Periodic Limb Movements and White Matter Hyperintensities in First-Ever Minor Stroke or High-Risk Transient Ischemic Attack

Purpose Carotid artery stenting (CAS) is a valuable alternative to carotid endarterectomy, especially in high-risk patients. However, the reported incidences of perioperative stroke and death remain higher than for carotid endarterectomy, even when using embolic protection devices (EPDs) during CAS. Our purpose was to evaluate 30-day major adverse events after CAS when selecting the most appropriate EPD. Methods We reviewed the clinical outcomes of 61 patients with 64 lesions who underwent CAS with EPDs. Patients who underwent CAS associated with thrombectomy and who had a preoperative modified Rankin scale score >3 were excluded from the analysis. The EPD was selected based on symptoms, carotid wall magnetic resonance imaging and lesion length, and we analyzed combined 30-day complication rates (transient ischemic attack, minor stroke, major stroke or death). Results Forty-nine patients were men and 12 were women. The median age was 72 years (range: 59–89 years) and 44 lesions were asymptomatic. A filter-type EPD was selected in 23 procedures, distal-balloon protection in 14 procedures and proximal-occlusive protection in 27 procedures. Two patients (3.1%) experienced a transient ischemic attack and one patient (1.6%) had a minor stroke within 30 days of the procedure. No patients experienced procedure-related morbidities (modified Rankin score >2) or death. Conclusions The perioperative stoke rate was low when we selected a proximal-occlusive-type EPD in high-risk patients with vulnerable carotid artery disease. Our algorithm for EPD selection was an effective tool in the perioperative management of carotid artery stenosis.

Download Full-text

White matter hyperintensity volume predicts persistent cognitive impairment in transient ischemic attack and minor stroke

International Journal of Stroke ◽

10.1177/1747493016676612 ◽

2016 ◽

Vol 12 (3) ◽

pp. 264-272 ◽

Cited By ~ 12

Author(s):

Leka Sivakumar ◽

Parnian Riaz ◽

Mahesh Kate ◽

Thomas Jeerakathil ◽

Christian Beaulieu ◽

...

Keyword(s):

Cognitive Impairment ◽

White Matter ◽

Transient Ischemic Attack ◽

Cognitive Assessment ◽

Diffusion Weighted Imaging ◽

Montreal Cognitive Assessment ◽

White Matter Hyperintensity ◽

Minor Stroke ◽

Diffusion Weighted ◽

Ischemic Attack

Background Temporary and permanent cognitive changes following transient ischemic attack/minor stroke have been described previously. It is unknown if persisting cognitive deficits in these patients are correlated with acute infarction identified using magnetic resonance imaging. Aims We tested the hypothesis that persistent cognitive impairment after transient ischemic attack/minor stroke can be predicted by the volume of diffusion-weighted imaging lesions. Methods Acute transient ischemic attack/minor stroke (NIH stroke scale score ≤ 3) patients were prospectively recruited within 72 h of onset. Patients underwent Montreal cognitive assessment and magnetic resonance imaging, including diffusion-weighted imaging and Fluid-Attenuated Inverse Recovery sequences, at baseline, days 7 and 30. Cognitive testing was repeated at day 90. Diffusion-weighted imaging lesion and Fluid-Attenuated Inverse Recovery chronic white matter hyperintensity volumes were measured planimetrically. Cognitive impairment was defined a priori as Montreal cognitive assessment score < 26. Results One hundred fifteen patients were imaged at a median (inter-quartile range) of 24.0 (16.6) h after onset. Acute ischemic lesions were present in 91 (79%) patients. Cognitive impairment rates were similar in patients with (47/91, 52%) and without diffusion-weighted imaging lesions (13/24, 54%; p = 0.83). Although linear regression indicated no relationship between acute diffusion-weighted imaging lesion volume and day 30 Montreal cognitive assessment scores (β = −0.163, [−2.243, 0.334], p = 0.144), white matter hyperintensity volumes at baseline were predictive of persistent cognitive deficits after 30 days (β = 2.24, [1.956, 45.369], p = 0.005). Conclusions In most transient ischemic attack/minor stroke patients who suffer acute cognitive impairment post event, deficits are temporary. Deficits after 30 days of onset are correlated with chronic white matter hyperintensity, suggesting subclinical cognitive impairment and/or impaired ability to compensate for the effects of acute ischemic infarcts.

Download Full-text

Letter by Benedict et al Regarding Article, “What Causes Disability After Transient Ischemic Attack and Minor Stroke? Results From the CT and MRI in the Triage of TIA and Minor Cerebrovascular Events to Identify High-Risk Patients (CATCH) Study”

Stroke ◽

10.1161/strokeaha.111.000224 ◽

2013 ◽

Vol 44 (4) ◽

Author(s):

Anna Benedict ◽

Ee Win Khoo ◽

Elaine Leung ◽

Anne Hamilton-Bruce ◽

Simon Koblar

Keyword(s):

High Risk ◽

Transient Ischemic Attack ◽

Minor Stroke ◽

High Risk Patients ◽

Cerebrovascular Events ◽

Risk Patients ◽

Ischemic Attack ◽

Ct And Mri

Download Full-text

Abstract WP56: Refinement of imaging predictors of recurrent events following Transient Ischemic Attack and Minor Stroke.

Stroke ◽

10.1161/str.44.suppl_1.awp56 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Myles Horton

Keyword(s):

White Matter ◽

Transient Ischemic Attack ◽

Recurrent Events ◽

Recurrent Stroke ◽

Initial Assessment ◽

Minor Stroke ◽

White Matter Disease ◽

Ischemic Attack ◽

Symptom Progression ◽

Prior Stroke

Background: Transient ischemic attack (TIA) and minor stroke have a high risk of recurrent stroke. We recently showed in the CATCH study that predefined radiographic abnormalities on CT/CTA and MRI predicted recurrent events after TIA and minor stroke. Specifically, the study recognized the predictive value of CT/CTA abnormalities that were defined apriori: acute ischemia on CT, intracranial or extracranial occlusion or stenosis > 50% (the CT/CTA positive metric), and diffusion-weighted imaging positivity on MRI. Aims: To improve upon the CT, CTA, MRI and clinical parameters that predict recurrent events after TIA and minor stroke. Our secondary aim was to explore predictors of stroke progression versus recurrence. Methods: 510 consecutive TIA and minor stroke patients (NIHSS score of <4) had CT/CTA and most had MRI. Primary outcome was recurrent events (combined outcome of stroke progression or distinct recurrent stroke) within 90 days. Imaging parameters not included in the original CATCH imaging (CT/CTA and MRI) metrics were assessed for prediction of recurrent events. We also completed an exploratory analysis comparing predictors of symptom progression versus recurrence. Results: There were 36 recurrent events (36/510, 7.1% (95%CI: 5.0-9.6)) including 19 progression and 17 recurrent strokes. On CT/CTA: white matter disease, prior stroke, aortic arch focal plaque≥4mm, or intraluminal thrombus did not predict recurrent events. On MRI: white matter disease, prior stroke, and microbleeds did not predict recurrent events. The only additional clinical predictor was symptom fluctuation (hazard ratio 2.3; 95% CI: 1.05-5.0). Parameters predicting symptom progression included: ongoing symptoms at initial assessment, symptom fluctuation, intracranial occlusion, intracranial occlusion or stenosis, and the CT/CTA metric. No parameter was strongly predictive of recurrent stroke. Conclusions: There was no imaging parameter that could improve upon our original CT/CTA or MRI metrics to predict recurrent events after TIA and minor stroke. Only the addition of symptom fluctuation to the CT/CTA metric improved the prediction of recurrent events. Imaging was more predictive of symptom progression than distinct recurrent events.

Download Full-text