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Timpone VM, Reid M, Jensen A, Poisson SN, Callen AL, Costa B, Trivedi PS. Association of Incomplete Neurovascular Imaging After Emergency Department Encounters for Transient Ischemic Attack and Odds of Subsequent Stroke: A National Medicare Analysis. AJR Am J Roentgenol 2023; 221:673-686. [PMID: 37255044 DOI: 10.2214/ajr.23.29352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND. Multisociety guidelines recommend urgent brain and neurovascular imaging for patients with transient ischemic attack (TIA), to identify and treat modifiable stroke risk factors. Prior research suggests that most patients with TIA who present to the emergency department (ED) do not receive prompt neurovascular imaging. OBJECTIVE. The purpose of this study was to evaluate the association between incomplete neurovascular imaging workup during ED encounters for TIA and the odds of subsequent stroke. METHODS. This retrospective study obtained data from the Medicare Standard Analytical Files for calendar years 2016 and 2017; these files contain 100% samples of claims for Medicare beneficiaries. Information was extracted using ICD 10th revision (ICD-10) and CPT codes. Those patients who were discharged from an ED encounter with a TIA diagnosis and who underwent brain CT or brain MRI during or within 2 days of the encounter were identified. Patients were considered to have complete neurovascular imaging if they underwent cross-sectional vascular imaging of both the brain (brain CTA or brain MRA) and neck (neck CTA, neck MRA, or carotid ultrasound) during or within 2 days of the encounter. The association between incomplete neurovascular imaging and a new stroke diagnosis within the subsequent 90 days was tested by multivariable logistic regression analysis. RESULTS. The sample included 111,417 patients (47,370 men, 64,047 women; 26.0% older than 84 years) who had TIA ED encounters. A total of 37.3% of patients (41,592) had an incomplete neurovascular imaging workup. A new stroke diagnosis within 90 days of the TIA ED encounter occurred in 4.4% (3040/69,825) of patients with complete neurovascular imaging versus 7.0% (2898/41,592) of patients with incomplete neurovascular imaging. Incomplete neurovascular imaging was associated with increased likelihood of stroke within 90 days (OR, 1.30 [95% CI, 1.23-1.38]) after adjustment for patient characteristics (age, sex, race and ethnicity, high-risk comorbidities, median county household income) and hospital characteristics (region, rurality, number of beds, major teaching hospital designation). CONCLUSION. TIA ED encounters with incomplete neurovascular imaging were associated with higher odds of subsequent stroke occurring within 90 days. CLINICAL IMPACT. Increased access to urgent neurovascular imaging for patients with TIA may represent a target that could facilitate detection and treatment of modifiable stroke risk factors.
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Affiliation(s)
- Vincent M Timpone
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Margaret Reid
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, CO
| | - Alexandria Jensen
- Department of Biostatistics & Informatics, Stanford School of Medicine, Palo Alto, CA
| | - Sharon N Poisson
- Department of Neurology, University of Colorado Hospital, Aurora, CO
| | - Andrew L Callen
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Bernardo Costa
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Premal S Trivedi
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
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Lapi D, Federighi G, Lonardo MS, Chiurazzi M, Muscariello E, Tenore G, Colantuoni A, Novellino E, Scuri R. Effects of physical exercise associated with a diet enriched with natural antioxidants on cerebral hypoperfusion and reperfusion injury in spontaneously hypertensive rats. Front Physiol 2023; 14:1091889. [PMID: 36755790 PMCID: PMC9900024 DOI: 10.3389/fphys.2023.1091889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023] Open
Abstract
Oxidative stress is implicated in the pathogenesis of arterial hypertension. The reduction in the bioavailability of nitric oxide (NO) causes endothelial dysfunction, altering the functions of cerebral blood vessels. Physical exercise and intake of antioxidants improve the redox state, increasing the vascular NO production and/or the decrease in NO scavenging by reactive oxygen species (ROS). The present study was aimed at assessing the effects of physical exercise associated with a diet enriched with antioxidants from the Annurca apple in preventing the microvascular damage due to cerebral hypoperfusion and reperfusion injury in spontaneously hypertensive rats (SHRs). The rat pial microcirculation was investigated by intravital fluorescence microscopy through a parietal closed cranial window. As expected, SHRs subjected to physical exercise or an antioxidants-enriched diet showed a reduction of microvascular permeability, ROS formation, and leukocyte adhesion to venular walls, with a major effect of the antioxidants-enriched diet, when compared to untreated SHRs. Moreover, capillary perfusion was preserved by both treatments in comparison with untreated SHRs. Unexpectedly, the combined treatments did not induce higher effects than the single treatment. In conclusion, our results support the efficacy of physical activity or antioxidant supplement in reducing the microvascular alterations due to hypertension and ascribe to an antioxidants-enriched diet effective microvascular protection in SHRs.
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Affiliation(s)
- Dominga Lapi
- Department of Biology, University of Pisa, Pisa, Italy,*Correspondence: Dominga Lapi,
| | - Giuseppe Federighi
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Maria Serena Lonardo
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Martina Chiurazzi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Espedita Muscariello
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Giancarlo Tenore
- Department of Pharmacy, University of Naples “Federico II”, Naples, Italy
| | - Antonio Colantuoni
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | | | - Rossana Scuri
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Nouri-Vaskeh M, Khalili N, Sadighi A, Yazdani Y, Zand R. Biomarkers for Transient Ischemic Attack: A Brief Perspective of Current Reports and Future Horizons. J Clin Med 2022; 11:jcm11041046. [PMID: 35207321 PMCID: PMC8877275 DOI: 10.3390/jcm11041046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023] Open
Abstract
Cerebrovascular disease is the leading cause of long-term disability in the world and the third-leading cause of death in the United States. The early diagnosis of transient ischemic attack (TIA) is of great importance for reducing the mortality and morbidity of cerebrovascular diseases. Patients with TIA have a high risk of early subsequent ischemic stroke and the development of permanent nervous system lesions. The diagnosis of TIA remains a clinical diagnosis that highly relies on the patient's medical history assessment. There is a growing list of biomarkers associated with different components of the ischemic cascade in the brain. In this review, we take a closer look at the biomarkers of TIA and their validity with a focus on the more clinically important ones using recent evidence of their reliability for practical usage.
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Affiliation(s)
- Masoud Nouri-Vaskeh
- Tropical and Communicable Diseases Research Centre, Iranshahr University of Medical Sciences, Iranshahr 7618815676, Iran;
- Network of Immunity in Infection, Malignancy and Autoimmunity, Universal Scientific Education and Research Network, Tehran 1419733151, Iran
| | - Neda Khalili
- School of Medicine, Tehran University of Medical Sciences, Tehran 1449614535, Iran;
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran 1419733151, Iran
| | - Alireza Sadighi
- Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA;
| | - Yalda Yazdani
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran;
| | - Ramin Zand
- Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA;
- Neuroscience Institute, Pennsylvania State University, State College, PA 16801, USA
- Correspondence: or ; Tel.: +1-570-808-7330; Fax: +1-570-808-3209
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Fonseca AC, Merwick Á, Dennis M, Ferrari J, Ferro JM, Kelly P, Lal A, Ois A, Olivot JM, Purroy F. European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack. Eur Stroke J 2021; 6:CLXIII-CLXXXVI. [PMID: 34414299 PMCID: PMC8370080 DOI: 10.1177/2396987321992905] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 01/16/2021] [Indexed: 01/14/2023] Open
Abstract
The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.
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Affiliation(s)
- Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Áine Merwick
- Department of Neurology, Cork University Hospital & University College Cork, Cork, Ireland
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Julia Ferrari
- Department of Neurology, St. John´s of God Hospital, Vienna, Austria
| | - José M Ferro
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Peter Kelly
- Stroke Service, Mater University Hospital and HRB Stroke Clinical Trials Network Ireland, University College Dublin, Ireland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Angel Ois
- Department of Neurology, Hospital del Mar, IMIM, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Jean Marc Olivot
- Acute Stroke Unit, Clinical Investigation Center and Toulouse Neuro Imaging Center, Toulouse University Medical Center, Toulouse, France
| | - Francisco Purroy
- Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomedica de Lleida (IRBLleida), Universitat de Lleida (UdL), Lleida, Spain
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Coutts SB, Moreau F, Asdaghi N, Boulanger JM, Camden MC, Campbell BCV, Demchuk AM, Field TS, Goyal M, Krause M, Mandzia J, Menon BK, Mikulik R, Penn AM, Swartz RH, Hill MD. Rate and Prognosis of Brain Ischemia in Patients With Lower-Risk Transient or Persistent Minor Neurologic Events. JAMA Neurol 2020; 76:1439-1445. [PMID: 31545347 DOI: 10.1001/jamaneurol.2019.3063] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Early treatment of patients with transient ischemic attack (TIA) reduces the risk of stroke. However, many patients present with symptoms that have an uncertain diagnosis. Patients with motor, speech, or prolonged symptoms are at the highest risk for recurrent stroke and the most likely to undergo comprehensive investigations. Lower-risk patients are much more likely to be cursorily investigated. Objective To establish the frequency of acute infarct defined by diffusion restriction detected on diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI) scan (DWI positive). Design, Setting, and Participants The Diagnosis of Uncertain-Origin Benign Transient Neurological Symptoms (DOUBT) study was a prospective, observational, international, multicenter cohort study of 1028 patients with low-risk transient or minor symptoms referred to neurology within 8 days of symptom onset. Patients were enrolled between June 1, 2010, and October 31, 2016. Included patients were 40 years or older and had experienced nonmotor or nonspeech minor focal neurologic events of any duration or motor or speech symptoms of short duration (≤5 minutes), with no previous stroke. Exposures Patients underwent a detailed neurologic assessment prior to undergoing a brain MRI within 8 days of symptom onset. Main Outcomes and Measures The primary outcome was restricted diffusion on a brain MRI scan (acute stroke). Results A total of 1028 patients (522 women and 506 men; mean [SD] age, 63.0 [11.6] years) were enrolled. A total of 139 patients (13.5%) had an acute stroke as defined by diffusion restriction detected on MRI scans (DWI positive). The final diagnosis was revised in 308 patients (30.0%) after undergoing brain MRI. There were 7 (0.7%) recurrent strokes at 1 year. A DWI-positive brain MRI scan was associated with an increased risk of recurrent stroke (relative risk, 6.4; 95% CI, 2.4-16.8) at 1 year. Absence of a DWI-positive lesion on a brain MRI scan had a 99.8% negative predictive value for recurrent stroke. Factors associated with MRI evidence of stroke in multivariable modeling were older age (odds ratio [OR], 1.02; 95% CI, 1.00-1.04), male sex (OR, 2.03; 95% CI, 1.39-2.96), motor or speech symptoms (OR, 2.12; 95% CI, 1.37-3.29), ongoing symptoms at assessment (OR, 1.97; 95% CI, 1.29-3.02), no prior identical symptomatic event (OR, 1.87; 95% CI, 1.12-3.11), and abnormal results of initial neurologic examination (OR, 1.71; 95% CI, 1.11-2.65). Conclusions and Relevance This study suggested that patients with transient ischemic attack and symptoms traditionally considered low risk carry a substantive risk of acute stroke as defined by diffusion restriction (DWI positive) on a brain MRI scan. Early MRI is required to make a definitive diagnosis.
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Affiliation(s)
- Shelagh B Coutts
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Francois Moreau
- Department of Medicine, Neurology, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Negar Asdaghi
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Jean-Martin Boulanger
- Department of Neurology, Charles LeMoyne Hospital, Sherbrooke University, Longeuil, Quebec, Canada
| | - Marie-Christine Camden
- Department of Neurosciences, Enfant-Jésus Hospital, Laval University, Quebec City, Quebec, Canada
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Thalia S Field
- Vancouver Stroke Program, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martin Krause
- Northern Clinical School, University of Sydney, Royal North Shore Hospital, Sydney, Australia
| | - Jennifer Mandzia
- Department of Clinical Neurosciences, Western University, London, Ontario, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Robert Mikulik
- International Clinical Research Center, Neurological Department, St Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Andrew M Penn
- Division of Neurology, Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Richard H Swartz
- Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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