XVII. European Stroke Conference
Nice, France
XVII. European Stroke Conference
Nice, France
Poster Session:
TIA
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
A time-efficient in-hospital management may improve prognosis in TIA patients
S. Anticoli
G. Scifoni
F.R.Pezzella
C. Pozzessere
STROKE UNIT Emergency Department San Camillo Hospital - Rome
ITALY
Background: Incidence of stroke 3 months after a TIA ranges from 10 to 15%. Recurrence of cerebrovascular events after TIA is higher than after Stroke or Minor Stroke. To improve TIA outcome, fast and efficient diagnostic workflows are desirable. We set up an in-hospital TIA clinical pathway to improve times of diagnostic evaluation, optimize resources and start promptly farmacological treatment for secondary prevention. Here we summarize the result of fifteen months of activity and the impact on cerebrovascular event recurrence. Methods:Patients presenting TIA history in the last 24 hours referred to our Emergency Department were evaluated by the stroke team. After clinical evaluation that confirmed the diagnosis, NIHSS and the ABCD2 score were calculated in all patients and blood chemistry, ECG, brain CT, MR DWI-ADC sequences and carotid ultrasounds were performed in all patients within 48 hours from admission. Patients underwent a follow-up visit at three, six, twelve months. Findings: 120 patients were exposed to the TIA clinical pathway managed by the stroke team. MR DWI was positive in 39,3%. There was no relation between MR DWI acute lesions and ABCD2 scores, clinical features, duration of symptoms, risk factors and etiologic subtype except cardioembolism (p=0.013). At 3 months 2.02% reported a major cerebrovascular event, two had a new TIA, one died for cardiovascular morbidity. Conclusion: We don't confirm the predictive value of ABCD2 score and DWI acute lesions. However, our data suggest that a time-efficient in-hospital management for TIA patients reduce high recurrence of major cerebrovascular events at 3 months and improve prprognosis. Emergency assessment may save more life and be more cost-effective than outpatients or community service.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
ABCD2 Score as a Predictor of Non-cerebrovascular Diagnoses
T.J.Quinn
A. Cameron
J. Dawson
M.R.Walters
K.R.Lees
Gardiner Institute of Cardiovascular and Medical Sciences
University of Glasgow
UNITED KINGDOM
Background: The ABCD2 score predicts short-term stroke risk after transient ischaemic attack (TIA). Ninety-day risk is negligible in patients with low scores. ABCD2 assumes presentation is with true TIA, but most TIA services assess a variety of other diagnoses. We hypothesised that low ABCD2 score patients have predominantly non-cerebrovascular diagnoses. Methods: Our TIA clinics assess all suspected cerebrovascular events. Comprehensive clinical and investigation details are prospectively recorded. Data were collated for patients seen between August 1992 and January 2005 inclusive. ABCD2 scores were calculated and proportions of non-cerebrovascular diagnoses for each ABCD2 grade were compared using chi-square analysis. Equivalent analyses were performed for brain imaging and carotid stenosis. We calculated positive-predictive-value (PPV) of low (0-1) ABCD2 score for non-cerebrovascular diagnosis and normal brain imaging. Results: ABCD2 scores were derived for 3015 patients (866 non-cerebrovascular diagnosis). There was a positive association between increasing ABCD2 score and cerebrovascular diagnosis (P<0.0001). Higher ABCD2 score was associated with vascular lesions on brain imaging (P<0.0001) but not moderate-severe carotid disease (P=0.202). The PPV of low ABCD score was 0.511 for non-cerebrovascular diagnosis; 0.186 for negative imaging. Discussion: For low scores, the ABCD2 scoring system may select out non-cerebrovascular diagnoses. However, this approach will potentially misclassify half of all true TIA. In ist current form, the ABCD2 score is unsuitable as a diagnostic tool.
http://www.eurostroke.org/ni_graphics/t_aid3003.htm
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
EXAMINING THE EXTERNAL VALIDITY OF THE ABCD SCORES IN A POPULATION-BASED COHORT – THE NORTH DUBLIN STROKE STUDY
O. Sheehan
L.A.Kelly
L. Kyne
P.M.E.Mc Cormack
N. Hannon
J. Duggan
A. Moore
J. Moroney
G. Horgan
P.J.Kelly
Neurovascular Clinical Science Unit, Mater University Hospital *Beaumont Hospital, Connolly Hospital
IRELAND
Background: External validation studies of clinical prediction scores are important before their introduction into clinical practice. Although the ABCD and ABCD2 scores have been validated in similar populations to those in which they were derived, few external validation studies have been performed. Of these, most have had relatively few outcomes and have been hospital-based, with potential for selection bias. We report a validation study in a large population-based cohort in North Dublin city. Methods: Patients with TIA were identified within a prospective cohort study of stroke and TIA in 294,592 individuals in North Dublin city, with multiple overlapping sources of hospital and community case ascertainment. The cohort was expanded by inclusion of patients with definite TIA over a further 6-month period, and inclusion of all patients with transient neurological events (TNEs) referred to a daily TIA clinic serving the population. All initial and recurrence assessments were performed in-person by a trained Stroke Physician. Results: Among 442 individuals with definite TIA (n=256) or TNEs (n=186), 25 recurrent strokes occurred by 90 days. An ABCD score of 4 or more (p=0.02) and ABCD2 score of 5 or more (p=0.05) were associated with higher risk of 90-day stroke. When ABCD2 was collapsed, 90-day stroke rates were 3.3% (score 0-3), 7.6% (score 4-5), and 8.5% (score 6-7) (p=0.05 for trend). However, only 5 strokes (20%) occurred in the highest ABCD2 category. Conclusions: In a large population-based external validation study, we found significant associations between higher scores and stroke at 90 days. However higher scores had limited specificity for prediction of future stroke in our population.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Transient ischemic attack: three radiological faces of one clinical entity
F. Purroy
R. Begué
A. Quílez
J. Sanahuja
L. Brieva
G. Pinyol-Ripoll
M.C.Salas
J. Díez
E. Setó
M.I.Gil
Hospital Universitari Arnau de Vilanova. Lleida
SPAIN
Despite the transience of symptoms in transient ischemic attack (TIA) patients, diffusion weighted images (DWI) reveal an area of water restriction due to acute brain ischemia in almost one half of patients. There are few data of the evolution of acute lesions in these patients. Objective: Our aim was to determine whether acute ischemic lesions on DWI in TIA patients are reversible or correspond to persistent cerebral ischemic infarction. Methods: Among 100 consecutive TIA patients admitted in our hospital DWI and fluid-attenuated inversion recovery (FLAIR) images were performed in 93 patients (delay from TIA 3.8+/-1.8 days). Clinical data, symptom duration,and ultrasonographic findings were collected. MR imaging follow-up (>3 months from initial TIA), including FLAIR, T2, T1 and DWI , was programmed in those patients with initial DWI abnormalities. Quantitative (volume) and qualitative (pattern of lesions) parameters on initial DWI were recorded. We studied variables associated with reversible or irreversible lesions. Results: A total of 46 (49.5%) patients revealed acute ischemic lesions on DWI (scattered pattern 15, single cortical 18 and subcortical 11). Thirty seven patients with 64 ischemic lesions had an MR imaging follow-up (4.9+/-2.4 months). We identified transient injury in 11 (29.7%) patients, while 40 (62.5%) lesions were definitive. Variables associated with permanent brain infarction were motor impairment (18.2% vs 61.5%, p=0.016), scattered pattern (63.6% vs 96.0%, p=0.010) and initial lesion on FLAIR images (9.1% vs 46.2%, p<0.025). The DWI volume was also significantly larger in permanent lesion than in those that were reversible (0.12+/-0.5 vs 1.15+/-1.7, p=0.004). Conclusion: Not all TIA patients with DWI abnormalities have permanent ischemic lesions. According to MRI evolution TIA patients could be classified as clinical TIA (DWI-negative, infarction with transient symptoms (DWI-positive with permanent lesions and transient infarction with transient symptoms (DWI-positive with transient lesions) .
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Do older patients with TIA and minor stroke receive adequate management in a neurovascular clinic?
Y.K.Kee
W. Brooks
A. Bhalla
Epsom & St Helier University Hospitals
UNITED KINGDOM
Background: National guidelines and government directives have adopted policies for urgent assessment of patients with TIA and minor stroke not admitted to hospital. The risk of recurrent stroke increases substantially with age as does the potential benefit of secondary prevention. In order to develop effective strategies for older patients, it is important to identify how stroke care is currently provided for this patient group. Methods: Between 2004 and 2006, older patients (≥75 years) referred with a suspected diagnosis of minor stroke and TIA were compared with younger patients (<75 years). Sociodemographic details, clinical features, resource use and secondary prevention in a neurovascular clinic were collected. Results: Of 379 patients referred to the clinic, 129 (34%) had non stroke diagnosis. Of 250 patients, 149 (60%) were under 75 years. Older patients were more likely to be hypertensive (P<0.001) and have lacunar stroke (P=0.04). Median time from symptom onset to clinic appointment was 24 days for both groups (P=0.58). Computed tomography (CT) were performed in 79% of younger patients compared with 80% of older patients (P=0.8). Waiting times were shorter for younger patients (P<0.001). Magnetic resonance imaging (MRI) scan rates were higher in younger patients (26%) than in older patients (4%), (P<0.01) as was carotid duplex imaging (92% vs. 77%) (P<0.01). There were no significant differences in secondary preventative therapies prescribed. Older patients experienced less delay for carotid endarterectomy, 49 days compared to 149 days for younger patients (P<0.01). Younger patients were given more advice on weight reduction (P<0.01) and dietary advice (P=0.02). Conclusion: Older patients were less likely to receive diagnostic investigations and lifestyle compared with younger patients. Guidelines need to be adopted to ensure prompt evidence based stroke care in the outpatient setting.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
TIA and minor stroke: comparison of risk factor profiles
M.Ö.McCarron
Altnagelvin Hospital, Derry
UNITED KINGDOM
Background: Transient ischaemic attacks (TIAs) and minor strokes are independent predictors of disabling strokes. Because of a similar early risk for subsequent stroke, these groups of patients are often categorised together. In the longer term there is evidence that TIA patients have a better prognosis than minor stroke patients. We therefore compared the risk factor profile in these two groups. Methods: Consecutive patients attending a neurovascular clinic with TIA and minor stroke were prospectively recruited to the study. Demographic and common cerebrovascular risk factors were recorded. The chi square and student’s t tests were used for statistical analyses. Results: Two hundred and eighty-three patients were assessed. Clinically 140 patients presented with cerebrovascular disease, 86 with TIA (40 men, 46 women, mean age 64.3+/-10.4 years) and 54 with stroke (32 men, 22 women, mean age 61.2+/-13.0 years). Sixty-four of 86 patients (74%) had a single TIA and 42 of 54 (77%) patients had a single stroke. Amaurosis fugax occurred in 13 TIA patients (15%). Anterior events were more frequently recognised in the TIA group compared to the minor stroke group (77 or 90% versus 43 or 80%, p>0.05). There were no significant differences among common risk factors (age, diabetes mellitus, ischaemic heart disease, smoking status, family history of cerebrovascular disease among first degree relatives and atrial fibrillation) except that a clinical history of hypertension was more frequent in the TIA group than in the stroke group (44 or 51% versus 18 or 33%, p<0.05) Discussion: Common cerebrovascular risk factors do not account for prognostic differences in TIA and minor stroke patients. Rather, the more favourable prognosis from TIA may be, at least partially due to the recognised better prognosis from amaurosis fugax
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
High Frequency of Ischemic Imaging Events in the FASTER Pilot trial: results of the MR substudy
J. Kennedy
Subramaniam
Hudon
Tymchuk
Ryckborst
Hill
Coutts
Buchan
Demchuk
on behalf of the FASTER Investigators
Acute Stroke Programme, Nuffield Department of Clinical Medicine, University of Oxford
UNITED KINGDOM
Background: Acute magnetic resonance imaging (MRI) following minor stroke or transient ischemic attack (TIA) can help in the stratification of future risk of stroke. The FASTER Pilot trial randomised patients to simvastatin and clopidogrel within 24 hours of onset of minor stroke or TIA to reduce the 90 day risk of stroke. We present the results of the FASTER Pilot MRI substudy. Methods: Consented patients randomised at a single centre in the FASTER pilot trial had an MRI prior to and 90 days following randomisation in addition to the clinical trial follow-up. All scans were read to determine lesions on diffusion weighted imaging (DWI), gradient echo (GRE), FLAIR and MR angiography. The combined outcome was defined as new clinical stroke or new diffusion or FLAIR lesions seen at 90 days. Results: 66 of 123 (53.4%) consecutive FASTER patients were enrolled in the MR substudy. 5 (7.6%) patients did not have 90 day imaging. The mean age was 69, 33 (50%) male and 36 (54.5%) had NIHSS>0 at baseline. Median ABCD2 was 5 (range 3-7). 40 (60.6%) had new DWI lesion at baseline. 5 (7.6%) had a stroke clinical outcome. 12 (18.2%) patients had new DWI or new FLAIR lesions seen on MRI at 90 days. No patients had a new hemorrhagic lesion on 90 day GRE. Randomisation to clopidogrel did not appear to have an effect on the combined (clinical and imaging) outcome (8/34 (23.5%) clopidogrel, 7/32 (21.9%) placebo (p=0.87)). Randomisation to simvastatin revealed trend to reduction in the combined outcome (4/30 (13.3%) simvastatin, 11/36 (30.6%) placebo (p=0.096)). Discussion: This substudy demonstrates feasibility and significant ischemic disease activity with a high 3 month imaging event rate when prerandomisation and 90 day MRI is performed in an acute stroke prevention trial.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
TIA protects ischemic brain by upregulating antioxidant defenses
A. Jurcau
A. Simion
D.S.Tertan
S.D.Covaciu-Marcov
Clinical Hospital of Neurology and Psychiatry
ROMANIA
Background: Transient ischemic attacks (TIAs) protect against a subsequent cerebral ischemia by inducing the ischemic tolerance phenomenon. We examined the incidence of TIA in ischemic stroke subtypes, the influence of previous TIA on recovery, and if the difference may be ascribed to a better defense against oxidative stress. Methods: We recorded for a consecutive series of 150 ischemic stroke patients the stroke subtype (TOAST criteria), the presence of TIAs in the last 10 days, and the clinical status (NIHSS score) on admittance and at discharge. Oxidative stress was evaluated by serum malondialdehyde (MDA) measurements, and antioxidant defenses by assessment of the serum superoxide dismutase (SOD) activity on days 1, 3, and 7. Results: TIAs were recorded in 14 (17%) of macroangiopathic (MA) strokes, 4 (11%) of lacunes (LA), and 11 (32%) of cardioembolisms (CE). Clinically, on admittance, MA and CE strokes preceded by TIAs had higher NIHSS scores (p=0.45, and p=0.001) on admission, but were discharged in similar status. LAs had similar neurological status on admittance and showed a trend towards complete recovery following TIA (p=0.07). Large infarcts (MA and CE) preceded by TIAs exhibited significantly higher serum SOD activity on all 3 measurements (p=0.001, and p=0.05), while in LA, despite a trend towards a higher SOD activity, the difference did not reach statistical significance, presumably due to the small number of cases. The MDA levels were similar for all TIA and non-TIA subtypes. Discussion: In our patients, TIA did not reduce stroke severity, but improved recovery in strokes with larger lesions (MA and CE). This outcome might be due, among others, to an up-regulation of the antioxidant defenses, as suggested by the higher SOD activities.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
A telephone interview to diagnose transient ischemic attack is feasible and sensitive.
D. Manawadu
L.M.Davies
A. Salam
A. Shuaib
T.J.Jeerakathil
University of Alberta
CANADA
Background There exists a need for an accurate telephone instrument to diagnose transient ischemic attack. Telephone contact may reduce delay in recognizing those who may have suffered a TIA, allowing early referral to stroke services. The current gold standard for comparison is the diagnosis made by a stroke physician after patient encounter. We hypothesized that our questionnaire would be accurate in making a diagnosis of TIA when compared with the clinic diagnosis made by a stroke physician. Methods We initially presented standardized clinical scenarios to 7 experienced stroke physicians to establish the particular combinations of symptoms, onset speed, and duration that most likely determined a TIA. A diagnostic algorithm was created from these responses. Patients already diagnosed in Stroke Clinic were telephoned by someone blinded to their diagnosis. Responses to a symptom questionnaire were recorded and the algorithm used to characterize patients into two categories: 1) definite/probable or possible TIA; and 2) non-TIA. Results Telephone interviews were done in 158 patients, 46% males, mean age 66. Average interview length was 10 minutes, performed at a mean of 20 +/- 8 days after Stroke Clinic consultation. The stroke physician diagnosis was definite/probable or possible TIA in 126 patients, and non-TIA in 32. The number of true positives detected by the algorithm was 120 and true negatives 10. The number of false positives diagnosed was 22 with 6 false negatives. The sensitivity of the questionnaire and algorithm for definite/probable or possible TIA was 95% with a specificity of 45%. Positive predictive value was 85% and negative predictive value 63%. Discussion A telephone interview to diagnose TIA is feasible. We noted high sensitivity and good positive predictive value of the questionnaire we designed for this purpose. Our questionnaire and algorithm might find future use as a rapid screening instrument to identify those with a potential TIA, since a screening instrument does not generally require a high specificity.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Long term prognosis of transient ischemic attacks according to causal mechanism
A. Tuna
M. Correia
E. Moreira
R. Magalhães
M.C.Silva
Serviço de Neurologia, Hospital Geral de Santo António, Porto
PORTUGAL
Background: Follow-up studies of TIA are scarce and long term determinants of survival and risk of vascular events are not well defined. This study analyses the 7-year prognosis of TIA according to aetiology. Methods: All patients with a first-ever TIA registered in a population-based study between October 1998 and September 2000 in the city of Oporto were evaluated at baseline, 3, 12 months and 7 years following the index event. Demographic and clinical data was collected and TIA aetiology was classified according to the TOAST classification. Prognosis was determined by the occurrence of a vascular event (stroke or myocardial infarction) or death. Results: Out of the 105 patients registered with a TIA, 74 (70.5%) were thoroughly examined and included in this study. Cardioembolism was the most frequent aetiology (39.2%), followed by small artery occlusion (SAO) (21.6%), large artery atherosclerosis (LAA) (5.4%), undetermined aetiology (28.4%) and others determined causes (5.4%). Compared with SAO+LAA and OTHERS, cardioembolic TIAs were more frequent in women (69% vs. 35% and 40%) and in patients aged ≥64 years (86.2% vs. 50% and 56%) while SAO+LAA TIAs were more frequent in hypertensive patients (90% vs. 75% and 50%) (chi-squared>7, df=2, p<0.005). The Kaplan-Meyer estimate of median time to occurrence of a major vascular event or death was 5 years; in patients older than 64 years the median time increased from 1.8 to 3.3 years when the mechanism was cardio-embolic while in younger patients this median time was 3.5 years and was not reached for other mechanisms (Log Rank chi-squared=8.4, df =3, p<0.04). Conclusion: Patients with cardioembolic TIAs have a worst prognosis then patients with SAO+LAA, other or multiple mechanisms TIAs, specially those 65 years or older. Supported by: FCT/FEDER project POCI/SAU-ESP/59885/2004
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Transient ischemic alarm (TIA)” patients are at high risk for early stroke
A. Chatzikonstantinou
O. Willmann
M.G.Hennerici
Universitaetsklinikum Mannheim, University of Heidelberg
GERMANY
Background: Transient ischemic attacks (TIAs) are difficult to separate from stroke within 24h after onset of symptoms. Today it is unknown which characteristics are useful to identify patients (pts.) at high risk for early recurrences: Neuroimaging has been suggested to support this separation, others prefer time windows for pts. with full recovery <2h vs >2h. Method: All pts. consecutively admitted to our Stroke Unit for suspected TIAs were recruited for this study throughout 2006. Pts. were neurologically examined and underwent prompt brain and cerebrovascular imaging on admission. Results: Among 122 pts., 49(40%) had symptoms lasting <2h, 35(29%) had symptoms >2h but 33(27%) showed recurrent symptoms, usually lasting a few minutes on the first day; in 5 cases (4%) symptom duration could not be determined sufficiently. Only 23 pts. (19%) revealed an acute ischemic lesion on immediate imaging (109 CT & 110 MRI scans). Pts. with/without ischemic lesions revealed symptoms either lasting <2h [10/39 (44%/40%)], or lasting >2h [5/30 (22%/31%)], but 7/26(30%/26%) presented with recurrent symptoms. 11 out of 122 pts. (9%) suffered a further stroke during hospitalisation (mean: 7 days): Among those, 9 initially presented with recurrent symptoms but only 1 with symptoms <2h and 1 >2h. Discussion: Suspected TIA pts. admitted within 24h are at high risk for stroke within a few days after onset of symptoms. Rather than currently assumed, pts. with repeated symptoms during the first day are at highest risk for early stroke, whereas time (<2/>2h) and the presence of early lesions on neuroimaging are of less importance. Thus, they should benefit particularly from continuous monitoring on a Stroke Unit for a few days because they represent pts. with unstable ‘transient ischemic alarms’.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Can we predict carotid stenosis by ABCD2 score or other simple clinical features?
R. Sivakumar
N. Shinh
B. Kingsnorth
A. Ravi
B. Jones
S. Somasundaram
A. Kapoor
Ipswich Hospital, Ipswich
UNITED KINGDOM
BACKGROUND: Early carotid endarterectomy is indicated in patients with severe symptomatic carotid stenosis(CS) and recent transient ischaemic attack(TIA) or minor stroke. However, immediate access to carotid imaging(CI) is limited in many centres where if CS can be suspected by simple clinical features, immediate CI can be prioritised. The following two methods •ABCD2 score of 5 or above and •presence of any one of the clinical features: previous TIA, carotid bruit, diabetes, not a lacunar event had been tested 1,2 previously and we sought to determine their utility in predicting CS in our population. We compared these two methods in TIA patients but in minor strokes we tested the second method only. METHODS: A prospective analysis of all the carotid TIA and minor stroke patients seen by a single senior clinician in a TIA clinic. CI was performed with duplex scanning. RESULTS: 64 TIA and 34 minor stroke patients were included. TIA PATIENTS: 19/64 of TIA patients had ABCD2 score of 5 or above. 46/64 of TIA patients had any one of the above four features. 8/64 patients had CS. The sensitivity(Sn), specificity(Sp), Positive predictive value (PP) and negative predictive value(NP) for ABCD2 score of 5 or above are 50,73,21,91(%) respectively. For the other method: 88,30,15,94 respectively.The difference was only significant for specificity(P<0.001) TIA AND MINOR STROKE PATIENTS: 70/98 of TIA and minor stroke patients had any one of the four features. 9/98 patients had CS. The Sn, Sp, PP and NP are 90,31,13 and 96.(%) DISCUSSION: Both these methods have high NP suggesting that if patient’s ABCD2 score is 4 or below or if none of the above 4 features is present, CS is unlikely. However, these methods are not 100% reliable and hence should be used to prioritise the timing of CI only if it cannot be provided to all patients immediately. References: 1.Cerebrovasc Dis2007;24(2-3):231-5. 2.J Neurol Neurosurg Psychiatry1999;66:16–19
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
High yield of clinically relevant abnormalities beyond the cervical carotid using Arch to Vertex CT-Angiography in TIA and minor stroke: The ideal emergency department vascular screening test?
N. Steffenhagen
I. Dzialowski
V. Puetz
C. O'Reilly
A. Demchuk
University of Calgary/ Department of Clinical Neurosciences
CANADA
Background: Cervical carotid investigations are the most important imaging tests in transient ischemic attack (TIA) and minor stroke patients to rule out carotid stenosis. Computer Tomography Angiography (CTA) has potential advantages over other modalities due to availability and extent of vascular assessment. We examined all vascular information gained by CTA even beyond the cervical carotid in TIA/minor stroke patients acutely evaluated by CTA. Methods: CTA head and neck radiology reports of patients with TIA or minor stroke (National Institute of Health Stroke Scale (NIHSS) score of <6) who were investigated within 24hours of symptom onset were screened for any symptom relevant vascular pathology. Results: 504 (59.4%) of 849 patients from a CTA database had NIHSS score of <6. Brain relevant aortic arch abnormalities were seen in 8 (1.6%). Extracranial vessel pathology included 77 (15.3%) patients with carotid stenosis/occlusions appropriate to symptoms, 46 (9.1%) with contralateral carotid stenosis/occlusions, 15 (3.0%) with nonstenotic carotid ulcerated plaque or intraluminal thrombus, 3 (0.6%) with carotid dissection, and 18 (3.6%) with symptom relevant vertebral stenosis/occlusions. Intracranial large artery stenosis/occlusion relevant to symptoms was present in 79 (15.7%) patients; (52 middle, 2 anterior, 5 posterior cerebral artery , 9 internal carotid artery, 11 vertebrobasilar junction/basilar artery). Typical patterns for vasculitis and arteriovenous malformations were found in 2 (0.4%) patients, respectively. Incidental findings including thyroid nodules, lymphadenopathy, abnormal pattern of vocal cords and lung masses requiring further investigation were reported in 25 (5.0%) cases. Conclusion: CTA identifies a large number of clinically relevant vascular abnormalities well beyond the cervical carotid especially intracranially. Given the practicality of this modality and its vascular yield it should be considered the standard vascular imaging investigation of TIA and minor stroke in the emergency department.
