cardiovascular-agents and Ischemic-Attack--Transient

Cryptogenic strokes account for about 25% to 40% of total ischemic strokes, and 1 of the 3 of these have a patent foramen ovale (PFO). A meta-analysis concerning the effectiveness and safety of PFO closure in cryptogenic strokes or transient ischemic attacks (TIAs) was performed. We systematically searched Medline, Embase, and the Cochrane Library through April 2018. Eligible studies were randomized clinical trials. Primary and secondary end points were, respectively, stroke or TIA and stroke recurrences. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for all end points using fixed- and random-effects meta-analyses. Data were included from 6 trials involving 3560 patients. In the pooled analysis, PFO closure was superior to medical treatment for both primary (RR: 0.39; 95% CI: 0.18-0.82; P < .02) and secondary end points (RR: 0.58; 95% CI: 0.44-0.76; P < .001). Transcatheter closure significantly increased the risk of new-onset atrial fibrillation (AF; RR: 5.74; P < .001). Percutaneous closure is superior to medical treatment in reducing stroke and TIA recurrence, even if with a significant risk increasing for new-onset AF. These findings suggest that transcatheter closure is indicated in patients with cryptogenic strokes and large PFO.

Topics: Adult; Age Factors; Atrial Fibrillation; Cardiac Catheterization; Cardiovascular Agents; Female; Foramen Ovale, Patent; Humans; Ischemic Attack, Transient; Male; Middle Aged; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Sex Factors; Stroke; Time Factors; Treatment Outcome

The ideal treatment strategy for patients with cryptogenic stroke and patent foramen ovale (PFO) is not yet clear. Previous randomized controlled trials (RCTs) comparing transcatheter PFO closure with medical therapy in patients with cryptogenic stroke to prevent recurrent ischemic stroke showed mixed results. This meta-analysis aims to compare rates of recurrent stroke, transient ischemic attack (TIA) and all-cause mortality with PFO closure and medical therapy vs. medical therapy alone.. PubMed and the Cochrane Center Register of Controlled Trials were searched for studies published through June 2018, comparing PFO closure plus medical therapy versus medical therapy alone. Six RCTs (n = 3750) comparing PFO closure with medical therapy were included in the analysis. End points were recurrent stroke, TIA and all-cause mortality. The odds ratios (OR) with 95% confidence interval (CI) were computed and p < 0.05 was considered as a level of significance.. A total of 1889 patients were assigned to PFO closure plus medical therapy and 1861 patients were assigned to medical therapy only. Risk of recurrent stroke was significantly lower in the PFO closure plus medical therapy group compared to medical therapy alone. (OR 0.47, 95% CI 0.33-0.67, p < 0.0001). Rate of TIA was similar between the two groups (OR 0.76, 95% CI 0.52-1.14), p = 0.18). There was no difference in all-cause mortality between two groups (OR 0.73, CI 0.33-1.58, p = 0.42). Patients undergoing PFO closure were more likely to develop transient atrial fibrillation than medical therapy alone (OR: 5.85; CI: 3.06-11.18, p ≤0.0001) whereas the risk of bleeding was similar between the groups (OR: 0.93; CI: 0.55-1.57, p = 0.78).. The results of this meta-analysis suggest that transcatheter closure of PFO plus medical therapy is superior to medical therapy alone for the prevention of recurrent cryptogenic stroke. However, PFO closure in these patients has not been shown to reduce the risk of recurrent TIA or all-cause mortality. There is a higher rate of transient atrial fibrillation post PFO closure device placement, the long-term effects of which have yet to be studied.

Topics: Adolescent; Adult; Cardiac Catheterization; Cardiovascular Agents; Combined Modality Therapy; Female; Foramen Ovale, Patent; Humans; Ischemic Attack, Transient; Male; Middle Aged; Randomized Controlled Trials as Topic; Recurrence; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome; Young Adult

Patent foramen ovale (PFO) closure has emerged as a secondary prevention option in patients with PFO and cryptogenic stroke. However, the comparative efficacy and safety of percutaneous closure and medical therapy in patients with cryptogenic stroke and PFO remain unclear.. Randomized controlled trials (RCTs) and comparative observational studies that compared PFO closure against medical therapy, each with a minimal of 20 patients in the closure arm and 1-year follow-up were included.. We analyzed 6961 patients from 20 studies (5 RCTs and 15 observational studies) with a median follow-up of 3.1 years. Moderate-quality evidence showed that PFO closure was associated with a significantly lower incidence of the composite outcome of ischemic stroke, transient ischemic attack (TIA), or all-cause death (odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.38 to 0.85; P = 0.006), mainly driven by lower incidence of stroke (OR: 0.39; 95% CI: 0.24 to 0.63; P < 0.001). The numbers needed to treat were 43 and 39 for the composite outcome and recurrent ischemic stroke respectively. PFO closure increased the risks for atrial fibrillation or atrial flutter (OR: 5.74; 95% CI: 3.08 to 10.70; P < 0.001; high-quality evidence) and pulmonary embolism (OR: 3.03; 95% CI: 1.06 to 8.63; P = 0.038; moderate-quality evidence), with the numbers needed to harm being 30 and 143 respectively. The risks for TIA, all-cause death, and major bleeding were not statistically different. Analyses limited to RCTs showed similar findings, as did a series of other subgroup analyses.. In conclusion, PFO closure reduced the incidences of stroke and the composite outcome of ischemic stroke, TIA, or all-cause death, but increased risks for atrial fibrillation or atrial flutter and pulmonary embolism compared with medical therapy.

Topics: Adult; Atrial Fibrillation; Atrial Flutter; Cardiac Catheterization; Cardiovascular Agents; Female; Foramen Ovale, Patent; Humans; Incidence; Ischemic Attack, Transient; Male; Middle Aged; Observational Studies as Topic; Pulmonary Embolism; Randomized Controlled Trials as Topic; Risk Factors; Stroke; Time Factors; Treatment Outcome

The optimal strategy of secondary stroke prevention in patients with patent foramen ovale (PFO) is controversial. This study was performed to evaluate the efficacy and safety of the device closure (DC) versus the medical therapy (MT) in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO.. Randomized controlled trials with active and control groups receiving the DC plus MT and MT alone in patients with history of cryptogenic stroke/TIA and diagnosis of PFO were systematically searched. The main efficacy outcome was stroke recurrence. Subgroup-analyses were performed according to age, shunt size, and presence of atrial septal aneurysm (ASA). Safety endpoints included any serious adverse event (SAE), atrial fibrillation (AF), and major bleeding complications. Risk ratios (RRs) and hazard ratios (HRs) with 95% CIs were estimated. Five trials were included, involving 3,440 participants (DC = 1,829, MT = 1,611). There was a protective effect of closure in the risk of recurrent stroke (RR 0.43 [0.21-0.90]; p = 0.024; HR = 0.39 [0.19-0.83]; p = 0.014). The benefit of PFO closure was significant in patients with PFO associated with substantial right-to-left shunt or ASA. There were no differences in the risks of SAEs and major bleedings between the groups. The rate of new-onset AF was higher in the DC than in the MT arm (RR 4.46 [2.35-8.41]; p < 0.001). Successful device implantation and effective PFO closure were achieved in 96 and 91% of the patients respectively. Key Messages: In selected adult patients with PFO and history of cryptogenic stroke, the DC plus MT is more effective to prevent stroke recurrence and is associated with an increased risk of new-onset AF compared to the MT alone.

Topics: Adult; Cardiac Catheterization; Cardiovascular Agents; Female; Foramen Ovale, Patent; Humans; Ischemic Attack, Transient; Male; Middle Aged; Protective Factors; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Stroke; Time Factors; Treatment Outcome

Medical therapy for asymptomatic carotid artery stenosis (ACAS) may obviate the carotid revascularization, according to recent literature reports, but many studies also considered moderate carotid artery stenosis (50-69% NASCET). This study reviews the most recent series of ACAS focusing on ipsilateral transient ischemic attack (TIA) stroke and annual risk of stroke in patients with ACAS ≥70%, thereby also evaluating the adherence to best medical therapy (BMT).. A systematic review consisting of all the series of patients with ACAS being treated medically was performed, which was published after 2005. The annual pooled risk of ipsilateral TIA-stroke and stroke in patients with ACAS ≥70% was calculated. A subgroup of studies with BMT defined as ≥90% of the patients in antiplatelet and statin therapy was performed.. Eleven studies, with the enrolling period from 1996 to 2009, were reviewed. Overall, 2185 patients were considered, with a follow-up from 2 to 13 years, for a total of 6834 patients/year. The pooled risk was 3.4%/year for ipsilateral TIA-stroke and 1.6%/year for stroke. Five studies, published from 2014, had BMT adherence, for a total of 1665 patients/year. The pooled risk was 3.5%/year for ipsilateral TIA-stroke and for stroke.. The most recent series of ACAS ≥70% and BMT had an overall stroke rate which is relatively low; however, the risk of developing symptoms is still relevant (3.4%/year).

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Databases, Factual; Endarterectomy, Carotid; Humans; Ischemic Attack, Transient; Medication Adherence

Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.

Topics: Amaurosis Fugax; Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Hemodynamics; Humans; Ischemic Attack, Transient; Patient Selection; Predictive Value of Tests; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Because of its high recurrence rate, active secondary prevention is mandatory once an episode of stroke has occurred. In non-cardioembolic stroke, in addition to lifestyle changes and to targeted treatments, current guidelines recommend aspirin, clopidogrel or aspirin+extended-release dipyridamole. In cardioembolic stroke (due to atrial fibrillation or flutter [AF]), vitamin K antagonists (VKAs) are recommended in most of patients. A favorable risk/benefit ratio of these treatments has been demonstrated also in elderly patients. However, registry data emphasize that such interventions are often under-used, especially in AF patients. A poor knowledge of current guidelines may play a role in hampering their application in clinical practice. The risk of major bleeding associated with antithrombotic drugs, their inherent limitations, such as socio-demographic (age >80 years, living alone) and clinical (previous or recent bleeding, trauma, cancer, dementia) features, may account for the gap between current guidelines for stroke/TIA prevention and clinical practice. The objective of the present report is to evaluate the gap between current recommendations/guidelines for stroke/TIA prevention and clinical practice (registry findings). In our opinion new antithrombotic drugs and detailed educational programs (especially devoted to general practitioners and to some medical specialists), concerning efficacy, safety and limitations of these strategies, are needed to better manage stroke epidemics in the third millennium.

Topics: Anticoagulants; Attitude of Health Personnel; Cardiovascular Agents; Evidence-Based Medicine; Fibrinolytic Agents; Guideline Adherence; Health Knowledge, Attitudes, Practice; Humans; Ischemic Attack, Transient; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Treatment Outcome

Stroke is a major cause of death and disability worldwide. Without improvements in prevention, the burden will increase during the next 20 years because of the ageing population, especially in developing countries. Major advances have occurred in secondary prevention during the past three decades, which demonstrate the broader potential to prevent stroke. We review the main medical treatments that should be considered for most patients with transient ischaemic attack or ischaemic stroke in the acute phase and the long term, and draw attention to recent developments.

Topics: Acute Disease; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Brain Ischemia; Cardiovascular Agents; Cholesterol, HDL; Cholesterol, LDL; Chronic Disease; Developing Countries; Dyslipidemias; Fibrinolytic Agents; Humans; Hypertension; Hypolipidemic Agents; Ischemic Attack, Transient; Predictive Value of Tests; Prognosis; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Time Factors; Triage

Medical treatment has a pivotal role in the treatment of patients with occlusive carotid artery disease. Large trials have provided the justification for operative treatment besides medical treatment in patients with recent significant carotid artery stenosis two decades ago. Since then, medical therapy has evolved tremendously. Next to aspirin, antiplatelet regimens acting on a different level in the modulation of platelet aggregation have made their entry. Moreover, statin therapy has been introduced. These changes among others in secondary stroke prevention, along with better understanding in life-style adjustments and perioperative medical management, have led to a decrease in stroke recurrence. Secondary prevention is therefore now the most important pillar of medical therapy. It consists of antiplatelet therapy, statins and blood pressure lowering agents in all patients. Small adjustments are recommended for those patients referred for invasive treatment. Moreover, long-term medical treatment is imperative. In this article, we summarize current evidence in literature regarding medical management in patients with previous stroke or TIA.

Topics: Antihypertensive Agents; Cardiovascular Agents; Carotid Stenosis; Drug Therapy, Combination; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Platelet Aggregation Inhibitors; Secondary Prevention; Stroke; Time Factors; Treatment Outcome

After a stroke or transient ischaemic attack (TIA) there is a high risk of stroke, particularly in the early days and weeks, and of other serious vascular events. Several preventive medical treatments can reduce these risks; starting them as early as possible will maximise the absolute risk reduction, as long as the diagnosis is secure, there is no known or suspected net harm from treatment, and they are acceptable to the patient. Medical treatments with clear evidence of benefit include: lowering blood pressure after all types of stroke or TIA; lowering blood cholesterol with a statin after ischaemic stroke or TIA; antiplatelet treatment after ischaemic stroke or TIA; and warfarin instead of antiplatelet treatment in patients with ischaemic stroke or TIA who have atrial fibrillation and no contraindications to anticoagulation. Lifestyle changes (for example, stopping smoking, reducing excess alcohol intake, adopting a healthy diet) and careful management of diabetes are also important.

Topics: Blood Pressure; Cardiovascular Agents; Cholesterol; Fibrinolytic Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Myocardial Infarction; Recurrence; Risk Factors; Stroke; Vascular Diseases

Stroke is an important cause of morbidity and mortality, and is an economic burden. Diabetes and obesity are two important modifiable risk factors for stroke. Patients with diabetes have a higher incidence of stroke and a poorer prognosis after stroke. Risk-factor modification is the most important aspect of prevention of stroke in diabetes and obesity. This includes lifestyle modifications and different therapeutic modalities to control conditions, such as diabetes, hypertension, dyslipidemia and arrhythmia. Recent landmark studies have shown the beneficial effects of statins in diabetic patients even with close to normal or normal low-density lipoprotein cholesterol. Obesity, which is a risk factor for diabetes, hypertension and hyperlipidemia has been shown to be an independent risk factor for stroke. Increased leptin, dysregulation of adipocyte proteins, increased insulin resistance and C-reactive protein may be factors involved in the increased incidence of cardiovascular morbidity and mortality directly related to obesity. Visceral fat is a much bigger health risk than subcutaneous fat. Lifestyle interventions and pharmacotherapeutic agents have been used to manage obesity. In morbidly obese patients, surgical intervention seems to be the best method of treatment with a long-lasting favorable metabolic outcome. In the 21st Century, with the advanced medical knowledge and the therapeutic modalities available, it should be possible to reduce the incidence of stroke associated with diabetes and obesity.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Atrial Fibrillation; Blood Glucose; Cardiovascular Agents; Carotid Stenosis; Diabetes Mellitus; Diabetic Angiopathies; Diabetic Nephropathies; Diabetic Retinopathy; Dyslipidemias; Humans; Hypertension; Insulin Resistance; Ischemic Attack, Transient; Leptin; Life Style; Lipoproteins; Obesity; Plasminogen Activator Inhibitor 1; Risk Factors; Smoking; Stroke

The aim of this study was to determine the impact of mean platelet volume (MPV) on the strategy for treatment of atrial fibrillation (AF) with respect to stroke prevention. MPV was analyzed in 265 patients with AF who were undergoing treatment using rhythm or rate control. The primary endpoint was ischemic stroke or a transient ischemic attack (TIA) event. Kaplan-Meier analysis revealed a significantly higher stroke rate in the rate control group compared to the rhythm control group. A significantly higher stroke rate was observed in the higher tertile MPV group (≥7.9 fL) compared to the lower tertile MPV group (<7.3 fL). When the MPV cut-off level was set to 7.85 fL using the receiver operating characteristic curve, the sensitivity was 80.0% and the specificity was 70.4% for differentiating between the group with stroke and the group without stroke. In the Cox proportional hazard analysis, after adjusting for sex, treatment strategy for AF, high MPV level, antithrombotic treatment, and high CHADS2 score, higher MPV, rate control strategy for treatment of AF, and high CHADS2 score were found to be independent predictors of stroke risk. In addition, patients with AF who were treated using rate control had high stroke risk with an MPV over 7.85 fL and high CHADS2 score. The results of this study demonstrate that the MPV and the rate control strategy for treatment of AF were predictive markers for stroke; its predictive power for stroke was independent of female sex and high CHADS2 score in patients with AF.

Topics: Aged; Anti-Arrhythmia Agents; Atrial Fibrillation; Brain Ischemia; Cardiovascular Agents; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Mean Platelet Volume; Middle Aged; Predictive Value of Tests; Proportional Hazards Models; ROC Curve; Sensitivity and Specificity; Stroke; Treatment Outcome

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?. 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.. 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.. ISRCTN62019087.

Topics: Antihypertensive Agents; Aspirin; Cardiovascular Agents; Clinical Protocols; Dipyridamole; Drug Administration Schedule; Drug Therapy, Combination; Emergency Service, Hospital; England; Feasibility Studies; General Practice; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Pilot Projects; Primary Health Care; Referral and Consultation; Research Design; Secondary Prevention; Simvastatin; Time Factors; Treatment Outcome

We sought to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total internal carotid artery (ICA) occlusion.. From January 2003 to December 2006, a total of 309 recently (within 12 months) symptomatic patients with near total ICA occlusion who were eligible for surgery were identified in our institution. Patients were nonrandomly divided into group A (259 patients), who underwent ECEA surgery, and group B (50 patients), who refused surgery. Patients in group B received the best medical treatment based on the opinion of the attending vascular surgeon and/or angiologist. Patients were followed for ipsilateral stroke, transient ischemic accident, and neurologic mortality for 12 months.. There were no intraoperative and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients. There were no differences between the groups with respect to medications on discharge. Cumulative 12 month incidence of TIA, ipsilateral stroke and neurologic mortality was lower in patients who underwent ECEA than in patients on medical therapy (13 [5%] versus 12 [24%], p < 0.001; 4 [1.5%] versus 7 [14%], p < 0.001; and 4 [1.5%] versus 4 [8%], p = 0.034, respectively). Restenosis of the operated ICA was noted in 7 (3%) patients, and progression of near to total occlusion was seen in 15 (37%) patients in group B.. Our data indicate that recently (within 12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

Topics: Aged; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Chi-Square Distribution; Endarterectomy, Carotid; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Patient Selection; Prospective Studies; Recurrence; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Late cerebral vasospasm after subarachnoid hemorrhage (SAH) is a disastrous phenomenon for the patients and a definite treatment has not been established. We studied 48 consecutive patients receiving high-dose diltiazem (5 micrograms/kg/min) injection combined with dextran and hydrocortisone to late cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). All but 2 patients underwent surgery within 72 hours after SAH. Diltiazem was continuously given via a central venous line for up to 2 weeks in conjunction with simple cisternal drainage. 5% of dextran solution (500 ml/day) was infused for 7-10 days. Hydrocortisone was given 1,600 mg on the first day, then the dose was gradually decreased over 14 days. Symptomatic vasospasm (SVS) occurred in 5 patients (10.4%), 4 patients recovered, but 1 had severe neurological deficit. A low density area on CT-scan was observed in 2 patients. Thirty patients (62.5%) had good recovery, 10 patients (20.8%) had moderate disability, 3 (6.3%) had severe disability and 3 (6.3%) had vegetative survival. Two patients died of the initial brain damage. There were no severely hypotensive side effects. However, 3 patients showed atrioventricular blockage on electrocardiogram. These side effects subsided after the dose of the drug was decreased or administration was stopped altogether. These findings show that high-dose calcium antagonist diltiazem therapy combined with dextran and hydrocortisone injection is safe and effective for prevention of late cerebral symptomatic vasospasm after SAH.

Topics: Adult; Aged; Aged, 80 and over; Aneurysm, Ruptured; Anti-Inflammatory Agents; Anticoagulants; Blood Pressure; Cardiovascular Agents; Dextrans; Diltiazem; Drug Therapy, Combination; Female; Heart Rate; Humans; Hydrocortisone; Intracranial Aneurysm; Ischemic Attack, Transient; Male; Middle Aged; Subarachnoid Hemorrhage; Tomography, X-Ray Computed

Transient ischaemic attack (TIA) clinics are important for secondary prevention of fatal or disabling stroke. Non-adherence to prescribed medications is an important reason for treatment failure but difficult to diagnose. This study ascertained the utility of a novel biochemical tool in the objective biochemical diagnosis of non-adherence.. One-hundred consecutive urine samples collected from patients attending the TIA clinic, at a tertiary centre, were analysed for presence or absence of prescribed cardiovascular medications using liquid chromatography-mass spectrometry (LC-MS/MS). Patients were classified as adherent or non-adherent, respectively. Demographic and clinical characteristics were compared between the two cohorts. Univariate regression analyses were performed for individual variables and model fitting was undertaken for significant variables.. The mean duration of follow-up from the index event was 31 days [standard deviation (SD): 18.9]. The overall rate of non-adherence for at least one medication was 24%. In univariate analysis, the number of comorbidities [3.4 (SD: 1.9) vs. 2.5 (1.9), P = 0.032] and total number of all prescribed medications [6.0 (3.3) vs 4.4 (2.1), P = 0.032] were higher in the non-adherent group. On multivariate analysis, the total number of medications prescribed correlated with increased non-adherence (odds ratio: 1.27, 95% Confidence Intervals: 1.1-1.5, P = 0.01).. LC-MS/MS is a clinically useful tool for the diagnosis of non-adherence. Nearly a quarter of TIA patients were non-adherent to their cardiovascular medications Addressing non-adherence early may reduce the risk of future disabling cardiovascular events.

Topics: Cardiovascular Agents; Chromatography, Liquid; Humans; Ischemic Attack, Transient; Secondary Prevention; Stroke; Tandem Mass Spectrometry

Topics: Angioplasty; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Constriction, Pathologic; Humans; Intracranial Arterial Diseases; Ischemic Attack, Transient; Risk; Stents; Stroke; Treatment Outcome

Topics: Angioplasty; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Constriction, Pathologic; Humans; Intracranial Arterial Diseases; Ischemic Attack, Transient; Stents; Stroke; Treatment Outcome

To report long-term results of stent placement and medical therapy for symptomatic and asymptomatic patients, respectively, with carotid artery near-occlusion with full collapse.. Between January 2008 and December 2010, 204 carotid arteries diagnosed by duplex scanning as exhibiting complete occlusion were re-examined with CT angiography; 46 arteries in 46 patients were patent with threadlike lumens and were reclassified as exhibiting near-occlusion with full collapse. Asymptomatic patients (n = 22) received best medical therapy (BMT) alone, and symptomatic patients (n = 24) were referred for carotid artery stent (CAS) placement plus BMT. Patients underwent clinical follow-up for 63.9 months ± 23.6 and duplex surveillance.. None of the 22 asymptomatic patients treated with BMT alone experienced neurologic events during the follow-up interval. Four died of unrelated causes, resulting in a cumulative survival rate of 81.8%. Technical failure occurred in 5 of 24 symptomatic patients, but none had perioperative complications related to inability to cross the near-occlusion. Of the 19 patients with procedural success, 1 developed immediate upper limb monoparesis; none had periprocedural myocardial infarction, and none died. At 60-month follow-up, patients who underwent successful CAS placement had neurologic event-free and cumulative survival rates of 89.4% and 89.4%; patients with failed recanalization had neurologic event-free and cumulative survival rates of 0% and 40.0% (P = .01).. Asymptomatic patients with carotid near-occlusion with full collapse experienced good outcomes with BMT alone. Symptomatic patients who underwent CAS placement demonstrated long-term survival and freedom from neurologic event rates comparable to those of asymptomatic patients.

Topics: Adult; Aged; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Computed Tomography Angiography; Disease-Free Survival; Endovascular Procedures; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Prospective Studies; Risk Factors; Severity of Illness Index; Stents; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone.. From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period.. There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65).. CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.

Topics: Age Factors; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Diagnostic Imaging; Disease Progression; Disease-Free Survival; Endarterectomy, Carotid; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Patient Selection; Recurrence; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

The aim of this study is to evaluate the rate of progression of stenosis and development of symptoms in patients with asymptomatic carotid artery stenosis (aCAS) treated with contemporary medical therapy over a prolonged time interval.. This study is a retrospective review of consecutive patients diagnosed with moderate or severe aCAS at our institution between 2000 and 2001. Data were gathered from both carotid arteries for each patient excluding vessels operated within 1 year of diagnosis and occlusions. Multivariate analysis was performed to analyze factors associated with ipsilateral transient ischemic attack (TIA)/stroke.. We identified 214 patients (58.8% men; median age 70 years) and collected data on 349 vessels. Degree of stenosis was severe (>70%) upon diagnosis in 92 (26.4%) vessels. Median length of follow-up was 13 years (interquartile range 10-14), and mean number of time points for follow-up imaging were 8.1 ± 3.9. Progression of stenosis was observed in 237 (67.9%) vessels, and 72 (20.6%) patients developed symptoms ipsilateral to the stenosis (TIA in 14.4%, non-disabling stroke in 4%, disabling stroke in 2.2%). Median time to appearance of first symptom was 6 years (range 1-13). On multivariate analysis, degree of baseline stenosis, intracranial stenosis >50%, plaque ulceration, silent infarction and previous history of TIA/stroke were associated with ipsilateral TIA/stroke, but progression of stenosis was not.. There was a substantial rate of progression of stenosis in patients with aCAS over time despite adequate medical therapy, but progression of stenosis did not increase the risk of ipsilateral TIA/stroke. Over long-term follow-up, 1 in 5 patients with aCAS developed ipsilateral TIA/stroke, though most events were either transient or non-disabling.

Topics: Aged; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Cerebral Infarction; Comorbidity; Disease Progression; Endarterectomy, Carotid; Female; Follow-Up Studies; Humans; Ischemic Attack, Transient; Male; Middle Aged; Retrospective Studies; Risk; Risk Factors; Stents

We aimed to identify factors easily collected at admission in patients with transient ischemic attack (TIA) that were associated with early recurrence, so as to guide clinicians' decision-making about hospitalization in routine practice. From September 2011 to January 2013, all TIA patients who were referred to the University Hospital of Dijon, France, were identified. Vascular risk factors and clinical information were collected. The etiology of the TIA was defined according to the results of complementary examinations performed at admission as follows: large artery atherosclerosis (LAA-TIA) TIA, TIA due to atrial fibrillation (AF-TIA), other causes, and undetermined TIA. Logistic regression analyses were performed to identify factors associated with any recurrence at 48 hours (stroke or TIA). Among the 312 TIA patients, the etiology was LAA-TIA in 33 patients (10.6%), AF-TIA in 57 (18.3%), other causes in 23 (7.3%), and undetermined in 199 (63.8%). Early recurrence rates were 12.1% in patients with LAA-TIA, 5.3% in patients with AF-TIA, 4.3% in patients with another cause of TIA, and 1.0% in patients with undetermined TIA. In multivariable analysis, the LAA etiology was independently associated with early recurrence (odds ratio [OR]: 12.03; 95% confidence interval [CI]: 1.84-78.48, p=0.009). A non-significant trend was also observed for AF-TIA (OR: 3.82; 95% CI: 0.40-36.62, p=0.25) and other causes (OR: 3.73; 95% CI: 0.30-46.26, p=0.31). A simple initial assessment of TIA patients in the emergency room would be helpful in targeting those with a high risk of early recurrence and who therefore need to be hospitalized.

Topics: Aged; Aged, 80 and over; Atherosclerosis; Atrial Fibrillation; Cardiovascular Agents; Coronary Disease; Diabetes Mellitus; Diagnostic Imaging; Emergencies; Female; France; Humans; Hypercholesterolemia; Hypertension; Ischemic Attack, Transient; Length of Stay; Male; Middle Aged; Patient Admission; Recurrence; Risk Factors; Smoking

Although level 1 evidence supports carotid endarterectomy (CEA) for stroke prevention in patients with asymptomatic severe carotid artery stenosis (ASCAS; >70%), medical therapy alone has been promulgated by some as equally effective. The goal of this study was to determine the natural history of medically treated patients with ASCAS.. Patients with ASCAS from 2005 to 2006 were identified in a health network database. Patients were included if the initial therapeutic plan involved medical therapy alone (usually because of comorbidities or patient preference). Study end points included: ipsilateral neurologic symptoms (INS) of transient ischemic attack and/or stroke, death, and INS and/or death.. There were 126 carotid arteries identified in 115 patients. Using standard duplex velocity criteria, 88 (70%) had severe (70%-89%) and 38 (30%) had very severe stenoses (VSS; 90%-99%). The average age was 73.5 years, demographic characteristics included: 66% hypertension, 64% coronary artery disease, 30% diabetes, 5% chronic kidney disease (CKD), and 86% were taking a statin drug (28% had a low-density lipoprotein level <100 mg/dL). There were 31 patients (24.6%) who developed INS during a mean follow-up of 27 months; most (23 of 31; 74%) occurred within 12 months of the initial duplex ultrasound examination; 14 (45%) were strokes. The 5-year actuarial freedom from INS was 70.1 ± 5%. Multivariate predictors of INS included: VSS (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.56-6.76; P = .002), CKD (HR, 6.25; 95% CI, 2.05-19.2; P = .001), and age (HR, 0.94; 95% CI, 0.91-0.98; P = .001). There were 41 patients (33%) who underwent eventual carotid revascularization (32 CEA, nine stent); 23 of 41 (56%) were performed for INS and 18 (44%) for plaque progression. Overall 5-year actuarial survival was 69.8% ± 4.1%. Multivariate predictors of death included: age (HR, 1.06; 95% CI, 1.03-1.1; P = .0001), chronic obstructive pulmonary disease (HR, 1.92; 95% CI, 1.08-3.41; P = .03), and diabetes (HR, 5.08; 95% CI, 2.86-9.01; P < .0001). The 5-year actuarial freedom from INS and/or death was 54 ± 4.4%. Multivariate predictors of INS and/or death were: VSS (HR, 1.98; 95% CI, 1.22-3.23; P = .006), CKD (HR, 5.46; 95% CI, 2.12-14.08; P = .0004), and diabetes (HR, 2.6; 95% CI, 1.59-4.24; P = .0001). Statin use was not protective against INS or death in this cohort.. Medically managed patients with ASCAS develop INS early, especially in patients with VSS. Medical therapy with aspirin and statins failed to control ASCAS, thus validating the role of CEA in these patients as promulgated in multiple current treatment guidelines.

Topics: Aged; Aspirin; Asymptomatic Diseases; Blood Flow Velocity; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Comorbidity; Disease Progression; Disease-Free Survival; Female; Fibrinolytic Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Multivariate Analysis; Predictive Value of Tests; Proportional Hazards Models; Registries; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Despite level 1 evidence in support of carotid endarterectomy vs medical therapy in selected asymptomatic patients, an alternative posture is that optimal medical therapy (OMT) has not been adequately studied and that such OMT has reduced stroke risk in asymptomatic patients to levels wherein carotid endarterectomy is no longer justified. The goal of this study was to determine the natural history of patients with asymptomatic moderate (50%-69%) carotid artery stenosis (AMCAS) in a contemporary cohort as a function of their associated medical therapy.. Patients with AMCAS determined by duplex ultrasound (DUS) from 2005-2006 were identified in our hospital database. Patients were included in the cohort if they had at least one additional DUS during the 6-year follow-up interval. Patient characteristics including medication history and lipid levels were collected. Patients were considered to have OMT if they were on aspirin and a statin with a low-density lipoprotein level that was always <100 mg/dL. Study end points included progression of carotid disease by DUS to severe stenosis (70%-100%), development of ipsilateral neurologic symptoms (INS) such as stroke or transient ischemic attack, and death.. There were 900 carotid arteries in 794 patients in the study cohort. The average age was 72.5 years, 77.2% had hypertension, 59.6% had coronary artery disease, and 87.1% were on a statin throughout the study. The low-density lipoprotein cholesterol level was always normal (<100 mg/dL) in 37.8% and accordingly, 241 (30.3%) had OMT as defined above. The 5-year actuarial survival was 81.9% ± 1.3% with no advantage seen with OMT. Multivariate analysis of survival showed statins were protective (hazard ratio [HR], 0.50; confidence interval [CI], 0.34-0.73; P = .0004). The 5-year freedom from plaque progression was 61.2% ± 2.1% with no benefit from OMT vs the control group. Multivariate predictors of plaque progression were chronic kidney disease (HR, 2.1; CI, 1.2-3.7; P = .009), aspirin use (HR, 1.9; CI, 1.2-3.0; P = .01), and the use of calcium channel blockers (HR, 1.4; CI, 1.1-1.8; P = .007). There were 90 (11.3%) patients who developed INS during follow-up (58% of these were strokes), and the 5-year freedom from INS was 88.4% ± 1.5%. Multivariate predictors of INS were diabetes (HR, 2.3; CI, 1.5-3.6; P = .0002) and warfarin use (HR, 1.9; CI, 1.2-2.9; P = .009); while statin use (HR, 0.37; CI, 0.22-0.65; P = .0005) was protective against symptom development.. At the 5-year of follow-up, OMT failed to prevent carotid disease progression or development of ipsilateral symptoms in 45% of patients with AMCAS.

Topics: Aged; Aged, 80 and over; Aspirin; Asymptomatic Diseases; Biomarkers; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Cholesterol, LDL; Comorbidity; Disease Progression; Drug Therapy, Combination; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Platelet Aggregation Inhibitors; Proportional Hazards Models; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Topics: Atrial Fibrillation; Cardiovascular Agents; Female; Heart Rate; Humans; Ischemic Attack, Transient; Male; Stroke

Topics: Atrial Fibrillation; Cardiovascular Agents; Female; Heart Rate; Humans; Ischemic Attack, Transient; Male; Stroke

Topics: Atrial Fibrillation; Cardiovascular Agents; Female; Heart Rate; Humans; Ischemic Attack, Transient; Male; Stroke

An aim of the present study was to evaluate the treatment efficacy of the antioxidant mildronate in patients with transitory ischemic attacks. We studied the dynamics of clinical status, psychometric data and indices of free-radical lipid oxidation in 40 patients. The improvement in the subjective state, memory and attention was seen in 24 patients.

Topics: Attention; Cardiovascular Agents; Disease Progression; Free Radical Scavengers; Humans; Ischemic Attack, Transient; Lipid Peroxidation; Magnetic Resonance Imaging; Memory; Methylhydrazines; Psychometrics; Treatment Outcome; Ultrasonography, Doppler, Transcranial

Topics: Angiography; Anti-Inflammatory Agents; Arterial Occlusive Diseases; Cardiovascular Agents; Cryoglobulinemia; Cryoglobulins; Diabetes Mellitus, Type 2; Diagnostic Imaging; Drug Therapy, Combination; Female; Fibrinogens, Abnormal; Fingers; Humans; Hypertension; Ischemia; Ischemic Attack, Transient; Middle Aged

Astragaloside IV and tetramethylpyrazine have been extensively used in the cardio-cerbrovascular diseases of medicine as a chief ingredient of glycoside or alkaloid formulations for the treatment of stroke and myocardial ischemia diseases.. To investigate the effects of astragaloside IV (ASG IV) and tetramethylpyrazine (TMPZ) on cerebral ischemia-reperfusion (IR) injury model in rat model.. Rats were randomly divided into the following five groups: sham group, IR group and treatment group including ASG IV, ASG IV-TMPZ and nimodipine treatment. The therapeutic effect was evaluated by micro-positron emission tomography (Micro-PET) using (18)F-fluoro-2-deoxy-d-glucose. The neurological examination, infarct volume and the levels of oxidative stress- and cell apoptosis-related molecules were assessed.. Micro-PET imaging showed that glucose metabolism in the right hippocampus was significantly decreased in the IR group compared to the sham group (P<0.01). ASG IV and ASG IV-TMPZ treatments reversed the decreased glucose metabolism in the model group (P<0.05 and P<0.01, respectively). IR induced the increase of Caspase-3 mRNA levels, MDA content and iNOS activity, but it caused the decrease of SOD activity and Bcl-2 expression compared the sham group (P<0.01). ASG IV-TMPZ and ASG IV reversed the IR-induced changes of these parameters, i.e. the down regulation of Caspase-3 mRNA, MDA content and iNOS activity, and the up regulation of SOD activity and Bcl-2 expression (P<0.05).. This study showed that ASG IV-TMPZ played a pivotal synergistic protective role against focal cerebral ischemic reperfusion damage in a rat experimental model.

Topics: Animals; Astragalus Plant; Cardiovascular Agents; Caspase 3; Disease Models, Animal; Drug Synergism; Glucose; Hippocampus; Ischemic Attack, Transient; Male; Malondialdehyde; Neuroprotective Agents; Nimodipine; Nitric Oxide Synthase Type II; Phytotherapy; Plant Extracts; Positron-Emission Tomography; Proto-Oncogene Proteins c-bcl-2; Pyrazines; Random Allocation; Rats; Rats, Sprague-Dawley; Reperfusion Injury; RNA, Messenger; Saponins; Superoxide Dismutase; Triterpenes

Stroke is a debilitating condition with an increased risk in patients with atrial fibrillation. Although data from clinical trials suggest that both rate and rhythm control are acceptable approaches with comparable rates of mortality in the short term, it is unclear whether stroke rates differ between patients who filled prescriptions for rhythm or rate control therapy.. We conducted a population-based observational study of Quebec patients ≥65 years with a diagnosis of atrial fibrillation during the period 1999 to 2007 with the use of linked administrative data from hospital discharge and prescription drug claims databases. We compared rates of stroke or transient ischemic attack (TIA) among patients using rhythm (class Ia, Ic, and III antiarrhythmics), versus rate control (β-blockers, calcium channel blockers, and digoxin) treatment strategies (either current or new users). The cohort consisted of 16 325 patients who filled a prescription for rhythm control therapy (with or without rate control therapy) and 41 193 patients who filled a prescription for rate control therapy, with a mean follow-up of 2.8 years (maximum 8.2 years). A lower proportion of patients on rhythm control therapy than on rate control therapy had a CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke or TIA) score of ≥2 (58.1% versus 67.0%, P<0.001). Treatment with any antithrombotic drug was comparable in the 2 groups (76.8% in rhythm control versus 77.8% in rate control group). Crude stroke/TIA incidence rate was lower in patients treated with rhythm control in comparison with rate control therapy (1.74 versus 2.49, per 100 person-years, P<0.001). This association was more marked in patients in the moderate- and high-risk groups for stroke according to the CHADS(2) risk score. In multivariable Cox regression analysis, rhythm control therapy was associated with a lower risk of stroke/TIA in comparison with rate control therapy (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74, 0.87). The lower stroke/TIA rate was confirmed in a propensity score-matched cohort.. In comparison with rate control therapy, the use of rhythm control therapy was associated with lower rates of stroke/TIA among patients with atrial fibrillation, in particular, among those with moderate and high risk of stroke.

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Cardiovascular Agents; Cohort Studies; Female; Follow-Up Studies; Heart Rate; Humans; Ischemic Attack, Transient; Male; Population Surveillance; Stroke; Treatment Outcome

Topics: Cardiovascular Agents; Developed Countries; Developing Countries; Disabled Persons; Genetic Predisposition to Disease; Humans; Interdisciplinary Communication; Ischemic Attack, Transient; Life Style; Patient Care Team; Risk Reduction Behavior; Secondary Prevention; Stroke; Stroke Rehabilitation

Topics: Aspirin; Blood Pressure; Cardiovascular Agents; Endarterectomy, Carotid; Fibrinolytic Agents; History, 20th Century; History, 21st Century; Humans; Ischemic Attack, Transient; Predictive Value of Tests; Prognosis; Stroke; United Kingdom

To assess the short-term prognosis of patients with recent symptomatic intracranial atherosclerotic disease in the posterior circulation and evaluate differences in the outcome of patients receiving medical or endovascular treatment.. The records of 50 consecutive patients with symptomatic intracranial atherosclerotic disease in the posterior circulation were reviewed to record the occurrence of transient ischemic attack, stroke, major bleeding, and/or death during the 12-month period following a neurological event. Twenty-five patients received medical treatment alone, 13 initially received medical treatment and subsequently were treated with angioplasty/stenting due to recurrent events (analyzed in both groups), and 12 patients received endovascular treatment initially. The crossover patients were considered as 1 treated patient in each group; thus, there were 38 subjects (33 men; mean age 68+/-9 years) receiving medical therapy compared with 25 patients (21 men; mean age 63+/-13 years) who underwent endovascular procedures.. During the 12-month period, subjects in the medically-treated group had a higher rate of events (37%, 14/38) than patients who received angioplasty/stenting (12%, 3/25; p = 0.042). Notably, there were 7 (18%) TIAs and 6 (16%) strokes in medically-treated patients versus no TIAs (0%, p = 0.035) and only 2 (8%, p = NS) strokes in the endovascular group, both of which occurred within 48 hours of the procedure. There were no deaths and only a single major bleeding event in each group.. Endovascular treatment of patients with symptomatic intracranial disease of the posterior territory appears to be associated with a substantially better outcome.

Topics: Aged; Angioplasty; Argentina; Cardiovascular Agents; Cerebrovascular Circulation; Chi-Square Distribution; Female; Hemorrhage; Humans; Intracranial Arteriosclerosis; Ischemic Attack, Transient; Male; Middle Aged; Retrospective Studies; Risk Assessment; Risk Factors; Stents; Stroke; Time Factors; Treatment Outcome

In human and experimental animals, the hippocampal CA1 region is one of the most vulnerable areas of the brain to ischemia. Pyramidal neurons in this region die 2-3 days after transient cerebral ischemia whereas other neurons in the same region remain intact. The mechanisms underlying the selective and delayed neuronal death are unclear. We tested the hypothesis that there is an increase in post-synaptic intrinsic excitability of CA1 pyramidal neurons after ischemia that exacerbates glutamatergic excitotoxicity. We performed whole-cell patch-clamp recordings in brain slices obtained 24 h after in vivo transient cerebral ischemia. We found that the input resistance and membrane time constant of the CA1 pyramidal neurons were significantly increased after ischemia, indicating an increase in neuronal excitability. This increase was associated with a decrease in voltage sag, suggesting a reduction of the hyperpolarization-activated non-selective cationic current (I(h)). Moreover, after blocking I(h) with ZD7288, the input resistance of the control neurons increased to that of the post-ischemia neurons, suggesting that a decrease in I(h) contributes to increased excitability after ischemia. Finally, when lamotrigine, an enhancer of dendritic I(h), was applied immediately after ischemia, there was a significant attenuation of CA1 cell loss. These data suggest that an increase in CA1 pyramidal neuron excitability after ischemia may exacerbate cell loss. Moreover, this dendritic channelopathy may be amenable to treatment.

Topics: Animals; Cardiovascular Agents; Cell Death; Disease Models, Animal; Dose-Response Relationship, Radiation; Electric Stimulation; Excitatory Amino Acid Antagonists; Hippocampus; In Vitro Techniques; Ischemic Attack, Transient; Lamotrigine; Male; Membrane Potentials; Patch-Clamp Techniques; Pyramidal Cells; Pyrimidines; Rats; Statistics, Nonparametric; Triazines

Striatal cholinergic interneurons are relatively resistant to ischemic insults. These neurons express hyperpolarization-activated cation current (I(h)) that profoundly regulates neuronal excitability. Changes in neuronal excitability early after ischemia may be crucial for determining neuronal injury. Here we report that I(h) in cholinergic interneurons was decreased 3 h after transient forebrain ischemia, which was accompanied by a negative shift of the voltage dependence of activation. The inhibition of I(h) might be due to the tonic activation of adenosine A1 receptors, as blockade of A1 receptors significantly increased I(h) in postischemic neurons, but had no effect on control neurons. Consistent with the inhibition of I(h), postischemic neurons showed a reduction in both spontaneous firing and hyperpolarization-induced rebound depolarization. These findings indicate that I(h) may play excitatory roles in striatal cholinergic interneurons. Postischemic inhibition of I(h) might be a novel mechanism by which adenosine confers neuronal resistance to cerebral ischemia.

Topics: Animals; Calcium; Cardiovascular Agents; Cholinergic Fibers; Corpus Striatum; Cyclic AMP; Interneurons; Ischemic Attack, Transient; Male; Membrane Potentials; Organ Culture Techniques; Patch-Clamp Techniques; Pyrimidines; Rats; Rats, Wistar; Receptor, Adenosine A1; Stroke

Limited data are available on management of outpatients with stroke or transient ischemic attack (TIA) and on clinicians' reasons for withholding procedures recommended by guidelines. We assessed to what extent guidelines are appropriately applied after ischemic stroke or TIA, in admitted patients as well as outpatients.. A survey was conducted in 11 centers in the Netherlands, which prospectively enrolled 579 admitted patients and 393 outpatients. Data were collected by trained research assistants. Duplicate assessment in 10% of patients showed good agreement with neurologists (median kappa=0.86). Treating neurologists were asked to provide arguments for withholding recommended procedures in eligible patients.. Recommended acute procedures were provided in the majority of admitted patients, but less often in outpatients: brain imaging (98% and 93%, respectively), 12-lead ECG (96% and 81%), laboratory tests (97% and 86%), aspirin within 48 hours (90% and 68% of eligible patients). Secondary preventive measures were not always taken in both eligible inpatients and eligible outpatients: carotid endarterectomy (provided in 31% and 30% of patients), antiplatelet agents (93% and 90%), oral anticoagulants (60% and 48%), antihypertensive agents (57% and 44%), and cholesterol-lowering therapy (71% and 52%). Reasons for withholding recommended procedures were plausible for almost all admitted patients, but were unclear in the majority of outpatients.. Compared with other national stroke surveys, we found high-quality acute care in admitted ischemic stroke patients, whereas secondary prevention was comparably poor. Although the majority of our centers have rapid-access TIA clinics, there is still substantial potential to improve quality of stroke care in outpatients.

Topics: Aged; Ambulatory Care; Cardiovascular Agents; Diagnostic Imaging; Diagnostic Tests, Routine; Drug Utilization; Early Diagnosis; Endarterectomy, Carotid; Female; Guideline Adherence; Health Surveys; Hospital Units; Hospitals, University; Humans; Inpatients; Ischemic Attack, Transient; Male; Middle Aged; Netherlands; Outpatient Clinics, Hospital; Outpatients; Prospective Studies; Quality Assurance, Health Care; Quality of Health Care; Stroke; Thrombolytic Therapy; Time Factors; Withholding Treatment

A wide range of pharmacological treatment options for medical management of vasospasm, following SAH, are reported, i.e. calcium-antagonists, 21-amino-steroids, fibrinolytics, vasodilators and CVF (venom of Cobra). Out of them, action mechanisms and clinical experiences are discussed, pointing out that surgical depletion of cisternal clots, hypertension, hypovolemia and hemodilution still represent a golden standard in the management of vasospasm due to SAH.

Topics: Cardiovascular Agents; Humans; Ischemic Attack, Transient

Topics: Arterial Occlusive Diseases; Arteriosclerosis Obliterans; Cardiovascular Agents; Humans; Ischemic Attack, Transient; Raynaud Disease