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Background Patients with transient ischemic attack (TIA) without large-artery disease (LAD) or atrial fibrillation (AF) on admission may be at higher risk of stroke than previously thought. The aim of this study was to investigate early stroke risk and its predictors in such patients. Methods We studied 410 TIA patients admitted to our institute within 48 hours of onset. Urgent etiological workup revealed that 210 patients had neither symptomatic LAD nor AF. The outcome measure was the stroke occurrence within 7 days after admission. Results Stroke occurred within 7 days in 15 patients, 7.1% of patients without LAD or AF and 6.5% of those with LAD or AF, showing no statistical difference between the 2 groups. Twelve of the 15 patients were diagnosed with small-vessel disease as the stroke etiology. In multivariable regression analysis, motor lacunar symptoms (odds ratio [OR], 5.7; 95% confidence interval [CI], 1.4-41.1), high systolic blood pressure on admission of 183 mm Hg or greater (OR, 15.3; 95% CI, 3.8-80.2), and positive diffusion-weighted imaging findings (OR, 6.1; 95% CI, 1.6-28.1) were independent predictors for the stroke occurrence within 7 days in patients without LAD or AF. Conclusions TIA patients should be cautiously managed, even when neither LAD nor AF are identified by urgent workup. Clinical findings as motor lacunar symptom or high admission blood pressure, besides diffusion-weighted imaging findings, may be helpful to predict early stroke in such patients.

Background There is little information about intracranial atherosclerotic disease (ICAD) and extracranial atherosclerotic disease (ECAD) in patients with acute spontaneous intracerebral hemorrhage (ICH). The purpose of the present study was to elucidate the prevalence of and the factors that correlate with ICAD and ECAD in patients with ICH. Methods A total of 274 patients with acute spontaneous ICH were enrolled. ICAD and ECAD (moderate to severe stenosis or occlusion) were mainly assessed by intracranial magnetic resonance angiography and carotid duplex sonography, respectively. Results Fifty-one patients (19%) had ICAD or ECAD; 32 had ICAD, and 21 had ECAD. On multivariable analyses, age (OR, 1.52; 95% CI, 1.06–2.28 for every 10years), monocyte count (OR, 1.37; 95% CI, 1.02–1.87 for every 100/mm 3 ), hemoglobin A1c (OR, 2.25; 95% CI, 1.08–5.15 for every 1%), and low-density lipoprotein cholesterol levels (OR, 1.23; 95% CI, 1.08–1.42 for every 10mg/dL) were independently associated with ICAD. Age (OR, 2.20; 95% CI, 1.20–4.38 for 10years) and dyslipidemia (OR, 3.95; 95% CI, 1.01–15.97) were independently associated with ECAD. Conclusions ICAD and ECAD were detected in approximately one-fifth of patients with spontaneous ICH. Age and dyslipidemia (or lipid profile) were associated with both ICAD and ECAD. Monocyte count and hemoglobin A1c were associated with ICAD.

We evaluated whether carotid duplex ultrasonography (US) can help predict the safety and efficacy of treating hyperacute stroke with intravenous (IV) tissue plasminogen activator (alteplase) therapy. Consecutive patients with stroke were assigned to the carotid artery occlusion (CO) group or the other (non-CO) group according to US findings before or immediately after receiving IV alteplase. Effectiveness and safety outcomes included early neurologic improvement, defined as a reduction in a National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points within the initial 24 hours after stroke onset; completely independent routine activity, defined as a modified Rankin Scale score of ≤1 at day 90 after stroke onset; symptomatic intracranial hemorrhage (ICH) occurring within 36 hours after stroke onset; and any ICH. We enrolled 127 patients (27 in the CO group and 100 in the non-CO group) with a median baseline NIHSS score of 13 (range, 4-30). The CO group had a higher baseline NIHSS score (median, 18 vs 12; P=.005). After multivariate adjustment, the CO group was inversely associated with early improvement (odds ratio [OR]=0.26; 95% confidence interval [CI]=0.09-0.72) and independence at day 90 (OR=0.23; 95% CI=0.05-0.73) and positively associated with any ICH (OR=3.11; 95% CI=1.23-8.48). Our findings indicate that CO identified by US in the emergency clinical setting is an independent predictor of unfavorable outcome and ICH following IV alteplase therapy.

A 63-year-old patient with the right supplementary motor area infarct developed early-onset dystonia in the left upper extremity. The mechanisms involved in the genesis of focal dystonia are discussed with emphasis on cortical basal ganglia circuit and efferent projections from the supplementary motor area.