TRANSIENT ISCHEMIC ATTACKS AND MINOR STROKES: HOW NEWER TECHNOLOGIES ARE HELPING IN BETTER DIAGNOSIS OF HIGH-RISK PATIENTS AND RESPONSE TO TREATMENT
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Abstract
Stroke is a leading cause of disability and death. In more than 30% of
patients a disabling stroke is preceded by milder transient symptoms.
The risk of stroke in patients with transient ischemic attacks (TIAs)
and minor stroke may be very high in the initial days following the
symptoms. Identification of such patients and appropriate treatment
can lead to a significant decrease in the risk of subsequent stroke. This
review will focus on two important issues; the impact of introduction of
newer technology on identification of high-risk patients and the recent
advances in antithrombotic therapy in stroke prevention in patients
with TIAs and minor stroke. Appropriate use of imaging and cardiac
rhythm monitoring allow for identification of high risk patients and the
use of dual antiplatelet therapy early, following an acute TIA or minor
stroke, significantly reduces the risk of recurrence.
Key Words: transient ischemic attacks (TIAs), Stroke, Ischemic Stroke.
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References
Giles MF, Rothwell PM. Risk of stroke
early after transient ischemic attack: A
systematic review and meta-analysis.
Lancet Neurol, 2007. 6(12): p. 1063-72.
KleindorferD, Panagos P, Pancioli A,
Khoury J, Kissela B, Woo D, et al., Incidence
and short-term prognosis of transient
ischemic attack in a population-based
study. Stroke 2005; 36(4): 720-3.
Rothwell PM, Giles MF, Chandratheva A,
Marquardt L, Geraghty O, Redgrave JN, et
al. Effect of urgent treatment of transient
ischemic attack and minor stroke on early
recurrent stroke (EXPRESS study): A
prospective population-based sequential
comparison. Lancet 2007; 370(9596):
-42.
Rao SV, Ohman EM, Granger CB, Armstrong
PW, Gibler WB, Christenson RH,
et al., Prognostic value of isolated troponin
elevation across the spectrum of chest
pain syndromes. Am J Cardiol 2003;
(8): 936-40.
Kennedy J, Hill MD, Ryckborst KJ, Eliasziw
M, Demchuk AM, Buchan AM; FASTER
Investigators. Fast assessment of stroke
and transient ischemic attack to prevent
early recurrence (FASTER): a randomised
controlled pilot trial. Lancet Neurol 2007;
(11): 961-9.
Johnston SC, Gress DR, Browner WS, Sidney
S. Short-term prognosis after emergency-
department diagnosis of transient
ischemic attack. JAMA 2000; 284: 2901-6.
Dean N, Shuaib A. Transient ischemic
attacks: unstable, treatable, neglected.
Lancet 2007; 370(9596): 1398-400.
Kang DW, Latour LL, Chalela JA, Dambrosia
JA, Warach S. Early and late recurrence
of ischemic lesion on MRI: evidence for a
prolonged stroke-prone state? Neurology
; 63(12): 2261-5.
Rothwell PM, Giles MF, Flossmann E,
Lovelock CE, Redgrave JN, Warlow CP,
et al., A simple score (ABCD) to identify
individuals at high early risk of stroke after
transient ischemic attack. Lancet 2005;
(9479): 29-36.
Coutts SB, Simon JE, Eliasziw M, Sohn
CH, Hill MD, Barber PA, et al., Triaging
transient ischemic attack and minor stroke
patients using acute magnetic resonance
imaging. Ann Neurol 2005; 57(6): 848-54.
Fuster V, Fayad ZA, Badimon JJ. Acute
coronary syndromes: biology. Lancet
; 353 Suppl 2: SII5-9.
CURE Investigators, Effects of clopidogrel
in addition to aspirin in patients with acute
coronary syndromes without ST-segment
elevation. N Engl J Med 200; 345: 494-502.
Wang Y, Zhao X, Liu L, Wang D, Wang
C, et al. Clopidogrel with aspirin in acute
minor stroke and transient ischemic attack
(CHANCE study). New E J Med 2013;
: 11-9.
Ovbiagele, B. Antiplatelet therapy in
management of transient ischemic attack:
overview and evidence-based rationale. J
Emerg Med 2008; 34(4): 389-96.
Kernan WN, Ovbiagele B, Black HR,
Bravata DM, Chimowitz MI, Ezekowitz
MD, et al. Guidelines for the prevention
of stroke in patients with stroke and
transient ischemic attack: a guideline for
healthcare professionals from the American
Heart Association/American Stroke
Association. Stroke. 2014 May 1 [Epub
ahead of print]. Available at: https://stroke.
ahajournals.org/content/early/2014/04/30/
STR.0000000000000024.full.pdf+html
Antithrombotic therapy and prevention
of thrombosis. American College of Physicians
evidence-based guidelines. Chest
; 142: supplement 1.
Lavallee PC, Meseguer E, Abboud H,
Cabrejo L, Olivot JM, Simon O, et al.,
A transient ischemic attack clinic with
round-the-clock access (SOS-TIA): feasibility
and effects. Lancet Neurol 2007;
(11): 953-60.
Antiplatelet Trialists’ Collaboration, Collaborative
overview of randomised trials
of antiplatelet therapy-I: Prevention of
death, myocardial infarction, and stroke by
prolonged antiplatelet therapy in various
categories of patients. Br Med J 1994;
(6921): 81-106.
Sharis PJ, Cannon CP, Loscalzo J. The
antiplatelet effects of ticlopidine and
clopidogrel. Ann Intern Med 1998; 129(5):
-405.
CAPRIE Steering Committee, A randomised,
blinded, trial of clopidogrel
versus aspirin in patients at risk of ischemic
events (CAPRIE). Lancet 1996; 348(9038):
-39. 103.
Abuzahra, M, Pillai M, Caldera A, Hartley
WB, Gonzalez R, Bobek J, et al., Comparison
of higher clopidogrel loading and maintenance
dose to standard dose on platelet
function and outcomes after percutaneous
coronary intervention using drug-eluting
stents. Am J Cardiol 2008; 102(4): 401-3.
Jauhar, R, Bergman G, Savino S, Deutsch
E, Shaknovich A, Parikh M, et al., Effectiveness
of aspirin and clopidogrel combination
therapy in coronary stenting. Am J
Cardiol 1999; 84(6): 726-8, A8.
Bhatt, DL, Fox KA, Hacke W, Berger PB,
Black HR, Boden WE, et al., Clopidogrel
and Aspirin versus Aspirin Alone for the
Prevention of Atherothrombotic Events.
N Engl J Med, 2006; 354(16): 1706-17.
Platelet-Oriented Inhibition in New TIA
and Minor Ischemic Stroke (POINT) Trial.
ClinicalTrials.gov Identifier: NCT00991029
[Cited on September 20, 2014]: Available
from URL: https://clinicaltrials.gov/ct2/
show/NCT00991029
SOCRATES -Acute Stroke Or Transient
IsChaemic Attack TReated With Aspirin or
Ticagrelor and Patient OutcomES]. ClinicalTrials.
gov Identifier: NCT01994720
[Cited on September 20, 2014]: Available
from URL: https://www.clinicaltrials.gov/
ct2/show/NCT01994720
Gladstone DJ, Spring M, Dorian P, Panzov
V, Thorpe KE, Hall J, et al for the EMBRACE
Investigators and Coordinators.
Atrial Fibrillation in Cryptogenic Stroke.
New Eng J Med 2014; 370: 2467-77.
Sanna T, Diener HC, Passman RS, Di
Lazzaro V, Bernstein RA, Morillo CA, et
al. Cryptogenic stroke and underlying
atrial fibrillation. New Eng J Med 2014;
: 2478-86.
Mouradian MS, Rodgers J, Kashmere J,
Jickling G, McCombe J, Emery DJ, et al.
Can t-PA be administered to the wrong
patient? Two Patients with Somatoform
Disorder, Can J Neurol Sci 2004; 31:
-101.
Johnston SC, Rothwell PM, Nguyen-Huynh
MN, Giles MF, Elkins JS, Bernstein AL, et
al. Validation and refinement of scores
to predict very early stroke risk after
transient ischemic attack. Lancet 2007;
(9558): 283-92.
Asdaghi N, Hill MD, Coulter JI, Butcher
KS, Modi J, Qazi A, et al. Perfusion MR
predicts outcome in high-risk TIA and
minor stroke. A derivation and validation
study. Stroke 2013; 44: 2486-92.
Ibrahim Y, Basir G, Ghrooda E, Mohammad
A, Khan N, Dobrowolski P, et al. Prolonged
monitoring of cardiac rhythm for
detection of atrial fibrillation after cerebral
ischemic events (PEAACE) study. Neurology
; 82 (10): Supplement P1.130.
Hart R, Deiner C, Coutts SB, Easton JD,
Granger CB, O’Donnell MJ, et al. Embolic
strokes of undetermined source: the case
for a new clinical construct. Lancet Neurol
; 13(4): 429-38.
Bell AD, Roussin A, Cartier R, Chan WS,
Douketis JD, Gupta A, et al. The use of
antiplatelet therapy in the outpatient
setting: Canadian Cardiovascular Society
Guidelines Executive Summary. Can J
Cardiol 2011; 27(2): 208-21.
Coutts SB, Eliasziw M, Hill MD, Scott JN,
Subramaniam S, Buchan AM, et al. An
improved scoring system for identifying
patients at high early risk of stroke and
functional impairment after an acute transient
ischemic attack or minor stroke. Int
J Stroke 2008; 3(1): 3-10.
Diener HC, Bogousslavsky J, Brass LM,
Cimminiello C, Csiba L, Kaste M, Leys D,
et al., Aspirin and clopidogrel compared
with clopidogrel alone after recent ischemic
stroke or transient ischemic attack in
high-risk patients (MATCH): randomised,
double-blind, placebo-controlled trial.
Lancet 2004; 364(9431): 331-7.
Markus HS, Droste DW, Kaps M, Larrue V,
Lees KR, Siebler M, et al., Dual antiplatelet
therapy with clopidogrel and aspirin in
symptomatic carotid stenosis evaluated
using doppler embolic signal detection: the
Clopidogrel and Aspirin for Reduction of
Emboli in Symptomatic Carotid Stenosis
(CARESS) trial. Circulation 2005; 111(17):
-40.