Five-Year Risk of Stroke after TIA or Minor Ischemic Stroke Amarenco, Pierre; Lavallée, Philippa C; Monteiro Tavares, Linsay ...
New England journal of medicine/The New England journal of medicine,
06/2018, Letnik:
378, Številka:
23
Journal Article
Recenzirano
Odprti dostop
In a follow-up to a 1-year study involving patients who had a TIA or minor stroke, the rate of cardiovascular events including stroke was 6.4% in the first year and 6.4% in the second through fifth ...years.
Highlights • This review is an up-date document on basic aspects of non-invasive stimulation of brain, spinal cord and nerve roots. • The main physiological, theoretical and methodological features ...of transcranial magnetic stimulation (TMS) are described. • Instructions for practical use of non-invasive stimulation in clinical applications and research are provided.
Carotid endarterectomy reduces the risk of stroke in patients with recently symptomatic stenosis. Benefit depends on the degree of stenosis, and we aimed to see whether it might also depend on other ...clinical and angiographic characteristics, and on the timing of surgery.
We analysed pooled data from the European Carotid Surgery Trial and North American Symptomatic Carotid Endarterectomy Trial. The risk of ipsilateral ischaemic stroke for patients on medical treatment, the perioperative risk of stroke and death, and the overall benefit from surgery were determined in relation to seven predefined and seven post hoc subgroups.
5893 patients with 33 000 patient-years of follow-up were analysed. Sex (p=0·003), age (p=0·03), and time from the last symptomatic event to randomisation (p=0·009) modified the effectiveness of surgery. Benefit from surgery was greatest in men, patients aged 75 years or older, and those randomised within 2 weeks after their last ischaemic event, and fell rapidly with increasing delay. For patients with 50% or higher stenosis, the number of patients needed to undergo surgery (ie, number needed to treat) to prevent one ipsilateral stroke in 5 years was nine for men versus 36 for women, five for age 75 years or older versus 18 for younger than 65 years, and five for those randomised within 2 weeks after their last ischaemic event, versus 125 for patients randomised after more than 12 weeks. These results were consistent across the individual trials.
Benefit from endarterectomy depends not only on the degree of carotid stenosis, but also on several other clinical characteristics such as delay to surgery after the presenting event. Ideally, the procedure should be done within 2 weeks of the patient's last symptoms.
The incidence of stroke is predicted to rise because of the rapidly ageing population. However, over the past two decades, findings of randomised trials have identified several interventions that are ...effective in prevention of stroke. Reliable data on time-trends in stroke incidence, major risk factors, and use of preventive treatments in an ageing population are required to ascertain whether implementation of preventive strategies can offset the predicted rise in stroke incidence. We aimed to obtain these data.
We ascertained changes in incidence of transient ischaemic attack and stroke, risk factors, and premorbid use of preventive treatments from 1981–84 (Oxford Community Stroke Project; OCSP) to 2002–04 (Oxford Vascular Study; OXVASC).
Of 476 patients with transient ischaemic attacks or strokes in OXVASC, 262 strokes and 93 transient ischaemic attacks were incident events. Despite more complete case-ascertainment than in OCSP, age-adjusted and sex-adjusted incidence of first-ever stroke fell by 29% (relative incidence 0·71, 95% CI 0·61–0·83, p=0·0002). Incidence declined by more than 50% for primary intracerebral haemorrhage (0·47, 0·27–0·83, p=0·01) but was unchanged for subarachnoid haemorrhage (0·83, 0·44–1·57, p=0·57). Thus, although 28% more incident strokes (366 vs 286) were expected in OXVASC due to demographic change alone (33% increase in those aged 75 or older), the observed number fell (262 vs 286). Major reductions were recorded in mortality rates for incident stroke (0.63, 0.44–0.90, p=0.02) and in incidence of disabling or fatal stroke (0·60, 0·50–0·73, p<0·0001), but no change was seen in case-fatality due to incident stroke (17·2% vs 17·8%; age and sex adjusted relative risk 0·85, 95% CI 0·57-1·28, p=0·45). Comparison of premorbid risk factors revealed substantial reductions in the proportion of smokers, mean total cholesterol, and mean systolic and diastolic blood pressures and major increases in premorbid treatment with antiplatelet, lipid-lowering, and blood pressure lowering drugs (all p<0.0001).
The age-specific incidence of major stroke in Oxfordshire has fallen by 40% over the past 20 years in association with increased use of preventive treatments and major reductions in premorbid risk factors.
Effective early management of patients with transient ischaemic attacks (TIA) is undermined by an inability to predict who is at highest early risk of stroke.
We derived a score for 7-day risk of ...stroke in a population-based cohort of patients (n=209) with a probable or definite TIA (Oxfordshire Community Stroke Project; OCSP), and validated the score in a similar population-based cohort (Oxford Vascular Study; OXVASC, n=190). We assessed likely clinical usefulness to front-line health services by using the score to stratify all patients with suspected TIA referred to OXVASC (n=378, outcome: 7-day risk of stroke) and to a hospital-based weekly TIA clinic (n=210; outcome: risk of stroke before appointment).
A six-point score derived in the OCSP (age ⩾60 years=1, blood pressure systolic >140 mm Hg and/or diastolic ⩾90 mm Hg=1, clinical features unilateral weakness=2, speech disturbance without weakness=1, other=0, and duration of symptoms in min ⩾60=2, 10–59=1, <10=0; ABCD) was highly predictive of 7-day risk of stroke in OXVASC patients with probable or definite TIA (p<0·0001), in the OXVASC population-based cohort of all referrals with suspected TIA (p<0·0001), and in the hospital-based weekly TIA clinic-referred cohort (p=0·006). In the OXVASC suspected TIA cohort, 19 of 20 (95%) strokes occurred in 101 (27%) patients with a score of 5 or greater: 7-day risk was 0·4% (95% CI 0–1·1) in 274 (73%) patients with a score less than 5, 12·1% (4·2–20·0) in 66 (18%) with a score of 5, and 31·4% (16·0–46·8) in 35 (9%) with a score of 6. In the hospital-referred clinic cohort, 14 (7·5%) patients had a stroke before their scheduled appointment, all with a score of 4 or greater.
Risk of stroke during the 7 days after TIA seems to be highly predictable. Although further validations and refinements are needed, the ABCD score can be used in routine clinical practice to identify high-risk individuals who need emergency investigation and treatment.
1 Centre for Functional Resonance Imaging of the Brain and 2 Department of Clinical Neurology, University of Oxford, Oxford; 3 Biological Imaging Centre, Imaging Sciences Department, MRC Clinical ...Sciences Centre and 4 Department of Clinical Neurosciences, Imperial College London and GSK Clinical Imaging Centre, Hammersmith Hospital; and 5 Sobell Department of Movement Neuroscience and Movement Disorders and 6 Wellcome Trust Centre for Neuroimaging, Institute of Neurology, University College, London, United Kingdom
Submitted 15 September 2008;
accepted in final form 24 March 2009
Continuous theta burst stimulation (cTBS) is a novel transcranial stimulation technique that causes significant inhibition of synaptic transmission for 1 h when applied over the primary motor cortex (M1) in humans. Here we use magnetic resonance spectroscopy to define mechanisms mediating this inhibition by noninvasively measuring local changes in the cortical concentrations of -aminobutyric acid (GABA) and glutamate/glutamine (Glx). cTBS to the left M1 led to an increase in GABA compared with stimulation at a control site without significant change in Glx. This direct evidence for increased GABAergic interneuronal activity is framed in terms of a new hypothesis regarding mechanisms underlying cTBS.
Address for reprint requests and other correspondence: C. J. Stagg, FMRIB Centre, Department of Clinical Neurology, John Radcliffe Hospital, Oxford, OX3 9DU, UK (E-mail: cstagg{at}fmrib.ox.ac.uk )
To study the early risk of recurrent stroke by etiologic subtype.
The authors studied risk of recurrent stroke by etiologic subtype (Trial of ORG 10172 in Acute Stroke Treatment TOAST classification) ...in patients in two population-based studies: the Oxford Vascular Study and the Oxfordshire Community Stroke Project. A meta-analysis was performed with data from the only two other published studies reporting equivalent data.
The four studies included 1,709 strokes with 30 recurrences at 7 days, 72 at 30 days, and 113 at 3 months. Recurrent stroke risk varied between subtypes (p < 0.001). Compared with other subtypes, patients with stroke due to large-artery atherosclerosis (LAA) had the highest odds of recurrence at 7 days (odds ratio OR = 3.3, 95% CI = 1.5 to 7.0), 30 days (OR = 2.9, 95% CI = 1.7 to 4.9), and 3 months (OR = 2.9, 95% CI = 1.9 to 4.5). Odds of recurrence at 30 days for other subtypes were cardioembolic (OR = 1.0, 95% CI = 0.6 to 1.7), undetermined (OR = 1.0, 95% CI = 0.6 to 1.6), and small-vessel stroke (OR = 0.2, 95% CI = 0.1 to 0.6). There was no significant heterogeneity between the studies. Although only 14% of strokes were associated with LAA, this subtype accounted for 37% of recurrences within 7 days.
The risk of early recurrent stroke is highest in patients with LAA. This supports the need for urgent carotid imaging and prompt endarterectomy.
Treatment of aneurysmal subarachnoid hemorrhage (SAH) has changed substantially over the last 25 years but there is a lack of reliable population-based data on whether case-fatality or functional ...outcomes have improved.
We determined changes in the standardized incidence and outcome of SAH in the same population between 1981 and 1986 (Oxford Community Stroke Project) and 2002 and 2008 (Oxford Vascular Study). In a meta-analysis with other population-based studies, we used linear regression to determine time trends in outcome.
There were no reductions in incidence of SAH (RR = 0.79, 95% confidence interval CI 0.48-1.29, p = 0.34) and in 30-day case-fatality (RR = 0.67, 95% CI 0.39-1.13, p = 0.14) in the Oxford Vascular Study vs Oxford Community Stroke Project, but there was a decrease in overall mortality (RR = 0.47, 0.23-0.97, p = 0.04). Following adjustment for age and baseline SAH severity, patients surviving to hospital had reduced risk of death or dependency (modified Rankin score > 3) at 12 months in the Oxford Vascular Study (RR = 0.51, 0.29-0.88, p = 0.01). Among 32 studies covering 39 study periods from 1980 to 2005, 7 studied time trends within single populations. Unadjusted case-fatality fell by 0.9% per annum (0.3-1.5, p = 0.007) in a meta-analysis of data from all studies, and by 0.9% per annum (0.2-1.6%, p = 0.01) within the 7 population studies.
Mortality due to subarachnoid hemorrhage fell by about 50% in our study population over the last 2 decades, due mainly to improved outcomes in cases surviving to reach hospital. This improvement is consistent with a significant decrease in case-fatality over the last 25 years in our pooled analysis of other similar population-based studies.
Highlights • The application of low intensity TES in humans appears to be safe. • The profile of AEs in terms of frequency, magnitude and type is comparable in different populations. • Structured ...checklists and interviews as recommended procedures are provided in this paper.
Benefit from carotid endarterectomy is greatest when performed within 2 weeks of a presenting TIA or stroke and decreases rapidly thereafter.
To determine the delays to carotid imaging and ...endarterectomy in Oxfordshire, UK, and the consequences for the effectiveness of stroke prevention.
All patients undergoing carotid imaging for ischemic retinal or cerebral TIA or stroke were identified in two populations: the population of Oxfordshire, UK (n = 680,772), from April 1, 2002, to March 31, 2003, and the Oxford Vascular Study (OXVASC) subpopulation (n = 92,000) from April 1, 2002, to March 31, 2004. The times from presenting event to referral, scanning, and endarterectomy (Oxfordshire population) and the risk of stroke prior to endarterectomy in patients with > or = 50% symptomatic carotid stenosis (OXVASC population) were determined.
Among 853 patients who had carotid imaging in the Oxfordshire population, median (interquartile range) times from presenting event to referral, scanning, and endarterectomy were 9 (3 to 30), 33 (12 to 62), and 100 (59 to 137) days. Eighty-five patients were found to have 50 to 99% symptomatic stenosis, of whom 49 had endarterectomy. Only 3 (6%) had surgery within 2 weeks of their presenting event and only 21 (43%) within 12 weeks. The risk of stroke prior to endarterectomy in the OXVASC subpopulation with > or = 50% stenosis was 21% (8 to 34%) at 2 weeks and 32% (17 to 47%) at 12 weeks, in half of which strokes were disabling or fatal.
Delays to carotid imaging and endarterectomy after TIA or stroke in the United Kingdom are similar to those reported in several other countries and are associated with very high risks of otherwise preventable early recurrent stroke.
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