Incidence of transient ischemic attacks and minor ischemic strokes in Segovia, Spain

BACKGROUND AND PURPOSE: The aim of this study was to determine the incidence of transient ischemic attacks (TIAs) and minor ischemic strokes (MISs) in Segovia, Spain. METHODS: A 2-year prospective community-based register of TIAs and MISs established in Segovia from February 16, 1992, to February 15, 1994. Every patient underwent underwent a complete clinical evaluation and cranial CT scan. Sex- and age-specific incidence rates with 95% confidence intervals (CIs) were calculated for all ages. RESULTS: The total series included 235 patients; 103 suffered TIAs and 132 suffered MISs. Mean age was 70.8 years (range, 29 to 96 years); 92 were women and 143 were men. The crude annual incidence was 0.80/1000 (95% CI, 0.70 to 0.90): 0.35/1000 (95% CI, 0.28 to 0.42) for TIAs and 0.45/1000 (95% CI, 0.37 to 0.53) for MISs. The incidence of TIAs and MISs increased with age. Approximately 78 of TIAs and MISs were in the carotid distribution, 19% were vertebrobasilar, and 3% were considered of uncertain vascular distribution. Cranial CT scan was performed in all patients. CT showed cerebral infarcts in 30.1% (31/103; 95% CI, 21% to 39%) of TIAs and 70% (92/132; 95% CI, 62% to 78%) of MISs (P<.00001). CONCLUSIONS: Our study is the first community-based register that provides sex-and age-specific rates for MISs and in which a CT scan was obtained in all patients. The incidence of TIAs in Segovia is comparable to that in other previous similar studies.     

Oculoplethysmography. Evaluation of patients with transient ischemic attacks from internal carotid artery disease

Oculoplethysmography was used to evaluate 66 patients with transient ischemic attacks prior to cerebral angiography. Fifty-eight (87.9%) symptomatic internal carotid arteries had anatomically significant stenosis. Only 69 per cent of these 58 arteries had positive OPG test. Thirty-one per cent of the arteries were well compensated hemodynamically with collaterals and had a false negative test. A negative OPG test does not rule out an anatomically significant internal carotid artery stenosis.     

Limb-shaking carotid transient ischemic attacks successfully treated with modification of the antihypertensive regimen

Involuntary episodic movements associated with transient cerebral ischemia are a rare but well-described presentation of carotid artery occlusive disease. We describe a young man with a left carotid artery occlusion who presented with daily episodes of involuntary movements of the right side that occurred for months. His symptoms virtually disappeared after his antihypertensive drug was reduced. This case supports the possibility of noninvasive management of this condition, which is traditionally treated with revascularization procedures.     

Right atrial metastatic melanoma in a patient with transient ischemic attacks

A 65-year-old-man was admitted for evaluation of a transient ischemic attack. A 4.5 x 5.3-cm right atrial mass and a patent foramen ovale were identified by echocardiography. A 0.5-cm lesion was identified in the left temporal lobe of the brain by magnetic resonance imaging. Positron emission tomography was used to differentiate a tumor from an infarct in the brain. The cardiac and the brain lesions were successfully resected. Histopathologic study of the atrial and cerebral tissue demonstrated that these were metastases from a previously excised scalp desmoplastic malignant melanoma. The patient remains well at 14 months' follow-up.     

Transient neurological deficits simulating transient ischemic attacks in a patient with meningioma--case report

The purpose of this study was to evaluate in vivo the changes in myometrial thickness throughout pregnancy. Myometrial thickness was measured in 25 singleton uncomplicated pregnancies. Ultrasonographic sagittal and transverse sections were used to measure uterine wall thickness from the low anterior wall (lower segment) and the anterior, posterior, right, and left walls of the upper segment and from the fundus. In each case four measurements were made in the second and third trimesters. Myometrial thickness of the upper uterine segment remains fairly constant in the first and second trimesters of pregnancy, whereas a significant linear trend was found between a decreasing thickness of the lower uterine segment and advancing gestational age. Myometrial thickness is significantly increased behind the placental insertion site as compared to other portions of the uterine wall. These data may serve as baseline reference values for further studies in the antepartum fetal surveillance of high-risk pregnancies.     

Primary antiphospholipid syndrome with recurrent transient ischemic attacks: report of a case and its successful treatment

A 35-year-old woman was admitted to our hospital with complaints of a two-year history of recurrent, daily episodes of transient ischemic attacks; the symptoms consisted of scotoma of her left eye, vertical diplopia, and paresthesia of her right arm. The presence of lupus anticoagulants and anticardiolipin antibodies led to the diagnosis of antiphospholipid syndrome (APS). After thrombotest values had decreased to 30% (international normalized ratio: 1.5) with warfarin, her symptoms did not recur. This suggests that anticoagulant therapy is effective for the prevention of recurrence of ischemic events complicated by primary APS, even when they occur repeatedly.     

Persisting perfusion defect in transient ischemic attacks: a new clinically useful subgroup?

BACKGROUND AND PURPOSE: Cerebral infarction and prolonged regional hypoperfusion have been described in patients with transient ischemic attacks (TIAs). The aim of this study was to compare the sensitivity of single-photon emission CT (SPECT) with that of brain CT and to evaluate the clinical significance of differentiation of TIA patients with or without focal hypoperfusion. METHODS: From a hospital-based population, we studied the SPECT and CT findings in 76 consecutive patients, without a stroke history, who presented with TIA in the carotid artery territory. The recorded variables were the time of SPECT, imaging (<36 or > or = 36 hours), clinical presentation, history of previous TIA(s), duration of the presenting attack (<2 or > or = 2 hours), vascular risk factors, and etiology. We used both visual and semiquantitative analyses for the SPECT evaluation. Acetazolamide challenge was not performed. RESULTS: The overall SPECT sensitivity was 36% (27/76). When brain CT and SPECT were performed in the same patients, the SPECT sensitivity was significantly higher than that of CT (19/59 [32%] versus 8/59 [14%]; P=.007). The SPECT sensitivity was not dependent on the time of investigation, duration of attacks, history of TIA(s), or the clinical presentation. The vascular risk and etiologic factors were not significantly different between the patients with or without prolonged focal hypoperfusion. Logistic regression did not identify any variable to discriminate the two groups. CONCLUSIONS: Despite its better sensitivity compared with CT, SPECT performed without the acetazolamide test provides no additional clinically useful information on the vascular risk factors and etiology in TIA patients.     

Cigarette smoking as a determinant of high-grade carotid artery stenosis in Hispanic, black, and white patients with stroke or transient ischemic attack

The effect of chitin, poly-beta-(1 --> 4)-N-acetyl-glucosamine, and chitosan, a polymer of glucosamine obtained by the deacetylation of chitin, on growth and nutrient digestibility was studied in grass shrimp, Penaeus monodon. Shrimp were fed for 8 wk diets containing no supplement (control) or 2, 5 or 10 g/100 g chitin or chitosan. Each diet was fed to triplicate groups of shrimp with a mean initial body weight of 0.45 +/- 0.05 g. Significantly higher body weight gains were observed in shrimp fed the 5% chitin diet than in those fed the 10% chitin or the control diet. The weight gain of shrimp decreased as dietary chitosan supplementation level increased (r = 0. 87, P < 0.05). Feed efficiencies (FE) and protein efficiency ratios (PER) followed the same pattern. Lower protein and lipid digestibilities and lower body protein and lipid contents were observed in shrimp fed all chitosan-containing diets than in controls (P < 0.05). Carbohydrate digestibility was lower in shrimp fed the 10% chitosan diet than in those fed the control diet. Lower protein and lipid digestibilities, body lipid content and blood cholesterol concentration were observed in shrimp fed the 10% chitin diet compared with controls (P < 0.05). Higher weight gains, body lipid contents and blood cholesterol concentrations were observed in shrimp fed the 2 and 5% chitin diets than in those fed the chitosan diets. Shrimp fed the 5% chitin diet had higher protein and lipid digestibilities and higher body protein content than those fed the 5% chitosan diet (P < 0.05). These data suggest that dietary chitin, supplemented at 5%, enhances P. monodon growth, whereas chitosan depresses shrimp growth, regardless of the supplementation level.     

Transcranial Doppler sonography in the pre- intra- and post-operative evaluation of 85 patients undergoing carotid endarterectomy

Porcine somatotropin (pST) administration reduces the sensitivity of pigs to insulin, and after several days of treatment, it alters baseline circulating concentrations of pST, insulin, glucose, and other metabolites. The length of time required to develop this reduction in whole-body insulin sensitivity has not been established. To investigate this, eight castrate pigs received daily injections of either recombinant pST (120 micrograms/kg BW) or exicipient. Intravenous insulin tolerance tests (1.0 microgram/kg BW) were done before the first pST injection (Day 0) and on Day 1, 3, 5, and 8 of pST treatment. Control animals had insulin tolerance tests on Day 0 and again on Day 8 of treatment. By Day 8, the glucose response to the insulin tolerance tests in pST-treated pigs was 45% of the response of the control group (P < 0.01). Glucose response areas between Day 1, 3, 5, and 8 of pST treatment were not different (P > 0.10). The maximum effect of pST on glucose response to insulin was achieved by Day 1. Therefore, factors responsible for the development of reduced whole-body insulin sensitivity in pST-treated pigs are fully expressed within 21 hr of the initial pST treatment.     

The characteristics of the effect of point and classical massage on the hemodynamics of patients with a history of transient ischemic attacks in the vertebrobasilar system

Clinical and instrumental studies have revealed differences in effects of nerve ending and classic massage on hemodynamics in 41 patients early after transitory ischemic attacks in the vertebrobasilar area. Point massage produced more potent vasotropic effect, contraindications to it are minimal. It can be considered as a pathogenetic therapy aimed at correction of cerebral circulation in patients with vertebrobasilar area applicable early after acute cerebrovascular episodes.     

Dolichoectasia of the intracranial arteries in patients with first ischemic stroke: a population-based study

OBJECTIVE: The objective of this study was to estimate the frequency of intracranial arterial dolichoectasia among patients with first ischemic stroke and to compare clinical characteristics, survival, and recurrence in those with and without the abnormality. BACKGROUND: Dolichoectasia may cause cerebral infarction by thrombosis, embolism, stenosis, or occlusion of deep penetrating arteries. METHODS: The chi-square, Fisher's exact, and logrank tests were used to compare clinical characteristics, survival, and recurrence for patients with and without dolichoectasia among the 387 residents of Rochester, MN, who had brain CT or MRI for first cerebral infarction from 1985 through 1989. RESULTS: Twelve patients (3.1%) had dolichoectasia. Patients with dolichoectasia were more likely to have had stroke fitting a clinical and radiographic pattern of lacunar infarction than those without (42% and 17% respectively; p=0.04). Dolichoectasia was detected in the vertebrobasilar system in eight patients (66.7%), in the carotid system in two patients (16.7%), and in both circulatory systems in two patients (16.7%). There were no significant differences in the following characteristics among those with and without dolichoectasia: age, sex, hypertension, diabetes, smoking, and preceding transient ischemic attack. Patients with dolichoectasia had better survival (relative risk [RR] for death, 0.26; p=0.04) after first cerebral infarction but higher rates of stroke recurrence (RR, 2.4; p=0.02). CONCLUSIONS: Dolichoectasia is detected in 38 of patients with first cerebral infarction and is associated with better survival but higher rates of stroke recurrence.     

Lipoprotein(a) in patients with carotid atherosclerosis and ischemic cerebrovascular disorders

Two novel peptides, named PACAP (pituitary adenylate cyclase activating polypeptide) containing 38 (PACAP38) and 27 residues (PACAP27) were recently isolated from ovine hypothalami. In order to investigate the pituitary cell type(s) that bear a receptor for PACAP, PACAP38 was biotinylated and used for cytochemical examination of binding. The cells were also identified by immunocytochemical methods using the antisera against each of the rat anterior pituitary hormones or an antiserum against S-100 protein, a marker for pituitary folliculo-stellate (FS) cells. Biotinylated PACAP38 (biot-PACAP) exhibited adenylate cyclase stimulating activity (ACSA) comparable to PACAP38 in rat pituitary cell cultures, and displaced the bound 125I-PACAP27 to the rat pituitary membrane preparation to the same extent as PACAP38. After 2-4 days of culture, dispersed rat pituitary cells were incubated with varying concentrations of biot-PACAP at room temperature or 4 degrees C. The bound biot-PACAP38 was visualized by avidin-biotin-peroxidase complex (ABC) method with nickel intensification. Biot-PACAP-positive and pituitary hormone or S-100-positive cells were counted. More than 90% of S-100-positive cells bound biot-PACAP38. A considerable number of GH and PRL cells and a lesser number of ACTH cells also bound biot-PACAP38, whereas only a few identified LH, FSH, or TSH cells bound biot-PACAP38. These results suggest that FS cells are a major target cell type for PACAP. A recent study from our laboratory demonstrated that PACAP stimulated the release of interleukin (IL)-6 in rat pituitary cell cultures. FS cells are known to produce IL-6.     

Recurrent ischemic strokes in a patient with Medtronic-Hall prosthetic aortic valve and valve strands

Fine strands associated with prosthetic heart valves have been demonstrated with transesophageal echocardiography, but the pathologic identity of these strands is unclear. A case of a man with a prosthetic aortic Medtronic-Hall valve with prominent valve strands and recurrent strokes is discussed. The patient underwent valve replacement surgery, and histopathologic examination of the strands identified them as Lambl's excrescences.     

Transient ischemic attacks in Chilean patients and their relationship with the country''s pattern of cerebrovascular disease

For the globular proteins with known three-dimensional structures, an ellipsoid model of each protein was constructed with least volume and its dimensions were derived. The spatial arrangements were made for the C alpha and side chain atoms of that protein within that ellipsoid. This new spatial representation shows the residue position from the centroid, as well as the depth from the surface. The average spatial parameters were then calculated. The correlations between these new spatial parameters and the existing parameters of the amino acid residues were then derived.     

Asymptomatic occlusive lesions of carotid and intracranial arteries in Japanese patients with ischemic heart disease: evaluation by brain magnetic resonance angiography

BACKGROUND AND PURPOSE: The purpose of this study was to elucidate the prevalence and degree of asymptomatic occlusive lesions in the carotid and intracranial arteries in Japanese patients with ischemic heart disease (IHD). METHODS: We performed carotid and intracranial MR angiography (MRA) on 67 patients (49 men, 18 women; age range, 40 to 78 years; mean age, 60.1 years) who had received selective coronary angiography for the clinical diagnosis of IHD. On the basis of these images, degree of stenosis in the regions of the bilateral carotid artery bifurcation and five regions of the intracranial arteries, ie, bilateral intracranial portions of the internal carotid arteries and the middle cerebral arteries and the basilar artery were estimated. RESULTS: Stenosis of more than 25% narrowing of the diameter of the target arteries was found in 15 patients (22.4%) in the extracranial carotid arteries and in 11 patients (16.4%) in the intracranial arteries. Most of the stenotic lesions were mild. The incidence of extracranial carotid stenosis and the severity of coronary atherosclerosis showed a significant correlation. The mean age of the patients with intracranial arterial lesions was statistically higher than those without intracranial lesions. CONCLUSIONS: Our data suggest that asymptomatic occlusive lesions in the carotid and intracranial arteries are fairly common in Japanese patients with IHD, although the degree of stenosis is relatively mild. Coexistence of carotid atherosclerosis should be suspected in IHD patients with severe coronary atherosclerosis, and the possibility of atherosclerosis in the intracranial arteries should be considered in aged IHD patients.     

Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack

To evaluate the additional value of transesophageal (TEE) compared with transthoracic (TTE) echocardiography and the role of patent foramen ovale (PFO) and deep vein thrombosis in the work-up of embolic events, patients with presumed cardiac embolic stroke or transient ischemic attack (neurovascular etiology was excluded) were prospectively studied by transthoracic and transesophageal contrast echocardiography. If PFO was detected echocardiographically, PFO size was assessed semiquantitatively and phlebography of both legs was performed. Two hundred forty-two consecutive patients (153 men, 60 +/- 15 years) were studied. In 197 patients, neuroimaging showed evidence of embolic infarction. TEE identified 138 potential cardiac sources of embolism in 111 patients, compared with 69 by TTE (p <0.01) in 59 patients. TEE detected potential cardiac sources in 52 patients with negative TTE examination and was significantly superior compared with TTE for identifying left atrial thrombi, spontaneous echo contrast, PFO, atrial septal aneurysm, and atheroma of the ascending aorta. In patients with a positive TTE, additional diagnostic information by TEE was found in only 6 patients and did not change therapy. Phlebography was performed in 53 patients with PFO and revealed deep vein thrombosis in 5 patients (9.5%); all had medium or large PFOs. Thus, in patients with cerebral ischemia of suspected cardiogenic origin and a normal TTE examination, TEE detects potential causes of embolism in 31% of patients and is therefore of diagnostic relevance. Conversely, in the presence of a diagnostic TTE an additional TEE confers only marginal diagnostic benefit. Deep venous thrombosis was detected in nearly 10% of patients with PFO as the sole identifiable cardiac risk factor. Given that in 4 of 5 patients deep vein thrombosis was clinically silent, phlebography should be performed in patients with medium or large interatrial shunts if paradoxical embolism is suspected.     

Fibromuscular dysplasia of the internal carotid artery as a cause of transient cerebral ischemia episodes

A person's susceptibility to onychomycosis and the course of the disease once the nails are infected are functions of the interaction of the fungal agent, the host, and environmental factors. The disease is reported to have an overall prevalence of 2% to 13%, but the prevalence is much higher in certain populations, such as older people and those with immunosuppressive conditions. Although onychomycosis may be merely a nuisance and an embarrassment for healthy individuals, some morbidity is seen with all population groups, but especially high-risk patients: diabetics, patients infected with human immunodeficiency virus (HIV), patients with acquired immunodeficiency syndrome (AIDS), and patients with other types of immunosuppression (eg, transplant recipients and patients on long-term corticosteroid therapy). Whether the increased prevalence of onychomycosis in the elderly (up to 30% by age 60) is related to changes in immune function is not known.     

The role of arterial hypertension in the occurrence of strokes at a young age

The analysis of insult occurrence in patients at the age under 45 years, caused by blood hypertension, shows, that they make 30.1% from common number of insult in 166 young people, treated in the neurological and other departments of Burdenko Main Military Clinical Hospital in 1989-1996. On occasion of ischemic insult were treated 37 patients, hemorrhagic--13. The reason of insults was "soft" blood hypertension: in 51.4%--at ischemic insult and in 30.1%--hemorrhagic. The authors consider, that the main direction of prophylaxis of insult is active revealing and adequate treatment of the patients with blood, including "soft" hypertension, use of hypotensive preparations and some non-medicative methods of treatment.