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.     

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.     

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 electrocardiographic records in patients with transient cerebral attacks or palpitation.

Continuous electrocardiographic (ECG) records were made over 24 hours in 130 ambulant outpatients complaining of syncope, dizzy turns, or palpitation. In all these patients resting ECGs had failed to show significant dysrhythmias. Exercise testing was performed on 64 patients and also failed to reveal any dysrhythmias. Analysis of the tape recordings, however, showed appreciable dysrhythmias in 74% of the group. In most cases the dysrhythmias were complex mixtures of rapid supraventricular and ventricular rhythms. bouts of ventricular tachycardia were seen in seven patients, all of whom were women. Episodic complete heart block was seen in only two patients, but prolonged ventricular gaps (greater than 1-5 s), not associated with ectopic beats, were found in 26. No episodes of ventricular fibrillation were recorded. We conclude that many patients with vague symptoms suggestive of transient cerebral ischaemia or irregular heart action have significant and often dangerous dysrhythmias which can be diagnosed only by long-term recording of the ECG under fully ambulant conditions.     

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.