Abstract 8: Early MRI in TIA And Minor Stroke: Do it or Lose it

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Francois Moreau ◽  
Jayesh Modi ◽  
Mohamed Almekhlafi ◽  
Simer Bal ◽  
Mayank Goyal ◽  
...  
Keyword(s):  
Symptom Onset ◽  
Diagnostic Yield ◽  
Lesion Detection ◽  
White Matter Hyperintensity ◽  
Minor Stroke ◽  
Presenting Symptoms ◽  
Lesion Pattern ◽  
Cortical Stroke ◽  
Stroke Lesion ◽  
The Impact

Background: MRI is not always completed early after TIA or minor stroke and this may affect its utility. We measured the impact of scanning an individual patient late versus early in the investigation of TIA and minor stroke. Methods: 263 patients with a TIA or minor stroke (NIHSS <4) from the CATCH study were included in this analysis. To be included in this sub study patients needed to have had a baseline MRI completed within 24 hours of symptom onset and a follow-up MRI at 90 days. All MRI images were acquired on a 3.0 Tesla GE scanner. Baseline and 90 day scans were assessed independently for the presence of any stroke lesion. The presence and pattern of any stroke lesion was then compared at the two time points. Lesion patterns were classified as: no definite stroke, single territory cortical stroke(s), multiple territory cortical strokes, single territory subcortical only stroke(s), multiple territory subcortical only strokes, and multiple strokes in one territory including a cortical stroke Results: Stroke of any age, in any location was more common on the baseline MRI versus 90day MRI (68% versus 58%, p=0.005). A substantial proportion of the negative scans at 90 days had a clearly identifiable stroke on the baseline scan (35/115: 30%) that was missed on the 90day scan. All of these lesions were acute or subacute DWI lesions on the baseline scan showing non-specific white matter hyperintensity or no abnormality on the 90day scan. Among 104 patients with a stroke lesion on the 90 day MRI considered as a cause for the presenting symptoms, this lesion was the correct lesion in only 78 (53%) patients. 89 (34%) patients had a different lesion pattern on the baseline scan versus the 90day scan. The main difference observed was that patients with multiple DWI lesions on the baseline scan were either seen as a single or no lesions on the 90day MRI. Conclusion: Completing an MRI in a delayed fashion after TIA or minor stroke reduces the diagnostic yield of the imaging. Not only does it reduce lesion detection, but also the pattern of the lesions is missed. Conclusions regarding the original event may be false if based only on a delayed MRI. If minor stroke and TIA patients are going to be scanned with MRI this should be completed early after symptom onset.

scholarly journals Lesions in putative language and attention regions are linked to more severe strokes in patients with higher white matter hyperintensity burden

2021 ◽  
Author(s):  
Anna K Bonkhoff ◽  
Sungmin Hong ◽  
Martin Bretzner ◽  
Markus D Schirmer ◽  
Robert W Regenhardt ◽  
...  
Keyword(s):  
White Matter ◽  
Functional Outcomes ◽  
Brain Regions ◽  
Bayesian Regression ◽  
White Matter Hyperintensity ◽  
Stroke Severity ◽  
Language Functions ◽  
Lesion Pattern ◽  
Stroke Lesion ◽  
Cortical Regions

Objective To examine whether high white matter hyperintensity (WMH) burden is associated with greater stroke severity and worse functional outcomes in lesion pattern-specific ways. Methods MR neuroimaging and National Institutes of Health Stroke Scale data at index stroke, as well as modified Rankin Scale (mRS) at 3-6 months post-stroke were obtained from MRI-GENIE study of acute ischemic stroke (AIS) patients. Individual WMH volume was automatically derived from FLAIR-images. Stroke lesions were automatically segmented from DWI-images, spatially normalized and parcellated into atlas-defined brain regions. Stroke lesion effects on AIS severity and unfavorable outcomes (mRS>2) were modeled within a purpose-built machine learning and Bayesian regression framework. In particular, interaction effects between stroke lesions and a high versus low WMH burden were integrated via hierarchical model structures. Models were adjusted for the covariates age, age2, sex, total DWI-lesion and WMH volumes, and comorbidities. Data were split into derivation and validation cohorts. Results A total of 928 AIS patients contributed to stroke severity analyses (mean age: 64.8(14.5), 40% women), 698 patients to functional outcome analyses (mean age: 65.9(14.7), 41% women). Individual stroke lesions were represented in five anatomically distinct left-hemispheric and five right-hemispheric lesion patterns. Across all patients, acute stroke severity was substantially explained by three of these patterns, that were particularly focused on bilateral subcortical and left-hemispherically pronounced cortical regions. In high WMH burden patients, two lesion patterns consistently emerged as more pronounced in case of stroke severity: the first pattern was centered on left-hemispheric insular, opercular and inferior frontal regions, while the second pattern combined right-hemispheric temporo-parietal regions. Bilateral subcortical regions were most relevant in explaining long term unfavorable outcome. No WMH-specific lesion patterns of functional outcomes were substantiated. However, a higher overall WMH burden was associated with higher odds of unfavorable outcomes. Conclusions Higher WMH burden increases stroke severity in case of stroke lesions involving left-hemispheric insular, opercular and inferior frontal regions (potentially linked to language functions) and right-hemispheric temporo-parietal regions (potentially linked to attention). These findings may contribute to augment stroke outcome predictions and motivate a WMH burden and stroke lesion pattern-specific clinical management of AIS patients.

Abstract P31: Intravenous Thrombolysis And Short-term Functional Outcome In Minor Stroke: Observational Study.

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Enrique Castellanos Pedroza ◽  
Diana Manrique Otero ◽  
Vanessa Cano Nigenda ◽  
María Fernanda Menéndez-Manjarrez ◽  
Miguel Calderón García ◽  
...  
Keyword(s):  
Emergency Department ◽  
Functional Outcome ◽  
Symptom Onset ◽  
Intravenous Thrombolysis ◽  
Minor Stroke ◽  
Categorical Variables ◽  
Poor Functional Outcome ◽  
Male Sex ◽  
The Impact ◽  
Favorable Functional Outcome

Background: Identification of predictive factors for favorable functional outcome after acute ischemic stroke is crucial. 1 Minor stroke (MS) is the most common exclusion criteria for intravenous thrombolysis and up to 30% of patients with MS will have a poor functional outcome at 3 months. 2 Objective: We reported the frequency of intravenous thrombolysis in the setting of minor stroke in the population of study and tried to identify clinical factors associated with favorable functional outcomes among these patients. Methods: Fifty-one consecutive patients with acute MS were selected (National Institute of Health Stroke Scale of 5 or less). Functional outcome was assessed using the modified Rankin scale (mRS) at 3 months after index event. Descriptive analysis through frequency and central tendency measures were applied and exact Fisher’s test was used for analysis of categorical variables and logistic regression analysis to determine the impact of independent factors related to functional outcome. Results: 60.8% of patients were males. Hypertension (43.1%) was the most frequent risk factor identified among these patients follow by diabetes (37.5%) and smoking (31.4%). 46.5% of patients presented in the <4.5 hours window for IV thrombolysis of these 4.7% presented within the first hour of symptom onset and only 11.8% were treated with rtPA. None of these patients had intracerebral hemorrhage (ICH). Small vessel disease was the most common cause of MS (37.2%) and no cause was identified in 13.7% of patients after evaluation. Favorable outcome (mRS 0 - 2) was observed in 88.2% of patients and one patient died after recurrence of stroke two weeks after MS. Male sex and time from symptom onset to the emergency department > 24 hours were associated with poor functional outcome (mRS 3 - 6) ( p 0.029 and p 0.014 respectively) without reaching statistical significance in the multivariate analysis. Conclusions: Most patients with MS had a favorable functional outcome (mRS 0 - 2) notwithstanding the low rate of IV thrombolysis compared with other study populations without increasing the risk of ICH in this group of patients. 3 A tendency towards poor functional outcome for male sex and time from symptom onset to the emergency department > 24 hours was observed

Abstract P323: Stroke Lesion Pattern-Specific Influence of White Matter Hyperintensities on Stroke Severity in Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Anna K Bonkhoff ◽  
Martin Bretzner ◽  
Markus D Schirmer ◽  
Sungmin Hong ◽  
Anne-Katrin Giese ◽  
...  
Keyword(s):  
White Matter ◽  
Acute Stroke ◽  
Inferior Frontal Gyrus ◽  
Brain Regions ◽  
Hierarchical Level ◽  
White Matter Hyperintensity ◽  
Hierarchical Regression ◽  
Stroke Severity ◽  
Lesion Pattern ◽  
Stroke Lesion

Introduction: MRI-detected white matter hyperintensity (WMH) burden is linked to the overall brain health and incident stroke outcomes. However, data are limited as to whether specific acute stroke lesion patterns purport greater stroke severity in patients with extensive pre-existing WMH. In this analysis, we sought to investigate lesion pattern-specific WMH effects on AIS severity. Methods: We analyzed clinical and lesion data from 621 AIS patients enrolled in the multi-site MRI-GENIE study. The acute NIHSS was modelled via Bayesian hierarchical regression. Using ten stroke lesion patterns, that served as input variables of main interest, we introduced a hierarchical level differentiating between patients with higher and lower than median WMH volume (WMHv). Lesion pattern posterior distributions for higher and lower WMHv patients were subtracted to infer substantial differences. Results: In this AIS cohort [age: 65.3±14.6, 60% male], a higher WMHv was associated with greater stroke severity only when specific left-hemispheric brain regions were infarcted. This “lesion pattern 3” was mainly characterized by left middle and inferior frontal gyrus, insular and opercular cortex, pre- and post-central gyrus, and subcortical basal ganglia regions ( Fig ). Conclusions: Higher WMH burden appears to enhance the detrimental effect of acute stroke lesions involving left-hemispheric brain regions underlying language and motor functions. This effect might be due to an exacerbated disruption of functional network integrity by the combination of WMH and stroke lesions and could be explored further in functional imaging studies that simultaneously considered information from both lesion types.

scholarly journals One in seven pathogenic variants can be challenging to detect by NGS: an analysis of 450,000 patients with implications for clinical sensitivity and genetic test implementation

2021 ◽  
Author(s):  
Stephen E. Lincoln ◽  
Tina Hambuch ◽  
Justin M. Zook ◽  
Sara L. Bristow ◽  
Kathryn Hatchell ◽  
...  
Keyword(s):  
Diagnostic Yield ◽  
Copy Number Variants ◽  
Low Complexity ◽  
Clinical Genetic ◽  
Clinical Sensitivity ◽  
Pathogenic Variants ◽  
Wide Range ◽  
Large Indels ◽  
Next Generation Sequencing Ngs ◽  
The Impact

Abstract Purpose To evaluate the impact of technically challenging variants on the implementation, validation, and diagnostic yield of commonly used clinical genetic tests. Such variants include large indels, small copy-number variants (CNVs), complex alterations, and variants in low-complexity or segmentally duplicated regions. Methods An interlaboratory pilot study used synthetic specimens to assess detection of challenging variant types by various next-generation sequencing (NGS)–based workflows. One well-performing workflow was further validated and used in clinician-ordered testing of more than 450,000 patients. Results In the interlaboratory study, only 2 of 13 challenging variants were detected by all 10 workflows, and just 3 workflows detected all 13. Limitations were also observed among 11 less-challenging indels. In clinical testing, 21.6% of patients carried one or more pathogenic variants, of which 13.8% (17,561) were classified as technically challenging. These variants were of diverse types, affecting 556 of 1,217 genes across hereditary cancer, cardiovascular, neurological, pediatric, reproductive carrier screening, and other indicated tests. Conclusion The analytic and clinical sensitivity of NGS workflows can vary considerably, particularly for prevalent, technically challenging variants. This can have important implications for the design and validation of tests (by laboratories) and the selection of tests (by clinicians) for a wide range of clinical indications.

A novel mitral stenosis assessment using projected transmitral gradient improves the diagnostic and prognostic yields of doppler-based gradient

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
N Kato ◽  
R Padang ◽  
C Pislaru ◽  
C.G Scott ◽  
V.T Nkomo ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Stenosis ◽  
Diagnostic Yield ◽  
Cardiac Events ◽  
Final Formula ◽  
Hemodynamic State ◽  
Tertiary Center ◽  
Novel Concept ◽  
The Impact

Abstract Background Transmitral gradient (TMG) is highly dependent on hemodynamic state, leading to discordance between TMG and mitral valve area (MVA). The effect of heart rate (HR) and stroke volume (SV) on TMG among patients with mitral stenosis (MS) is poorly understood. Purposes We aimed to (1) develop a formula for projected TMG (proTMG) for assessment of MS severity under varying hemodynamics; (2) assess the prognostic value of proTMG in patients with MS. Methods All patients evaluated for suspected MS without ≥moderate other valve disorder at our tertiary center between 2001 and 2017 were analyzed. Projected TMG is the expected gradient under normal flow (SV 80–94 ml and HR 60–79 bpm), and was modeled based on the observed impact of HR and SV on TMG by multiple regression analysis. The data were randomly split (2:1) into training and testing sets. The improvement in agreement between MVA and proTMG was evaluated. Composite cardiac events including all-cause death and mitral valve interventions were compared according to TMG grade using TMG and proTMG. Severe and moderate MS were defined as MVA ≤1.5 cm2 and 1.5–2.0 cm2 respectively, by the continuity equation. MVA ≤1.0 cm2 was considered as very severe MS. Results Of 4973 patients with suspected MS (age 73±12 years, 33% male), severe MS was present in 437 (9%, including 98 with very severe MS) and moderate MS in 934 (19%). In 838 patients with normal HR and SV, very severe, severe and moderate MS corresponded to TMG ≥12 mmHg, ≥6 mmHg and 4–6 mmHg, respectively. In the training set (n=3315), the median [interquartile range] of HR and SV were 70 [61–80] bpm and 97 [83–113] mL in men (n=1120), and 72 [63–82] bpm and 84 [71–97] mL in women (n=2195), respectively. The impact of HR and SV on TMG for men and women were 0.07 and 0.08 mmHg per 1 bpm increase in HR (95% confidence interval [CI] 0.06–0.07 and 0.07–0.08), and 0.03 and 0.05 mmHg per 1 mL increase in SV (95% CI 0.03–0.03 and 0.04–0.05), respectively. Therefore, the final formula to calculate proTMG was: proTMG=TMG-0.07(HR-70)-0.03(SV-97) in men and proTMG=TMG-0.08(HR-72)-0.05(SV-84) in women. In the testing set (n=1658), the proTMG (kappa=0.63, 95% CI 0.60–0.66) had better agreement with MS severity by MVA than TMG (kappa=0.28, 95% CI 0.24–0.32). To explore the prevalence of patients reclassified using proTMG, in 98 with TMG ≥12 mmHg, proTMG remained ≥6 mmHg. Of 657 with TMG 6–12 mmHg, proTMG remained ≥6 mmHg in 356 (54%), and decreased to &lt;6 mmHg in 301 (46%). In patients with TMG 6–12 mmHg, proTMG ≥6 mmHg was associated with higher probability of cardiac events compared with &lt;6 mmHg during follow-up of 2.8±3.1 years (Figure). Conclusion We propose a novel concept of projected TMG defined as the expected transmitral gradient at normal HR and SV levels. This improved the diagnostic yield of Doppler TMG measurements for MS severity assessment and identified a low-risk subset of patients with elevated TMG due to high HR or SV. Funding Acknowledgement Type of funding source: None

scholarly journals Social perception of persons with PTSD symptoms: a test of some predictions of attribution theory

2018 ◽  
Vol 36 (13) ◽  
Author(s):  
Vera Ćubela
Keyword(s):  
Attribution Theory ◽  
Target Person ◽  
Ptsd Symptoms ◽  
Social Evaluation ◽  
Presenting Symptoms ◽  
Symptom Pattern ◽  
Affective Experiences ◽  
The University ◽  
The Impact ◽  
Very High

A broad research of the impact of PTSD diagnosis and presenting symptoms of this disorder on social reactions to persons with PTSD has been undertaken to test the prediction that the relative absence of fairly recognizable symptoms of this disorder promotes less positive social evaluation. This paper presents the effects of manipulating with the PTSD label and the recognizability of presented symptom pattern on ratings of the target person responsibility and elicited affective reactions and support giving intention in subjects.Three vignettes, differing in recognizability of presented symptoms of PTSD, were given to the subjects (228 students at the University of Mostar), and about a half of the subjects in each of these symptom pattern conditions was told that the target is a PTSD casualty. Subjects responded to the vignettes by rating target’s responsibility and their own reactions to him (pity, anger and willingness to give him support) on a five-point scale.The results showed significant effect of the symptom pattern manipulation, which was most pervasive in responsibility judgments and reported support intentions. The pattern of differences in judgments of responsibility suggests that the prevalence of less recognizable symptoms of PTSD might result in ascription of some responsibility to a target person for causing actual conditions. The relative absence of these symptoms appears to reduce, in particular, the variability in the subject's willingness to give support to the person, which is generally reported as being very high. Unlike these responsibility and support ratings, the effects of the symptom pattern on reported affective experiences of pity and anger do not match the pattern predicted from the attribution model of B. Weiner and an extension of this model made by Lopez and Wolkenstein. The absence of the predicted Label x Symptom pattern interaction was explained in terms of some drawbacks in the construction of the stimulus material.

scholarly journals Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

2021 ◽  
Vol 2021 ◽  
pp. 1-5
Author(s):  
Cesar Velasco ◽  
Brandon Wattai ◽  
Scott Buchle ◽  
Alicia Richardson ◽  
Varun Padmanaban ◽  
...  
Keyword(s):  
Urban Areas ◽  
Stroke Care ◽  
Final Diagnosis ◽  
Medical Attention ◽  
Presenting Symptoms ◽  
Number Of Patients ◽  
Community Transmission ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7   min ) compared to the same time period in 2019 ( 42 ± 8.2   min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

scholarly journals TIA and minor stroke: A qualitative study of long-term impact and experiences of follow-up care

2019 ◽  
Author(s):  
Grace M Turner ◽  
Christel McMullan ◽  
Lou Atkins ◽  
Robbie Foy ◽  
Jonathan Mant ◽  
...  
Keyword(s):  
Qualitative Study ◽  
Stroke Prevention ◽  
Community Care ◽  
Minor Stroke ◽  
Framework Analysis ◽  
Diverse Range ◽  
Follow Up Care ◽  
The Impact

Abstract Background Transient ischaemic attack (TIA) and minor stroke are often considered transient events; however, many patients experience residual problems and reduced quality of life. Current follow-up healthcare focuses on stroke prevention and care for other long-term problems is not routinely provided. We aimed to explore patient and healthcare provider (HCP) experiences of residual problems post-TIA/minor stroke, the impact of TIA/minor stroke on patients’ lives, and current follow-up care and sources of support. Methods This qualitative study recruited participants from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Semi-structured interviews were conducted with 12 TIA/minor stroke patients and 24 HCPs from primary, secondary and community care with framework analysis. Results A diverse range of residual problems were reported post-TIA/minor stroke, including psychological, cognitive and physical impairments. Consultants and general practitioners generally lacked awareness of these long-term problems; however, there was better recognition among nurses and allied HCPs. Residual problems significantly affected patients’ lives, including return to work, social activities, and relationships with family and friends. Follow-up care was variable and medically focused. While HCPs prioritised medical investigations and stroke prevention medication, patients emphasised the importance of understanding their diagnosis, individualised support regarding stroke risk, and addressing residual problems. Conclusion HCPs could better communicate lay information about TIA/minor stroke diagnosis and secondary stroke prevention, and improve their identification of and response to important residual impairments affecting patients.

scholarly journals EUS-guided sampling with 25G biopsy needle as a rescue strategy for diagnosis of small subepithelial lesions of the upper gastrointestinal tract

2018 ◽  
Vol 06 (07) ◽  
pp. E892-E897 ◽  
Author(s):  
Filippo Antonini ◽  
Sara Giorgini ◽  
Lorenzo Fuccio ◽  
Lucia Angelelli ◽  
Giampiero Macarri
Keyword(s):  
Diagnostic Yield ◽  
Final Diagnosis ◽  
Fine Needle Biopsy ◽  
Gastric Fundus ◽  
Gastric Body ◽  
Biopsy Needle ◽  
Duodenal Lesions ◽  
Procedural Complications ◽  
Subepithelial Lesions ◽  
The Impact

Abstract Background and study aims This study was designed to evaluate the impact of additional tissue obtained with endoscopic ultrasound (EUS)-guided 25-gauge core biopsy needle (25G-PC) following an unsuccessful fine-needle biopsy (FNB) performed with larger-bore needles for the characterization of gastrointestinal subepithelial lesions (GI-SELs). Patients and methods We prospectively collected and retrospectively analyzed information in our database from January 2013 to June 2017 for all patients with GI-SELs who received a EUS-guided FNB (EUS-FNB) with 25G-PC during the same procedure after failure of biopsy performed with larger-bore needle. Diagnostic yield, diagnostic accuracy and procedural complications were evaluated. Results Sixteen patients were included in this study, 10 men and 6 women, median age 67.8 (range 43 to 76 years). Five patients were found to have a SEL localized in the distal duodenum, five in the gastric antrum, two in the gastric fundus and four in the gastric body. The mean size of the lesions was 20.5 mm (range 18 – 24 mm). EUS-FNB with 25G-PC enabled final diagnosis in nine patients (56.2 %). Regarding the subgroup of duodenal lesions, the procedure was successful in four of five (80 %). Final diagnoses with EUS-guided sampling were GIST (n = 6), leiomyoma (n = 2) and metastatic ovarian carcinoma (n = 1). No procedure-related complications were recorded. Conclusion In patients with small GI-SELs, additional tissue obtained with 25G-PC could represents a “rescue” strategy after an unsuccessful procedure with larger-bore needles, especially when lesions are localized in the distal duodenum.

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