Angiographic appearance of carotid bifurcation in pateints with completed stroke,transient ischaemic attacks,and cerebral tumour.

The angiographic appearance of the carotid bifurcation was compared in groups of patients aged 50-59 suffering from transient ischaemic attacks (40 cases), cerebral infarction with completed stroke (44 cases), and cerebral hemisphere tumour (66 cases). Carotid occlusion was found in 14% of those with infarcts and 5% of those with transient ischaemic attacks. Carotid stenosis was found in 40% of those with ischaemic attacks and 14% of those with infarcts. Minor irregularity of the carotid arterial wall was equally common in all three groups.     

Relevance of duration of transient ischaemic attacks in carotid territory.

A retrospective review of the clinical and angiographic features of 116 patients who had had one or more transient ischaemic attacks in the carotid territory showed that stenosis of ther cervical portion of the internal carotid artery was significantly more prevalent among patients whose attacks had been brief, with full recovery in under one hour. This information may be helpful in selecting patients for angiography.     

Management and outcomes of transient ischemic attacks in Ontario

BackgroundCanadian data on the characteristics, management and outcomes of patients with transient ischemic attack (TIA) are lacking. We studied prospectively a cohort of consecutive patients presenting with TIA to the emergency department of 4 regional stroke centres in Ontario.MethodsUsing data from the Ontario Stroke Registry linked with provincial administrative databases, we determined the short-term outcomes after TIA and assessed patient management in the emergency department and within 30 days after the index TIA. We compared the TIA patients with a cohort of patients who had ischemic stroke.ResultsThree-quarters of the TIA patients were discharged from the emergency department. After discharge, the 30-day stroke risk was 5% (13/265) overall and 8% (13/167) among those with a first-ever TIA; the 30-day risk of stroke or death was 9% (11/127) among the TIA patients with a speech deficit and 12% (9/76) among those with a motor deficit. Half of the cases of stroke occurred within the first 2 days after the TIA. Diagnostic investigations were underused in hospital and on an outpatient basis within 30 days after the index TIA, the rates being as follows: CT scanning, 58% (211/364); carotid Doppler ultrasonography, 44% (162/364); echocardiography, 19% (70/364); cerebral angiography, 5% (19/364); and MRI, 3% (11/364). Antithrombotic therapy was not prescribed for more than one-third of the patients at discharge. Carotid endarterectomy was performed in 2% within 90 days.InterpretationPatients in whom TIA is diagnosed in the emergency department have high immediate and short-term risks of stroke. However, their condition is underinvestigated and undertreated compared with stroke: many do not receive the minimum recommended diagnostic tests within 30 days. We need greater efforts to improve the timely delivery of care for TIA patients, along with investigation of treatments administered early after TIA to prevent stroke.Transient ischemic attack (TIA) precedes 15% of stroke cases and represents a special opportunity for preventive intervention. Despite published recommendations,^1,2,3,4,5 management of TIA in clinical practice is variable and often suboptimal.^6,7,8,9 According to Goldstein and colleagues,¹⁰ one-third of patients presenting to a primary care office with a first-ever TIA or minor stroke did not receive diagnostic investigations or hospitalization within 1 month. Patients and physicians may underestimate the serious nature of TIA or the need for prompt evaluation and treatment.^7,9,11We studied a consecutive series of patients with an emergency department diagnosis of TIA at 4 regional centres participating in the Ontario Stroke Registry. Through links with provincial administrative databases, we evaluated the short-term outcomes after TIA as well as the patterns of practice and resource use in the management of TIA.     

Why is the outcome of transient ischaemic attacks different in different groups of patients?

The outcomes of each of three large cohorts of patients with transient ischaemic attacks, which were studied in the same country at much the same time with the same methods, were compared and found to be quite different from each other. The differences in outcome were related not only to different strategies of treatment but also to differences in the prevalence and level of important prognostic factors (for example, case mix) and other factors such a the time delay from transient ischaemic attack to entry into the study and the play of chance. The implications for purchasers of health care are that they cannot rely solely on non-randomised comparisons of outcome of patients treated in competing units as a measure of the quality of care (which has only rather modest effects) without accounting for other factors that may influence outcome such as the nature of the illness, the case mix, observer bias, and the play of chance.     

Ambulatory Goeckerman treatment of psoriasis: experience with 200 patients.

At a psoriasis day care centre 200 patients were treated with an ambulatory Goeckerman regimen, 25 of them twice, because of recurrence. This treatment consists of the application of a coal tar preparation at home at bedtime, followed the next day by exposure to high-intensity short wavelength ultraviolet radiation (UVB) at the centre. Treatment was given 5 days a week for 1 month. The psoriasis cleared in 86% of the patients after a mean of 21.6 UVB treatment sessions. The mean length of remission was 5.1 months, but at the time of follow-up 15 patients were still free of psoriasis. Compliance with the regimen was good to excellent in 94% of the patients. In our hands ambulatory treatment of psoriasis is much less expensive than hospital treatment and gives better results than photochemotherapy.     

Neuroprotective effects of tanshinones in transient focal cerebral ischemia in mice.

Tanshinones are the major lipid soluble pharmacological constituents of Danshen, the dried roots of Salvia miltiorrhiza Bunge (Labiatae), a well known traditional Chinese medicine used for the treatment of cerebrovascular diseases including stroke. Potential neuroprotective effects of tanshinones IIA (TsIIA) and IIB (TsIIB) were examined in adult mice subjected to transient focal cerebral ischemia caused by middle cerebral artery occlusion (MCAo). Our results revealed that TsIIA (16 mg/kg) readily penetrated the blood brain barrier reaching a peak concentration of 0.41 nmol/g brain wet weight 60 minutes after intraperitoneal injection and decreased slowly over several hours. Twenty-four hours after middle cerebral artery occlusion, brain infarct volume was reduced by 30% and 37% following treatment with TsIIA and TsIIB, respectively. The reduction in brain infarct volume was accompanied by a significant decrease in the observed neurological deficit. Tanshinones or other structurally related compounds may have potential for further development as neuroprotective drugs.     

Survey of general practitioners' attitudes to management of patients with heart attacks.

Out of 305 general practitioners sent a questionnaire asking how they would treat three hypothetical patients with heart attacks 231 (76%) replied. Of these, only 179 were prepared to make an unqualified choice of home or hospital treatment for a middle-aged man with an uncomplicated attack, 70 (39%) saying that they would keep the patient at home. Practitioners qualifying before 1960 were more likely to do this than those qualifying in 1960 or later. If a patient declined hospital treatment 161 (70%) of the practitioners would keep him in bed for a week or less, but the date of the practitioners'' qualification significantly affected the time they would advise him to remain off work. Faced with a patient acutely ill after a heart attack, 162 (70%) of the practitioners would arrange his immediate admission to hospital and 51 (22%) would send him to hospital after initial treatment at home. The numbers of partners in the practice, the nature of the premises, and the location of the practice in urban or rural areas affected the practitioners'' attitude to the management of severely ill patients but not to the management of patients with uncomplicated attacks.     

Ambulatory ECG-based T-wave alternans and heart rate turbulence can predict cardiac mortality in patients with myocardial infarction with or without diabetes mellitus

ABSTRACT: BACKGROUND: Many patients who survive a myocardial infarction (MI) remain at risk of sudden cardiac death despite revascularization and optimal medical treatment. We used the modified moving average (MMA) method to assess the utility of T-wave alternans (TWA) and heart rate turbulence (HRT) as risk markers in MI patients with or without diabetes mellitus (DM). METHODS: We prospectively enrolled 248 consecutive patients: 96 with MI (post-MI patients); 77 MI with DM (post-MI + DM patients); 75 controls without cardiovascular disease (group control). Both TWA and HRT were measured on ambulatory electrocardiograms (AECGs). HRT was assessed by two parameters [BOX DRAWINGS LIGHT HORIZONTAL] turbulence onset (TO) and turbulence slope (TS). HRT was considered positive when both TO [GREATER-THAN OR EQUAL TO]0% and TS [LESS-THAN OR EQUAL TO]2.5 ms/R-R interval were met. The endpoint was cardiac mortality. RESULTS: TWA values differed significantly between MI and controls. Post-MI + DM patients had higher TWA values than post-MI patients (58 [PLUS-MINUS SIGN] 21 muV VS 52 [PLUS-MINUS SIGN] 18 muV, P = 0.029). Impaired HRT--increased TO and decreased TS were observed in MI patients with or without DM. During follow-up of 578 [PLUS-MINUS SIGN] 146 days, cardiac death occurred in ten patients and three of them suffered sudden cardiac death (SCD). Multivariate analysis determined that a HRT-positive outcome [HR (95% CI): 5.01, 1.33--18.85; P = 0.017], as well as the combination of abnormal TWA ([GREATER-THAN OR EQUAL TO]47 muV) and positive HRT had significant association with the endpoint [HR (95% CI): 9.08, 2.21--37.2; P = 0.002)]. CONCLUSION: This study indicates that AECGs-based TWA and HRT can predict cardiac mortality in MI patients with or without DM. Combined analysis TWA and HRT may be a convenient and useful method of identifying patients at high risk for cardiovascular death.     

Fibrinogen and lipid concentrations as risk factors for transient ischaemic attacks and minor ischaemic strokes.

OBJECTIVES--To determine whether fibrinogen and lipid concentrations are risk factors for ischaemic stroke. DESIGN--Case-control study with a population based comparison within the overall study. SETTING--Oxfordshire community stroke project and a neurology clinic. SUBJECTS--105 patients who had a transient ischaemic attack or minor ischaemic stroke and 352 randomly chosen controls matched for age and sex from the same general practitioners as the incident cases. 52 controls were ineligible or refused interview. 104 cases and 241 controls gave blood samples for analysis. MAIN OUTCOME MEASURES--Response to structured questionnaire, height, weight, blood pressure, and serum concentrations of fibrinogen and lipids. RESULTS--Adjusted for other variables, odds ratios of ischaemic stroke were 1.78 (95% confidence interval 0.91 to 3.48; p = 0.09) [corrected] for fibrinogen concentrations greater than 3.6 g/l; 1.73 (0.90 to 3.29; p = 0.09) [corrected] for total cholesterol concentrations greater than 6.0 mmol/l; 1.34 (0.69 to 2.61; p greater than 0.4) for low density lipoprotein cholesterol concentrations greater than 3.5 mmol/l; and 0.32 (0.15 to 0.69; p = 0.002) for high density lipoprotein cholesterol concentration greater than 1.2 mmol/l. Similar results emerged comparing only community derived cases with transient ischaemic attacks and controls. The effects of fibrinogen, total cholesterol, and high density lipoprotein cholesterol were significant in a test of trend after adjusting for all other variables in the study (chi 2 = 4.14, p less than 0.05; chi 2 = 4.31, p less than 0.05, and chi 2 = 12.15, p greater than 0.001, respectively). History of ischaemic heart disease and hypertension were the only other variables that showed significance, though both lost significance after adjustment (2.06, p = 0.08 and 1.53, p = 0.2, respectively). CONCLUSIONS--Fibrinogen and lipids are important risk factors for ischaemic stroke. The pattern of changes mirrors that found in ischaemic heart disease.