Delirium and subsyndromal delirium are associated with the long-term risk of death after ischaemic stroke

Background Post-stroke delirium has a negative impact on functional outcome. We explored if there is any association between delirium, subsyndromal delirium and long-term mortality after ischaemic stroke and transient ischaemic attack. Methods We included 564 patients with ischaemic stroke or transient ischaemic attack. We assessed symptoms of delirium during the first 7 days after admission. We used Cox proportional hazards models to analyse all-cause mortality during the first 5 years after stroke. Results We diagnosed delirium in 23.4% and subsyndromal delirium in 10.3% of patients. During the follow-up, 72.7% of patients with delirium, 51.7% of patients with subsyndromal delirium and 22.7% of patients without delirious symptoms died (P < 0.001). Patients with subsyndromal delirium and delirium had higher risk of death in the multivariate analysis (HR 1.72, 95% CI 1.11–2.68, P = 0.016 and HR 3.30, 95% CI 2.29–4.76, P < 0.001, respectively). Conclusions Post-stroke delirium is associated with long-term mortality. Patients with subsyndromal delirium are at the intermediate risk of death.

Working Memory Impairment in Transient Ischaemic Attack: N-back as a Sensitive Measure for Detection

Background: Transient ischaemic attack (TIA) can lead to lasting changes in brain structure and function resulting in cognitive impairment. Cognitive screening tools may lack sensitivity for detecting cognitive impairments, particularly executive function, which tends to be the earliest affected domain in vascular cognitive impairment. Aim: In this preliminary study, we examine a working memory (WMem) task as a sensitive measure of cognitive impairment in TIA. Method: Patients referred to a TIA clinic for transient neurological symptoms completed a general cognitive screening tool (Montreal Cognitive Assessment; MoCA), and a WMem task (2-N-back) in a cross-sectional design. Results: TIA patients (n = 12) showed significantly reduced WMem performance on the N-back compared to patients diagnosed with mimic clinical conditions with overlapping symptoms (n = 16). No group differences were observed on the MoCA. Conclusions: Assessing WMem may provide a sensitive measure of cognitive impairment after TIA, with implications for cognitive screening in TIA services to triage patients for further neuropsychological support, or for interventions to prevent vascular dementia.

A Multicentre Study Comparing Cerebrovascular Disease Profiles in Pacific Islander and Caucasian Populations Presenting with Stroke and Transient Ischaemic Attack

<b><i>Introduction:</i></b> In a multicentre study, we contrasted cerebrovascular disease profiles in Pacific Island (PI)-born patients (Indigenous Polynesian [IP] or Indo-Fijian [IF]) presenting with transient ischaemic attack (TIA), ischaemic stroke (IS) or intracerebral haemorrhage (ICH) with those of Caucasians (CSs). <b><i>Methods:</i></b> Using a retrospective case-control design, we compared PI-born patients with age- and gender-matched CS controls. Consecutive patients were admitted to 3 centres in South Western Sydney (July 2013–June 2020). Demographic and clinical data studied included vascular risk factors, stroke subtypes, and imaging characteristics. <b><i>Results:</i></b> There were 340 CS, 183 (27%) IP, and 157 (23%) IF patients; mean age 65 years; and 302 (44.4%) female. Of these, 587 and patients presented with TIA/IS and 93 (13.6%) had ICH. Both IP and IF patients were significantly more likely to present &#x3e;24 h from symptom onset (odds ratios [ORs] vs. CS 1.87 and 2.23). IP patients more commonly had body mass indexes &#x3e;30 (OR 1.94). Current smoking and excess alcohol intake were higher in CS. Hypertension, diabetes, and chronic kidney disease were significantly higher in both IP and IF groups in comparison to CS. IP patients had higher rates of AF and those with known AF were more commonly undertreated than both IF and CS patients (OR 2.24, <i>p</i> = 0.007). ICH was more common in IP patients (OR 2.32, <i>p</i> = 0.005), while more IF patients had intracranial arterial disease (OR 5.10, <i>p</i> &#x3c; 0.001). <b><i>Discussion/Conclusion:</i></b> Distinct cerebrovascular disease profiles are identifiable in PI-born patients who present with TIA or stroke symptoms in Australia. These may be used in the future to direct targeted approaches to stroke prevention and care in culturally and linguistically diverse populations.

Acute stroke and transient ischaemic attack

The World Health Organization defines a stroke as ‘rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than vascular origin’. If the symptoms last less than 24 hours, typically less than 2 hours, then this is classified as a transient ischaemic attack. ‘Brain attack’ is a term that is increasingly used, as the rapid nature of treatment means the differentiating criterion of symptoms lasting at least 24 hours, is often not met before initiation of treatment.

Incidence of stroke, transient ischaemic attack and determinants of poststroke mortality among immigrants in Denmark, 2004‒2018: a population-based cohort study

ObjectiveUsing recent registry data, we aimed to quantify the incidence of stroke and transient ischaemic attack (TIA) and to examine factors influencing the risk of poststroke mortality among immigrants compared with Danish-born individuals.DesignPopulation-based cohort study between 2004 and 2018. We estimated age-standardised incidence rate ratios (IRR) of stroke, stroke types and TIA for each ethnic group using Danish-born individuals as the reference by direct method of standardisation. We calculated the risk of poststroke mortality using Cox proportional hazard regression.SettingThe study was conducted using Danish nationwide registers.ParticipantsAll cases of first-ever stroke and TIA by country of origin (n=132 936) were included.ResultsOverall, Western immigrants (IRR=2.25; 95% CI 2.20 to 2.31) and non-Western immigrants (IRR=1.37; 95% CI 1.30 to 1.44) had a higher risk of stroke than Danish-born individuals. The risk of TIA was higher in Western immigrants (IRR=2.08; 95% CI 1.93 to 2.23) followed by non-Western immigrants (IRR=1.45; 95% CI 1.27 to 1.63) than in Danish-born individuals. All-cause 1-year mortality hazard was higher but not significantly different in non-Western men (adjusted HR=1.38; 95% CI 0.92 to 2.08) compared with Danish-born men and additional adjustment for comorbidities reduced the HR to 0.85 (0.51 to 1.40) among ischaemic stroke cases. Among intracerebral haemorrhage cases, the adjusted mortality hazard was decreased in Western men (from HR of 1.76; 95% CI 1.09 to 2.85 to HR of 1.30; 95% CI 0.80 to 2.11) compared with Danish-born men after adjustment for stroke severity. Immigrants with ≤15 years of residence had a lower poststroke mortality hazard than Danish-born individuals after additional adjustment for sociodemographic factors (HR=0.36; 95% CI 0.14 to 0.91).ConclusionsThe age-standardised risk of stroke and TIA was significantly higher among the majority of immigrants than Danish-born individuals. Interventions that reduce the burden of comorbidities, improve acute stroke care and target sociodemographic factors may address the higher risk of poststroke mortality among immigrants.

An observational study of T2-weighted white matter hyperintensities on magnetic resonance imaging of the internal auditory meatus and brain: ignore or not?

Background Magnetic resonance imaging of the internal auditory meatus frequently detects incidental white matter hyperintensities. This study investigated the association between these and the risk of stroke and transient ischaemic attack, or myocardial infarction. Methods The records of patients with incidental white matter hyperintensities were reviewed, and data were collected on: age, sex, cardiovascular risk factors, and incidence of stroke and transient ischaemic attack, or myocardial infarction, five years later. The risk factors associated with vascular events were explored. Results Of 6978 patients, 309 (4.4 per cent) had incidental white matter hyperintensities. Of these, 20 (6.5 per cent) had a stroke or transient ischaemic attack within five years, and 5 (1.7 per cent) had a myocardial infarction. The number of cardiovascular risk factors was significantly associated with the incidence of stroke and transient ischaemic attack (p = 0.004), and myocardial infarction (p = 0.023). Conclusion The number of cardiovascular risk factors predicts the likelihood of vascular events; appropriate risk factor management is recommended for patients with incidental white matter hyperintensities of presumed vascular origin.

Dose-Dependent Association of Inflammatory Cytokines with Carotid Atherosclerosis in Transient Ischaemic Attack: Implications for Clinical Trials

<b><i>Introduction:</i></b> The 5-year recurrence risk after ischaemic stroke and transient ischaemic attack (TIA) is 25–30%. Although inflammation may be a target for prevention trials, the contribution of plaque inflammation to acute cerebrovascular events remains unclear. We investigated the association of acute inflammatory cytokines and high-sensitivity C-reactive protein (CRP) with recently symptomatic carotid atherosclerosis in a prospective cohort study. <b><i>Methods:</i></b> Blood and Imaging markers of TIA BIO-TIA) is a multicentre prospective study of imaging and inflammatory markers in patients with TIA. Exclusion criteria were infection and other co-morbid illnesses associated with inflammation. CRP and serum cytokines (interleukin [IL]-6, IL-1β, IL-8, IL-10, IL-12, interferon-γ [IFN-γ] and tumour necrosis factor-α [TNF-α]) were measured. All patients had carotid imaging. <b><i>Results:</i></b> Two hundred and thirty-eight TIA cases and 64 controls (TIA mimics) were included. Forty-nine (20.6%) cases had symptomatic internal carotid artery stenosis. Pro-inflammatory cytokine levels increased in a dose-dependent manner across controls, TIA without carotid stenosis (CS), and TIA with CS (IL-1β, <i>p</i>_trend = 0.03; IL-6, <i>p</i>_trend &#x3c; 0.0001; IL-8, <i>p</i>_trend = 0.01; interferon (IFN)-γ, <i>p</i>_trend = 0.005; TNF-α, <i>p</i>_trend = 0.003). Results were unchanged when DWI-positive cases were excluded. On multivariable linear regression, only age (<i>p</i> = 0.01) and CS (<i>p</i> = 0.04) independently predicted log-IL-6. On multivariable Cox regression, CRP was the only independent predictor of 90-day stroke recurrence (adjusted hazard ratio per 1-unit increase 1.03 [95% CI: 1.01–1.05], <i>p</i> = 0.003). <b><i>Conclusion:</i></b> Symptomatic carotid atherosclerosis was associated with elevated cytokines in TIA patients after controlling for other sources of inflammation. High-sensitivity CRP was associated with recurrent ischaemic stroke at 90 days. These findings implicate acute plaque inflammation in the pathogenesis of cerebral thromboembolism and support a rationale for randomized trials of anti-inflammatory therapy for stroke patients, who were excluded from coronary trials.

Age-specific cerebral haemodynamic effects of early blood pressure lowering after transient ischaemic attack and non-disabling stroke

Introduction There is limited knowledge of the effects of blood pressure (BP) lowering on cerebral haemodynamics after transient ischaemic attack (TIA) and non-disabling stroke, particularly at older ages. We aimed to evaluate changes in transcranial Doppler (TCD) haemodynamic indices in patients undergoing early blood pressure lowering after TIA/non-disabling stroke, irrespective of age. Patients and methods Among consecutive eligible patients attending a rapid-access clinic with suspected TIA/non-disabling stroke and no evidence of extra/intracranial stenosis, hypertensive ones underwent intensive BP-lowering guided by daily home telemetric blood pressure monitoring (HBPM). Clinic-based BP, HBPM, End-tidal CO2 and bilateral middle cerebral artery (MCA) velocity on TCD were compared in the acute setting versus one-month follow-up; changes were stratified by baseline hypertension (clinic-BP≥140/90) and by age (<65, 65–79 and ≥80). Results In 697 patients with repeated TCD measures, mean/SD baseline systolic-BP (145.0/21.3 mmHg) was reduced by an average of 11.3/19.9 mmHg ( p < 0.0001) at one-month (133.7/17.4 mmHg), driven by patients hypertensive at baseline (systolic-BP change = −19.0/19.2 mmHg, p < 0.001; vs −0.5/15.4, p = 0.62 in normotensives). Compared with baseline, a significant change was observed at one-month only in mean/SD MCA end diastolic velocity (EDV) (0.77/7.26 cm/s, p = 0.005) and in resistance index (RI) (−0.005/0.051, p = 0.016), driven by hypertensive patients (mean/SD EDV change: 1.145/6.96 cm/s p = 0.001, RI change −0.007/0.06, p = 0.014). Findings were similar at all ages (EDV change – ptrend=0.357; RI change – ptrend=0.225), including 117 patients aged ≥80. EDV and RI changes were largest in 100 patients with clinic systolic-BP decrease ≥30 mmHg (mean/SD EDV change = 2.49/7.47 cm/s, p = 0.001; RI change −0.024/0.063, p < 0.0001). Conclusion There was no evidence of worsening of TCD haemodynamic indices associated with BP-lowering soon after TIA/non-disabling stroke, irrespective of age and degree of BP reduction. In fact, EDV increase and RI decrease observed after treatment of hypertensive patients suggest a decrease in distal vascular resistance.

Screening and follow-up care for cognitive and emotional problems after transient ischaemic attack and ischaemic stroke: a national, cross-sectional, online survey among neurologists in the Netherlands

BackgroundAfter stroke, many patients experience cognitive and/or emotional problems. While national guidelines recommend screening for these problems, actual screening rates might be limited.ObjectiveThis study aimed to examine the clinical practice at neurology departments regarding screening, information provision and follow-up care for cognitive and emotional problems after transient ischaemic attack (TIA) and ischaemic stroke.MethodsA nationwide, cross-sectional, online survey was conducted between October 2018 and October 2019 among neurologists in all hospitals in the Netherlands.ResultsNeurologists in 78 hospitals were invited to join the survey, and 52 (67%) of them completed it. Thirty-one (59%) neurologists reported that screening for cognitive problems after TIA and ischaemic stroke was mostly or always performed. When cognitive screening was performed, 42 (84%) used validated screening instruments. Twenty-nine (56%) of the respondents reported that screening for emotional problems was mostly or always performed. When emotional screening was performed, 31 (63%) reported using validated screening instruments. Timing of screening and information provision was highly variable, and the majority reported that there was no protocol for follow-up care when cognitive or emotional problems were found.ConclusionsThis study demonstrates that clinical practice at neurology departments is highly variable regarding screening, information provision and follow-up care for cognitive and emotional problems in patients after TIA or ischaemic stroke. Approximately half of the participating neurologists reported that screening was performed only sometimes or never for cognitive and emotional problems after TIA and ischaemic stroke.