Transient ischemic attacks characterized by RNA profiles in blood.

Objective: Transient ischemic attacks (TIA) are common. Though systemic inflammation and thrombosis are associated with TIA, further study may provide insight into TIA pathophysiology and possibly lead to the development of treatments specifically targeted to TIA. We sought to determine whether gene expression profiles in blood could better characterize the proinflammatory and procoagulant states in TIA patients.

Validation of the Stroke Prognostic Instrument-II in a large, modern, community-based cohort of ischemic stroke survivors.

Background And Purpose: The risk of recurrent stroke in the modern era of secondary stroke prevention is not well defined. Several prediction models, including the Stroke Prognostic Instrument-II (SPI-II), have been created to identify patients at highest risk, but their performance in modern populations has been infrequently tested. We aimed to assess the 1-year risk of recurrence after hospital discharge in a recent, large, community-based cohort of patients with ischemic stroke and to validate the SPI-II prediction model in this cohort.

Secondary preventive medication persistence and adherence 1 year after stroke.

Objective: Data on long-term use of secondary prevention medications following stroke are limited. The Adherence eValuation After Ischemic stroke-Longitudinal (AVAIL) Registry assessed patient, provider, and system-level factors influencing continuation of prevention medications for 1 year following stroke hospitalization discharge.

Methods: Patients with ischemic stroke or TIA discharged from 106 hospitals participating in the American Heart Association Get With The Guidelines-Stroke program were surveyed to determine their use of warfarin, antiplatelet, antihypertensive, lipid-lowering, and diabetes medications from discharge to 12 months.

A randomized trial of hypothesis-driven vs screening neurologic examination.

Objective: We hypothesized that trainees would perform better using a hypothesis-driven rather than a traditional screening approach to the neurologic examination.

Methods: We randomly assigned 16 medical students to perform screening examinations of all major aspects of neurologic function or hypothesis-driven examinations focused on aspects suggested by the history. Each student examined 4 patients, 2 of whom had focal deficits.

Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: a multicenter study.

Objectives: Stroke risk immediately after TIA defined by time-based criteria is high, and prognostic scores (ABCD2 and ABCD3-I) have been developed to assist management. The American Stroke Association has proposed changing the criteria for the distinction between TIA and stroke from time-based to tissue-based. Research using these definitions is lacking.

Feasibility study to assess the use of the Cincinnati stroke scale by emergency medical dispatchers: a pilot study.

The emergency medical dispatcher (EMD) receiving a call via 911 is the first point of contact within the acute care system and plays an important role in early stroke recognition. Published studies show that the diagnostic accuracy of stroke of EMD needs to be improved. Therefore, the National Association of Emergency Medical Dispatchers implemented a stroke diagnostic tool modelled after the Cincinnati stroke scale across 3000 cities worldwide.

Profiles of lacunar and nonlacunar stroke.

Objective: Determining which small deep infarcts (SDIs) are of lacunar, arterial, or cardioembolic etiology is challenging, but important in delivering optimal stroke prevention therapy. We sought to distinguish lacunar from nonlacunar causes of SDIs using a gene expression profile.

Methods: A total of 184 ischemic strokes were analyzed.

Global variation in the relative burden of stroke and ischemic heart disease.

Background: Although stroke and ischemic heart disease (IHD) have several well-established risk factors in common, the extent of global variation in the relative burdens of these forms of vascular disease and reasons for any observed variation are poorly understood.

Methods And Results: We analyzed mortality and disability-adjusted life-year loss rates from stroke and IHD, as well as national estimates of vascular risk factors that have been developed by the World Health Organization Burden of Disease Program. National income data were derived from World Bank estimates.

A cost-utility analysis of mechanical thrombectomy as an adjunct to intravenous tissue-type plasminogen activator for acute large-vessel ischemic stroke.

Background And Purpose: Mechanical thrombectomy has the potential to improve recanalization rates and outcomes for patients with ischemic stroke, but potential gains could be offset by procedural complications and costs. We evaluated the cost and utility of combined intravenous (IV) tissue-type plasminogen activator (tPA) and mechanical thrombectomy compared to IV tPA alone for acute large-vessel ischemic stroke.

Methods: We constructed a decision tree for a hypothetical 68-year-old with a large-vessel ischemic stroke who is eligible for IV tPA.

Practice variation in neuroimaging to evaluate dizziness in the ED.

Background: The appropriate role of neuroimaging to evaluate emergency department (ED) patients with dizziness is not established by guidelines or evidence.

Methods: We identified all adults with a triage complaint of dizziness who were evaluated at 20 EDs of a large Northern California integrated health care program in 2008. Using comprehensive medical records, we captured all head computed tomographies (CTs) or brain magnetic resonance images (MRIs) completed at presentation or within 2 days and all stroke diagnoses within 1 week.

Detection of atrial fibrillation after stroke and the risk of recurrent stroke.

Failure to expeditiously diagnose atrial fibrillation (AF) as the cause of ischemic stroke has unclear consequences. We studied the association between detection of AF after discharge and the risk of recurrent stroke. We followed a prospectively assembled cohort of patients hospitalized for stroke for 1 year for new diagnoses of AF and recurrent stroke.

Prevention of stroke following transient ischemic attack.

Transient ischemic attacks (TIAs) are common neurologic events characterized by stroke-like symptoms that completely resolve. They were previously thought to be benign but research over the past decade has revealed the high risk of further neurologic and cardiac events following TIA. With the knowledge of prognosis following TIA, the need for more urgent diagnostic workup and treatment has become clear, and several tools for identifying patients at the highest risk have been developed.

Enhancing ties between academia and industry to improve health.

Concerns about conflicts of interest have driven a wedge between academia and the pharmaceutical and devices industries. Although elevated concern for bias is justified, particularly when academics may affect drug sales, partnerships between industry and academia are essential to achieve the full promise of health improvement from the public investment in biomedical research. New models for such partnerships are developing and should be encouraged.

High-sensitivity C-reactive protein and clopidogrel treatment in patients at high risk of cardiovascular events: a substudy from the CHARISMA trial.

Aims: This study investigated the effect of clopidogrel treatment on inflammatory activity as evidenced by the change in high-sensitivity C-reactive protein (hsCRP) levels in a broad population of patients who are at high risk of atherothrombotic events. The predictive value of hsCRP levels for a treatment benefit of clopidogrel was also explored.

Methods: The study included 8021 patients with established atherosclerotic disease or multiple cardiovascular risk factors enrolled in the CHARISMA trial.

National Stroke Association recommendations for systems of care for transient ischemic attack.

Transient ischemic attacks (TIAs) are common and portend a high short-term risk of stroke. Evidence-based recommendations for the urgent evaluation and treatment of patients with TIA have been published. However, implementation of these recommendations reliably and consistently will require changes in the systems of care established for TIA.

NIH disease funding levels and burden of disease.

Background: An analysis of NIH funding in 1996 found that the strongest predictor of funding, disability-adjusted life-years (DALYs), explained only 39% of the variance in funding. In 1998, Congress requested that the Institute of Medicine (IOM) evaluate priority-setting criteria for NIH funding; the IOM recommended greater consideration of disease burden. We examined whether the association between current burden and funding has changed since that time.

Is mechanical clot removal or disruption a cost-effective treatment for acute stroke?

Background And Purpose: It is unclear whether the costs and risks of mechanical therapies make them cost-effective. We examined whether interventions such as mechanical clot removal or disruption with angioplasty are cost-effective for acute ischemic stroke compared with best medical therapy.

Materials And Methods: We performed a cost-utility analysis of patients with acute stroke due to large intracranial artery occlusion presenting beyond the 3-hour window for IV tPA.

Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.

Background: Cardiovascular disease (CVD) is the leading cause of death in the United States and is responsible for 17% of national health expenditures. As the population ages, these costs are expected to increase substantially.

Methods And Results: To prepare for future cardiovascular care needs, the American Heart Association developed methodology to project future costs of care for hypertension, coronary heart disease, heart failure, stroke, and all other CVD from 2010 to 2030.

Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

Background: Stroke is a major cause of disability and death. The Brain Attack Coalition has proposed establishment of primary and comprehensive stroke centers to provide appropriate care to stroke patients who require basic and more advanced interventions, respectively. Primary stroke centers have been designated by The Joint Commission since 2003, as well as by various states.

Effect of clopidogrel plus ASA vs. ASA early after TIA and ischaemic stroke: a substudy of the CHARISMA trial.

Background: The Clopidogrel for High Atherothrombotic Risk and Ischaemic Stabilisation, Management and Avoidance (CHARISMA) trial reported no statistically significant benefit of adding clopidogrel to acetylsalicylic acid in the long-term management of a broad population of patients with stable vascular disease. However, a subanalysis raised the hypothesis that dual antiplatelet therapy with clopidogrel plus acetylsalicylic acid may be more effective than aspirin in patients with prior ischaemic stroke, myocardial infarction of symptomatic peripheral arterial disease. We aimed to determine whether the possible benefits of clopidogrel plus acetylsalicylic acid in patients with transient ischaemic attack and ischaemic stroke may be 'front-loaded', and maximal within the first 30-days of randomisation, without being unduly hazardous.