antithrombotic agents and statins with or without antihypertensive agents is common in the treatment of acute ischemic stroke in Nepal. Short-term outcomes of the current practice have been studied. We aim to explore the predictors of ischemic stroke outcomes at 3 months, with the current combined medications practice. METHODS The study population (N=56) included acute ischemic stroke patients treated at the Neurology Department of the College of Medical Sciences-Teaching Hospital, Chitwan, Nepal, from May 2014 to August 2014 and followed up at 3 months. Death or disability (modified Rankin scale >2) was defined as poor outcomes. Multivariate logistic regression analysis (P<0.10) using potential variables from bivariate analysis (P≤0.20) was adjusted to predict outcomes at 3 months. RESULTS At 3 months, 29 (51.8%) patients were independent, eleven (19.6%) were dependent, while 16 (28.6%) died. Stroke subtype and baseline National Institute of Health Stroke Scale (NIHSS) scores were associated with death/disability (27, 48.2%) at 3 months. Regression analysis showed that large-artery stroke (odds ratio [OR] =284.145, 95% confidence interval [CI] =5.221-15,465.136, P=0.006), age (OR =1.113, 95% CI =1.002-1.236, P=0.045), and baseline NIHSS score (OR =1.557, 95% CI =1.194-2.032, P=0.001) were significant predictors of poor outcome at 3 months. CONCLUSION Stroke subtype, age, and baseline NIHSS score are predictors of ischemic stroke outcomes in Nepalese population treated with the current practice of using combined antithrombotic and statins with or without antihypertensive agents, and these predictors can be used for the improvement of selection of patients for the appropriate treatment.
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Affiliation(s)
- Shakti Shrestha
- Department of Pharmacy, Shree Medical and Technical College, Chitwan, Nepal
| | - Ramesh Sharma Poudel
- Department of Pharmacy, College of Medical Sciences-Teaching Hospital, Chitwan, Nepal
| | - Dipendra Khatiwada
- Department of Community Medicine, College of Medical Sciences-Teaching Hospital, Chitwan, Nepal
| | - Lekhjung Thapa
- Department of Neurology, College of Medical Sciences-Teaching Hospital, Chitwan, Nepal
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11
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Hospital-Based Prospective Registration of Acute Transient Ischemic Attack and Noncerebrovascular Events in Korea. J Stroke Cerebrovasc Dis 2015; 24:1803-10. [PMID: 26139456 DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 04/01/2015] [Accepted: 04/03/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There have been no prospective studies on the clinical features, etiologies, and outcome of transient ischemic attack (TIA) in Korea. The aim of this study was to identify variables that can discriminate TIA from TIA mimics. Also we evaluated the characteristic of TIA patients according to the presence of diffusion-weighted imaging (DWI) lesion. METHODS Patients were categorized into TIA and TIA mimics according to the result of an initial workup. TIA patients were divided according to the presence of DWI lesions. Baseline demographics, risk factors, laboratory results, initial blood pressure, imaging findings, recurrence rate of TIA or stroke at 3 months, and initial neurologic manifestations were prospectively collected and compared. RESULTS We evaluated a total of 252 patients (212 with TIA and 40 with TIA mimics). Steno-occlusion of the relevant artery (odds ratio [OR], 22.39; 95% confidence interval [CI], 2.03-246.73) and cardioembolic risk (OR, 32.15; 95% CI, 1.12-922.97) were significantly associated with TIA. Amnesia (OR, .001; 95% CI, .00-.05) and consciousness disturbance (OR, .003; 95% CI, .00-.06) favored TIA mimics. Perfusion defect (OR, 5.56; 95% CI, 2.90-10.68) and cardioembolic risk (OR, 2.68; 95% CI, 1.14-6.32) were significantly associated with DWI lesion. Recurrence did not significantly differ according to the presence of a lesion on DWI (positive, 4.9%; negative, 7.8%; P = .41). CONCLUSION Steno-occlusive disease and cardioembolic risk were independently associated with TIA. Perfusion defect and cardioembolic risk predicted positive DWI lesion. The value of various imaging modalities for predicting TIA etiology needs further evaluation.
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Heron N, Kee F, Donnelly M, Cupples ME. Systematic review of rehabilitation programmes initiated within 90 days of a transient ischaemic attack or 'minor' stroke: a protocol. BMJ Open 2015; 5:e007849. [PMID: 26088808 PMCID: PMC4480011 DOI: 10.1136/bmjopen-2015-007849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Transient ischaemic attacks (TIAs) and strokes are highly prevalent conditions. Stroke killed 5.7 million people worldwide in 2005 and is estimated to cause 6.5 million deaths globally in 2015. Stroke survivors are often left with considerable disability. Many strokes are preceded by a TIA/'minor' stroke in the previous 90 days and therefore the immediate period after a TIA/minor' stroke is a crucial time to intervene to tackle known vascular risk factors. Although rehabilitation following a TIA/minor stroke is widely recommended, there is a paucity of research that offers an evidence base on which the development or optimisation of interventions can be based, particularly for home-based approaches and non-pharmacological interventions in the acute period following the initial TIA/'minor' stroke. This systematic review will investigate the effect of rehabilitation programmes initiated within 90 days of the diagnosis of a TIA or 'minor' stroke aimed at reducing the subsequent risk of stroke. METHODS/DESIGN This systematic review will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses(PRISMA) guidance. Randomised and quasi-randomised controlled trials of rehabilitation programmes initiated within 90 days of a TIA or 'minor' stroke will be included. Articles will be identified through a comprehensive search of the following databases, guided by a medical librarian: the Cochrane Library, Web of Science, MEDLINE, Embase, CINAHL and PsycINFO. Two review authors will independently screen articles retrieved from the search for eligibility and extract relevant data on methodological issues. A narrative synthesis will be completed when there is insufficient data to permit a formal meta-analysis. DISCUSSION This review will be of value to clinicians and healthcare professionals working in TIA and stroke services as well as to general practitioners/family physicians who care for these patients in the community and to researchers involved in designing and evaluating rehabilitation interventions. TRIAL REGISTRATION NUMBER CRD42015016450.
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Affiliation(s)
- Neil Heron
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Science, Queens University Belfast, Institute of Clinical Science B, Royal Victoria Hospital, Belfast, Antrim, UK
- UKCRC Centre of Excellence for Public Health (Northern Ireland), Institute of Clinical Science B, Royal Victoria Hospital, Belfast, Antrim, UK
| | - Frank Kee
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Science, Queens University Belfast, Institute of Clinical Science B, Royal Victoria Hospital, Belfast, Antrim, UK
- UKCRC Centre of Excellence for Public Health (Northern Ireland), Institute of Clinical Science B, Royal Victoria Hospital, Belfast, Antrim, UK
| | - Michael Donnelly
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Science, Queens University Belfast, Institute of Clinical Science B, Royal Victoria Hospital, Belfast, Antrim, UK
- UKCRC Centre of Excellence for Public Health (Northern Ireland), Institute of Clinical Science B, Royal Victoria Hospital, Belfast, Antrim, UK
| | - Margaret E Cupples
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Science, Queens University Belfast, Institute of Clinical Science B, Royal Victoria Hospital, Belfast, Antrim, UK
- UKCRC Centre of Excellence for Public Health (Northern Ireland), Institute of Clinical Science B, Royal Victoria Hospital, Belfast, Antrim, UK
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Dutta D, Bowen E, Foy C. Four-Year Follow-Up of Transient Ischemic Attacks, Strokes, and Mimics. Stroke 2015; 46:1227-32. [DOI: 10.1161/strokeaha.114.008632] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/03/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
There is limited information on outcomes from rapid access transient ischemic attack (TIA) clinics. We present 4-year outcomes of TIAs, strokes, and mimics from a UK TIA clinic database.
Methods—
All patients referred between April 2010 and May 2012 were retrospectively identified and outcomes determined. End points were stroke, myocardial infarction, any vascular event (TIA, stroke, or myocardial infarction), and all-cause death. Data were analyzed by survival analysis.
Results—
Of 1067 patients, 31.6% were TIAs, 18% strokes, and 50.4% mimics. Median assessment time was 4.5 days from onset and follow-up was for 34.9 months. Subsequent strokes occurred in 7.1% of patients with TIA, 10.9% of patients with stroke, and 2.0% of mimics at the end of follow-up. Stroke risk at 90 days was 1.3% for patients diagnosed as TIA or stroke. Compared with mimics, hazard ratios for subsequent stroke were 3.88 (1.90–7.91) for TIA and 5.84 (2.81–12.11) for stroke. Hazard ratio for any subsequent vascular event was 2.91 (1.97–4.30) for TIA and 2.83 (1.81–4.41) for stroke. Hazard ratio for death was 1.68 (1.10–2.56) for TIA and 2.19 (1.38–3.46) for stroke.
Conclusions—
Our results show a lower 90-day stroke incidence after TIA or minor stroke than in earlier studies, suggesting that rapid access daily TIA clinics may be having a significant effect on reducing strokes.
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Affiliation(s)
- Dipankar Dutta
- From the Stroke Service (D.D., E.B.) and Research Design Service (C.F.), Gloucestershire Royal Hospital, Gloucester, UK
| | - Emily Bowen
- From the Stroke Service (D.D., E.B.) and Research Design Service (C.F.), Gloucestershire Royal Hospital, Gloucester, UK
| | - Chris Foy
- From the Stroke Service (D.D., E.B.) and Research Design Service (C.F.), Gloucestershire Royal Hospital, Gloucester, UK
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Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P, Dennis M. An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation. Health Technol Assess 2014; 18:1-368, v-vi. [PMID: 24791949 DOI: 10.3310/hta18270] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment. OBJECTIVES Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention? DATA SOURCES Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. REVIEW METHODS Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios. RESULTS The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective. LIMITATIONS Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity. CONCLUSIONS Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Miriam Brazzelli
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hector Miranda
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zahid Quayyum
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Duncan Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Abstract
Background:transient ischemic attack (tIA) and minor stroke have a high risk of early neurological deterioration, and patients who experience early improvement are at risk of deterioration. We generated a score for quantifying the worst reported motor and speech deficits and assessed whether this predicted outcome.Methods:510 tIA or minor stroke (NIHSS>4) patients were included. the Historical Stroke Severity Score (HSSS) prospectively quantified the patient's description of the worst motor or speech deficits. the HSSS was rated at the time of first assessment with more severe deficits scoring higher. Motor HSSS included assessments of arm and leg motor power (score total 0-5). Speech HSSS assessed severity of dysarthria and aphasia (total 0-3). the association between motor and speech HSSS and symptom progression was assessed during the 90-day follow-up period.Results:the proportion of patients in each category of the motor HSSS was 0: 43% (216/510), 1: 22%(110/510), 2: 17% (89/510), 3: 7% (37/510), 4: 5% (28/510) and 5: 6% (30/510). Motor HSSS was associated with symptom progression (p=0.004) but not recurrent stroke. Speech HSSS was not associated with either progression or recurrent stroke. Motor HSSS predicted disability (p=0.002) and intracranial occlusion (p=0.012). Disability increased with increasing motor HSSS.Conclusions:taking a detailed history about the severity of motor deficits, but not speech, predicted outcome in tIA and minor stroke patients. A score based on the patient's description of the severity of motor symptoms predicted symptom progression, intracranial occlusion and functional outcome, but not recurrent stroke in a tIA and minor stroke population.
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Chiu LHS, Yau WH, Leung LP, Pang P, Tsui CT, Wan KA, Au TTS, Fong WC, Chung SHJ. Short-Term Prognosis of Transient Ischemic Attack and Predictive Value of the ABCD(2) Score in Hong Kong Chinese. Cerebrovasc Dis Extra 2014; 4:40-51. [PMID: 24715897 PMCID: PMC3975175 DOI: 10.1159/000360074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 01/27/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Literature on prognosis of transient ischemic attack (TIA) in Chinese is scarce. The short-term prognosis of TIA and the predictive value of the ABCD(2) score in Hong Kong Chinese patients attending the emergency department (ED) were studied to provide reference for TIA patient management in our ED. METHODS A cohort of TIA patients admitted through the ED to 13 acute public hospitals in 2006 was recruited through the centralized electronic database by the Hong Kong Hospital Authority (HA). All inpatients were e-coded by the HA according to the International Classification of Diseases, Ninth Revision (ICD9). Electronic records and hard copies were studied up to 90 days after a TIA. The stroke risk of a separate TIA cohort diagnosed by the ED was compared. RESULTS In the 1,000 recruited patients, the stroke risk after a TIA at days 2, 7, 30, and 90 was 0.2, 1.4, 2.9, and 4.4%, respectively. Antiplatelet agents were prescribed in 89%, warfarin in 6.9%, statin in 28.6%, antihypertensives in 39.3%, and antidiabetics in 11.9% of patients after hospitalization. Before the index TIA, the prescribed medications were 27.6, 3.7, 11.3, 27.1, and 9.7%, respectively. The accuracy of the ABCD(2) score in predicting stroke risk was 0.607 at 7 days, 0.607 at 30 days, and 0.574 at 90 days. At 30 days, the p for trend across ABCD(2) score levels was 0.038 (OR for every score point = 1.36, p = 0.040). Diabetes mellitus, previous stroke and carotid bruit were associated with stroke within 90 days (p = 0.038, 0.045, 0.030, respectively). A total of 45.4% of CTs of the brain showed lacunar infarcts or small vessel disease. There was an increased stroke risk at 90 days in patients with old or new infarcts on CT or MRI. Patients with carotid stenosis ≥70% had an increased stroke risk within 30 (OR = 6.335, p = 0.013) and 90 days (OR = 3.623, p = 0.050). Stroke risks at days 2, 7, 30, and 90 in the 289 TIA patients diagnosed by the ED were 0.35, 2.4, 5.2, and 6.2%, respectively. CONCLUSION The short-term stroke risk in Hong Kong Chinese TIA patients is low. The administered nonurgent treatment cannot solely explain the favorable outcome, the lower risk can be due to the different pathophysiological mechanisms of stroke between Caucasians and Chinese. The predictive value of the ABCD(2) score is low in our population.
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Affiliation(s)
- Lai Hong Simon Chiu
- Accident and Emergency Department at Princess Margret Hospital, Hong Kong, SAR, PR China
| | - Wah Hon Yau
- Accident and Emergency Department at Queen Elizabeth Hospital, Hong Kong, SAR, PR China
| | - Ling Pong Leung
- Accident and Emergency Department at Queen Mary Hospital, Hong Kong, SAR, PR China
| | - Peter Pang
- Accident and Emergency Department at Yan Chai Hospital, Hong Kong, SAR, PR China
| | - Chee Tat Tsui
- Accident and Emergency Department at Princess Margret Hospital, Hong Kong, SAR, PR China
| | - Kuang An Wan
- Accident and Emergency Department at Ruttongie and Tang Siu Kin Hospital, Hong Kong, SAR, PR China
| | - Thomas Tak-Shun Au
- Accident and Emergency Department at Pamela Youde Nethersole Eastern Hospital, Hong Kong, SAR, PR China
| | - Wing Chi Fong
- Department of Medicine and Geriatrics, Queen Elizabeth Hospital, Hong Kong, SAR, PR China
| | - Shun Hang Joseph Chung
- Accident and Emergency Department at Tuen Mun Hospital, Queen Elizabeth Hospital, Hong Kong, SAR, PR China
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Hao Z, Liu M, Wang D, Wu B, Tao W, Chang X. Etiologic subtype predicts outcome in mild stroke: prospective data from a hospital stroke registry. BMC Neurol 2013; 13:154. [PMID: 24156360 PMCID: PMC4015702 DOI: 10.1186/1471-2377-13-154] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 10/15/2013] [Indexed: 02/05/2023] Open
Abstract
Background Few studies on whether etiologic subtype can predict outcome in mild stroke are available. The study aim to explore the effect of different etiologic subtype on prognosis of these patients. Methods We prospectively registered consecutive cases of acute ischemic stroke from September. 01, 2009 to August. 31, 2011. Patients with National Institute of Health Stroke Scale (NIHSS) ≦3 and within 30 days of symptom onset were included. All cause death or disability (defined as modified Rankin Scale >2) were followed up at 3 months. The multivariate logistical regression model was used to analyse relationship between etiologic subtype and clinical outcomes. Results We included 680 cases, which accounted for 41.1% (680/1655) of the total registered cases. Mean age were 62.54 ± 13.51 years, and males were 65.4%. The median time of symptoms onset to admission was 72 hours. 3.8% (26/680) of cases admitted within 3 hours and 4.7% (32/680) admitted within 4.5 hours. However, no patient received intravenous thrombolysis. Of included patients, 21.5% large-artery atherosclerosis, 40.6% small-vessel disease, 7.5% cardioembolisms, 2.2% other causes and 28.2% undetermined causes. The rate of case fatality and death/disability was 2.2% and 10.1% respectively at 3 months. After adjustment of potential confounders, such as age, sex, NIHSS on admission and vascular risk factors et al., cardioembolism (RR = 3.395;95%CI 1.257 ~ 9.170) was the predictor of death or disability at 3 months and small vessel occlusion (RR = 0.412;95%CI 0.202 ~ 0.842) was the protective factor of death or disability at 3 months. Conclusion Different etiologic subtype can predict the outcome in patients with mild stroke and it can help to stratify these patients for individual decision-making.
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Affiliation(s)
| | - Ming Liu
- From the Stroke Clinical Research Unit, Department of Neurology, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu 610041, China.
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ABCD2 Score May Discriminate Minor Stroke from TIA on Patient Admission. Transl Stroke Res 2013; 5:128-35. [DOI: 10.1007/s12975-013-0286-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/12/2013] [Accepted: 08/29/2013] [Indexed: 10/26/2022]
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Edwards D, Fletcher K, Deller R, McManus R, Lasserson D, Giles M, Sims D, Norrie J, McGuire G, Cohn S, Whittle F, Hobbs V, Weir C, Mant J. RApid Primary care Initiation of Drug treatment for Transient Ischaemic Attack (RAPID-TIA): study protocol for a pilot randomised controlled trial. Trials 2013; 14:194. [PMID: 23819476 PMCID: PMC3716929 DOI: 10.1186/1745-6215-14-194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 06/14/2013] [Indexed: 11/23/2022] Open
Abstract
Background People who have a transient ischaemic attack (TIA) or minor stroke are at high risk of a recurrent stroke, particularly in the first week after the event. Early initiation of secondary prevention drugs is associated with an 80% reduction in risk of stroke recurrence. This raises the question as to whether these drugs should be given before being seen by a specialist – that is, in primary care or in the emergency department. The aims of the RAPID-TIA pilot trial are to determine the feasibility of a randomised controlled trial, to analyse cost effectiveness and to ask: Should general practitioners and emergency doctors (primary care physicians) initiate secondary preventative measures in addition to aspirin in people they see with suspected TIA or minor stroke at the time of referral to a specialist? Methods/Design This is a pilot randomised controlled trial with a sub-study of accuracy of primary care physician diagnosis of TIA. In the pilot trial, we aim to recruit 100 patients from 30 general practices (including out-of-hours general practice centres) and 1 emergency department whom the primary care physician diagnoses with TIA or minor stroke and randomly assign them to usual care (that is, initiation of aspirin and referral to a TIA clinic) or usual care plus additional early initiation of secondary prevention drugs (a blood-pressure lowering protocol, simvastatin 40 mg and dipyridamole 200 mg m/r bd). The primary outcome of the main study will be the number of strokes at 90 days. The diagnostic accuracy sub-study will include these 100 patients and an additional 70 patients in whom the primary care physician thinks the diagnosis of TIA is possible, rather than probable. For the pilot trial, we will report recruitment rate, follow-up rate, a preliminary estimate of the primary event rate and occurrence of any adverse events. For the diagnostic study, we will calculate sensitivity and specificity of primary care physician diagnosis using the final TIA clinic diagnosis as the reference standard. Discussion This pilot study will be used to estimate key parameters that are needed to design the main study and to estimate the accuracy of primary care diagnosis of TIA. The planned follow-on trial will have important implications for the initial management of people with suspected TIA. Trial registration ISRCTN62019087
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Affiliation(s)
- Duncan Edwards
- General Practice and Primary Care Research Unit, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
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Does Diffusion-Weighted Imaging Predict Short-Term Risk of Stroke in Emergency Department Patients With Transient Ischemic Attack? Ann Emerg Med 2013; 61:62-71.e1. [DOI: 10.1016/j.annemergmed.2012.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 01/10/2012] [Accepted: 01/10/2012] [Indexed: 11/22/2022]
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Olson DM, Cox M, Pan W, Sacco RL, Fonarow GC, Zorowitz R, Labresh KA, Schwamm LH, Williams L, Goldstein LB, Bushnell CD, Peterson ED. Death and rehospitalization after transient ischemic attack or acute ischemic stroke: one-year outcomes from the adherence evaluation of acute ischemic stroke-longitudinal registry. J Stroke Cerebrovasc Dis 2012; 22:e181-8. [PMID: 23273788 DOI: 10.1016/j.jstrokecerebrovasdis.2012.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 09/11/2012] [Accepted: 11/01/2012] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Longitudinal data directly comparing the rates of death and rehospitalization of patients discharged after transient ischemic attack (TIA) versus acute ischemic stroke (AIS) are lacking. METHODS Data were analyzed from 2802 patients (TIA n = 552; AIS n = 2250) admitted to 100 U.S. hospitals participating in the Get With The Guidelines-Stroke and the Adherence Evaluation of Acute Ischemic Stroke-Longitudinal registry. The primary composite outcome was the adjusted rate of all-cause death and rehospitalization over 1 year after discharge. Four additional single or combined outcomes were explored. RESULTS Compared with AIS, TIA patients were older (median 69 v 66 years; P = .007) and more likely female (53.3% v 44.2%; P < .0001). Secondary prevention medication use after hospital discharge was less intensive after TIA, with underuse for both conditions. All-cause death or rehospitalization at 1 year was similar for TIA and AIS patients (37.7% v 34.6%; P = .271); the frequency for TIA patients was higher after covariate adjustment (hazard ratio [HR] 1.19; 95% confidence interval [CI] 1.01-1.41). One-year all-cause mortality was similar among those with TIA compared to AIS patients (3.8% v 5.7%; P = .071; adjusted HR 0.86; 95% CI 0.52-1.42). All-cause rehospitalizations were higher for TIA compared to AIS patients (36.4% v 33.0%; P = .186; adjusted HR 1.20; 95% CI 1.02-1.42), but similar for stroke rehospitalizations (10.1% v 7.4%; P = .037; adjusted HR 1.38, 95% CI 0.997-1.92). CONCLUSIONS Patients with TIA have similar or worse 12-month postdischarge risk of death or rehospitalization as compared with those with AIS. Outcomes after TIA and AIS might be improved with better adherence to secondary preventive guidelines.
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Affiliation(s)
- Daiwai M Olson
- Department of Medicine, Duke Clinical Research Institute, Durham, NC, Durham, NC.
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22
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Assessment of ABCD² scale in patients with transient ischaemic attack or stroke. Neurol Neurochir Pol 2012; 46:421-7. [PMID: 23161185 DOI: 10.5114/ninp.2012.31351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in patients with transient ischaemic attack (TIA) or minor ischaemic stroke (MIS). MATERIAL AND METHODS Consecutive patients with TIA or MIS referring to Ghaem Hospital, Mashhad presenting within 24 hours from the onset of symptoms were recruited to the prospective cohort study between 2010 and 2011. MIS was defined as an ischaemic stroke with National Institutes of Health Stroke Scale (NIHSS) score < 4. The end-point of the study was a new ischaemic cerebrovascular event or vascular death at 90 days and, additionally, at 3 days after the index TIA or MIS. The decision to admit and of method of treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD2 scoring system for recurrent stroke or TIA was quantified by the area under the curve (AUC), using the c-statistics. RESULTS The study included 393 patients with TIA (238 males, 155 females) and 118 patients with MIS (77 males, 41 females). Among 511 patients with minor ischaemic events, 117 strokes (23.2%), 99 TIAs (19.6%), and 11 vascular deaths (2.2%) occurred within 3 months after the index event. The ABCD2 score had a weak predictive value for 3-month and 3-day recurrent stroke in patients with TIA (AUC = 0.599 and 0.591, respectively), but a high predictive value for 3-month and 3-day recurrent stroke in patients with MIS (AUC = 0.727 and 0.728, respectively). CONCLUSION The ABCD2 score is highly predictive for short-term recurrent stroke in patients with MIS but not in patients with TIA, although it was originally designed for patients with TIA.
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Bedada GB, Smith CJ, Tyrrell PJ, Hirst AA, Agius R. Short-term effects of ambient particulates and gaseous pollutants on the incidence of transient ischaemic attack and minor stroke: a case-crossover study. Environ Health 2012; 11:77. [PMID: 23067103 PMCID: PMC3533825 DOI: 10.1186/1476-069x-11-77] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 10/10/2012] [Indexed: 05/18/2023]
Abstract
BACKGROUND While several studies have investigated the effects of short-term air pollution on cardiovascular disease, less is known about its effects on cerebrovascular disease, including stroke and transient ischaemic attack (TIA). The aim of the study was to assess the effects of short-term variation in air pollutants on the onset of TIA and minor stroke. METHODS We performed secondary analyses of data collected prospectively in the North West of England in a multi-centre study (NORTHSTAR) of patients with recent TIA or minor stroke. A case-crossover study was conducted to determine the association between occurrence of TIA and the concentration of ambient PM10 or gaseous pollutants. RESULTS A total of 709 cases were recruited from the Manchester (n = 335) and Liverpool (n = 374) areas. Data for the Manchester cohort showed an association between ambient nitric oxide (NO) and risk of occurrence of TIA and minor stroke with a lag of 3 days (odds ratio 1.06, 95% CI: 1.01 - 1.11), whereas negative association was found for the patients from Liverpool. Effects of similar magnitude, although not statistically significant, were generally observed with other pollutants. In a two pollutant model the effect of NO remained stronger and statistically significant when analysed in combination with CO or SO2, but was marginal in combination with NO2 or ozone and non-significant with PM10. There was evidence of effect modification by age, gender and season. CONCLUSIONS Our data suggest an association between NO and occurrence of TIA and minor stroke in Greater Manchester.
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Affiliation(s)
- Getahun Bero Bedada
- Institute of Environmental Medicine, Unit of Environmental Health, Karolinska Institutet, Scheele lab, 5th floor, Nobels väg 13, Solna Campus, SE-171 77, Stockholm, Sweden
| | - Craig J Smith
- Brain Injury Research Group, School of Biomedicine, The University of Manchester, Clinical Sciences Building, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Manchester, M6 8HD, UK
| | - Pippa J Tyrrell
- Brain Injury Research Group, School of Biomedicine, The University of Manchester, Clinical Sciences Building, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Manchester, M6 8HD, UK
| | - Adrian A Hirst
- Centre for Epidemiology, Institute of Population Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Raymond Agius
- Centre for Epidemiology, Institute of Population Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL, UK
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Ghandehari K, Ahmadi F, Ebrahimzadeh S, Shariatinezhad K, Ghandehari K. The ABCD(2) Score is Highly Predictive of Stroke in Minor Ischemic Stroke Patients. Transl Stroke Res 2012; 3:273-8. [PMID: 24323783 DOI: 10.1007/s12975-012-0146-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 02/08/2012] [Indexed: 11/30/2022]
Abstract
Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in transient ischemic attack (TIA) and minor ischemic stroke (MIS) patients. Consecutive TIA or MIS patients referred to Ghaem Hospital, Mashhad were enrolled in a prospective cohort study during 2010-2011. Only TIA or MIS patients presenting within 24 h from the onset of symptoms were recruited. MIS was considered as ischemic stroke with NIHSS <4. The end point of the study was a new ischemic cerebrovascular event or vascular death at 90 days and additionally at 3 days. The decision to admit and treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD(2) scoring system for recurrent stroke or TIA was quantified by the area under the cure (AUC) using the c statistics. Three hundred ninety-three TIA patients (238 males, 155 females) and 118 MIS patients (77 males, 41 females) were enrolled in the study. One hundred seventeen strokes (23.2%), 99 TIA (19.6%), and 11 vascular death (2.2%) occurred within 3 months postevent in the whole of our 511 patients with minor ischemic events. The ABCD(2) score had a weak predictive value for 3 months and 3 days recurrent stroke in our TIA patients (AUC = 0.599, AUC = 0.591), but a high predictive value for 3 months and 3 days recurrent stroke in our MIS patients (AUC = 0.727, AUC = 0.728), respectively. The ABCD(2) score is highly predictive of short-term recurrent stroke in MIS patients but not TIA cases, despite its creation for TIA cohorts.
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Affiliation(s)
- Kavian Ghandehari
- Neuroscience Research Center, Mashhad University of Medical Sciences (MUMS), Mashhad, Iran,
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Selvarajah JR, Smith CJ, Hulme S, Georgiou R, Sherrington C, Staniland J, Illingworth KJ, Jury F, Payton A, Ollier WE, Vail A, Rothwell NJ, Hopkins SJ, Tyrrell PJ. Does Inflammation Predispose to Recurrent Vascular Events after Recent Transient Ischaemic Attack and Minor Stroke? the North West of England Transient Ischaemic Attack and Minor Stroke (NORTHSTAR) Study. Int J Stroke 2011; 6:187-94. [DOI: 10.1111/j.1747-4949.2010.00561.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background and hypothesis Inflammation is implicated in the pathogenesis and outcome of ischaemic injury. Poststroke inflammation is associated with outcome but it remains unclear whether such inflammation precedes or results from ischaemic injury. We hypothesised that inflammatory markers are associated with an increased risk of recurrent vascular events soon after transient ischaemic attack and minor stroke. Methods This was a multicentre, prospective, nested case–control study. Plasma concentrations of C-reactive protein, interleukin-6, interleukin-1-receptor antagonist and fibrinogen, leucocyte counts, erythrocyte sedimentation rate and inflammatory gene allele frequencies were analysed in 711 patients with recent transient ischaemic attack or minor stroke. Cases were defined by the incidence of one or more recurrent vascular events during the three-month follow-up. Association of inflammatory markers with case-status was determined using conditional logistic regression. Results Plasma concentrations of C-reactive protein, interleukin-1-receptor antagonist and interleukin-6 were not associated with case-status. In secondary analyses, only erythrocyte sedimentation rate was significantly associated with case-status (odds ratio 1·39, 95% confidence interval 1·03–1·85; P=0·03), but this effect did not persist after adjustment for smoking and past history of transient ischaemic attack or stroke. Single nucleotide polymorphisms in four inflammatory genes (interleukin-6, fibrinogen, P-selectin and vascular cell adhesion molecule-1) were nominally associated with case-status. Conclusions Circulating inflammatory markers were not associated with recurrent vascular events. Nominally significant associations between genetic markers and case-status will require replication. These data provide little evidence for an inflammatory state predisposing to stroke and other vascular events in a susceptible population.
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Affiliation(s)
| | - Craig J. Smith
- Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Sharon Hulme
- School of Biomedicine, The University of Manchester, UK
| | | | | | - John Staniland
- Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | | | - Francine Jury
- Centre for Integrated Genomic Medical Research, The University of Manchester, Manchester, UK
| | - Antony Payton
- Centre for Integrated Genomic Medical Research, The University of Manchester, Manchester, UK
| | - William E. Ollier
- Centre for Integrated Genomic Medical Research, The University of Manchester, Manchester, UK
| | - Andy Vail
- Health Methodology Research Group, The University of Manchester, UK
| | | | | | - Philippa J. Tyrrell
- Salford Royal Hospitals NHS Foundation Trust, Salford, UK
- School of Biomedicine, The University of Manchester, UK
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Holzer K, Feurer R, Sadikovic S, Esposito L, Bockelbrink A, Sander D, Hemmer B, Poppert H. Prognostic value of the ABCD2 score beyond short-term follow-up after transient ischemic attack (TIA)--a cohort study. BMC Neurol 2010; 10:50. [PMID: 20565966 PMCID: PMC2906428 DOI: 10.1186/1471-2377-10-50] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 06/21/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transient ischemic attack (TIA) patients are at a high vascular risk. Recently the ABCD2 score was validated for evaluating short-term stroke risk after TIA. We assessed the value of this score to predict the vascular outcome after TIA during medium- to long-term follow-up. METHODS The ABCD2 score of 176 TIA patients consecutively admitted to the Stroke Unit was retrospectively calculated and stratified into three categories. TIA was defined as an acute transient focal neurological deficit caused by vascular disease and being completely reversible within 24 hours. All patients had to undergo cerebral MRI within 5 days after onset of symptoms as well as extracranial and transcranial Doppler and duplex ultrasonography. At a median follow-up of 27 months, new vascular events were recorded. Multivariate Cox regression adjusted for EDC findings and heart failure was performed for the combined endpoint of cerebral ischemic events, cardiac ischemic events and death of vascular or unknown cause. RESULTS Fifty-five patients (32.0%) had an ABCD2 score < or = 3, 80 patients (46.5%) had an ABCD2 score of 4-5 points and 37 patients (21.5%) had an ABCD2 score of 6-7 points. Follow-up data were available in 173 (98.3%) patients. Twenty-two patients (13.8%) experienced an ischemic stroke or TIA; 5 (3.0%) a myocardial infarction or acute coronary syndrome; 10 (5.7%) died of vascular or unknown cause; and 5 (3.0%) patients underwent arterial revascularization. An ABCD2 score > 3 was significantly associated with the combined endpoint of cerebral or cardiovascular ischemic events, and death of vascular or unknown cause (hazard ratio (HR) 4.01, 95% confidence interval (CI) 1.21 to 13.27). After adjustment for extracranial ultrasonographic findings and heart failure, there was still a strong trend (HR 3.13, 95% CI 0.94 to 10.49). Whereas new cardiovascular ischemic events occurred in 9 (8.3%) patients with an ABCD2 score > 3, this happened in none of the 53 patients with a score < or = 3. CONCLUSIONS An ABCD2 score > 3 is associated with an increased general risk for vascular events in the medium- to long-term follow-up after TIA.
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Affiliation(s)
- Katrin Holzer
- Department of Neurology, Klinikum rechts der Isar, Technische Universität, Munich, Germany.
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Giles MF, Rothwell PM. Systematic review and pooled analysis of published and unpublished validations of the ABCD and ABCD2 transient ischemic attack risk scores. Stroke 2010; 41:667-73. [PMID: 20185786 DOI: 10.1161/strokeaha.109.571174] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The ABCD system was derived to predict early risk of stroke after transient ischemic attack. Independent validations have reported conflicting results. We therefore systematically reviewed published and unpublished data to determine predictive value and generalizability to different clinical settings and users. METHODS Validations of the ABCD and ABCD2 scores were identified by searching electronic databases, reference lists, relevant journals, and conference abstracts. Unpublished tabulated data were obtained where available. Predictive value, expressed as pooled areas under the receiver operator characteristic curves (AUC), was calculated using random-effects meta-analysis, and analyses for heterogeneity were performed by categorization according to study setting and method. RESULTS Twenty cohorts were identified reporting the performance of the ABCD system in 9808 subjects with 456 strokes at 7 days. Among the 16 studies of both the ABCD and ABCD2 scores, pooled AUC for the prediction of stroke at 7 days were 0.72 (0.66 to 0.78) and 0.72 (0.63 to 0.82), respectively (P diff=0.97). The pooled AUC for the ABCD and ABCD2 scores in all cohorts reporting relevant data were 0.72 (0.67 to 0.77) and 0.72 (0.63 to 0.80), respectively (both P<0.001). Predictive value varied significantly between studies (P<0.001), but 75% of the variance was accounted for by study method and setting, with the highest pooled AUC for face-to-face clinical evaluation and the lowest for retrospective extraction of data from emergency department records. CONCLUSION Independent validations of the ABCD system showed good predictive value, with the exception of studies based on retrospective extraction of nonsystematically collected data from emergency department records.
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Affiliation(s)
- Matthew F Giles
- Stroke Prevention Research Unit, NIHR Biomedical Research Centre, Oxford University Department of Clinical Neurology, John Radcliffe Hospital, Oxford , UK.
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Asimos AW, Johnson AM, Rosamond WD, Price MF, Rose KM, Catellier D, Murphy CV, Singh S, Tegeler CH, Felix A. A Multicenter Evaluation of the ABCD2 Score's Accuracy for Predicting Early Ischemic Stroke in Admitted Patients With Transient Ischemic Attack. Ann Emerg Med 2010; 55:201-210.e5. [DOI: 10.1016/j.annemergmed.2009.05.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Revised: 03/24/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
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Ibayashi S. [The secrets how to examine elderly stroke patients]. Nihon Ronen Igakkai Zasshi 2010; 47:544-546. [PMID: 21301147 DOI: 10.3143/geriatrics.47.544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Fothergill A, Christianson TJH, Brown RD, Rabinstein AA. Validation and refinement of the ABCD2 score: a population-based analysis. Stroke 2009; 40:2669-73. [PMID: 19520983 DOI: 10.1161/strokeaha.109.553446] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Transient ischemic attacks are a frequent diagnosis in the emergency department setting, yet expert opinion as to the proper follow-up and need for hospitalization differs widely. Recently, an effort has been made to risk-stratify patients presenting with transient ischemic attacks through scoring systems such as the ABCD and ABCD2 scales. The aim of our study was to independently validate these scores using a population-based cohort. METHODS Using the data from the Rochester Stroke and Transient Ischemic Attack Registry and resources of the Rochester Epidemiology Project, medical records of all residents of Rochester, Minn, with a diagnosis of incident transient ischemic attack from 1985 through 1994 were examined (N=284). Patients were scored on the ABCD and ABCD2 scales and new scores were created by adding hyperglycemia and a history of hypertension. The end points of stroke and death were collected previously and were verified through the Rochester Epidemiology Project data. RESULTS Although our study did find that scores >4 had a statistically significant predictive value for future stroke, a substantial proportion of strokes within 7 days (9 of 36 cases [25%]) occurred in patients with low or intermediate risk scores (< or =4) on the ABCD2 scale. Including history of hypertension and hyperglycemia on presentation increased the sensitivity of the score to identify patients who had a stroke within 7 days. CONCLUSIONS Reliance on the ABCD and ABCD2 scores misses some patients who will have a stroke within 7 days of a transient ischemic attack. Adding hyperglycemia and a history of hypertension to the predictive model could be useful, but the value of these additions need to be evaluated further.
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Affiliation(s)
- Amy Fothergill
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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