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Objectives: Diffusion weighted brain imaging (DWI) is used in acute stroke, and also shows an acute ischaemic lesion in most transient ischamic attack (TIA) patients scanned acutely. However, it may also be useful in identifying subacute ischaemic lesions in patients with minor stroke or TIA who present several weeks after symptom onset. This study investigated the sensitivity and the observer reproducibility of DWI in cerebral TIA and minor ischaemic stroke patients scanned more than two weeks after the last symptomatic event.Methods: Consecutive patients underwent magnetic resonance imaging (T2, DWI, ADC). The presence of clinically appropriate lesions was assessed by two independent observers, and related to the type of presenting event, the NIH score, persistence of symptoms and signs, and the time since the presenting event.Results: 101 patients (53 men) were scanned at a median time of 21 days (IQR=17-28) after symptom onset. Reproducibility of the assessment of DWI abnormalities was high: interobserver agreement =97% (kappa=0.94, p<0.0001); intraobserver agreement =94% (kappa=0.88, p<0.0001). DWI showed a clinically appropriate ischaemic lesion in 29 of 51 (57%) minor stroke patients, and in 7 of 50 (14%) TIA patients. The independent predictors of a positive DWI scan were presentation with minor stroke versus TIA (p=0.009) and increasing NIH score (p=0.009), but there was no difference between patients presenting 2-4 weeks compared with >4 weeks after symptom onset. In minor stroke patients, the presence of a clinically appropriate lesion was associated with persistent symptoms (63% versus 36%; p=0.12) and signs (64% versus 33%, p=0.06) at the time of scanning.Conclusions: DWI shows a clinically appropriate ischaemic lesion in more than half of minor stroke patients presenting more than two weeks after the symptomatic event, but only in a small proportion of patients with TIA. The persistence of lesions on DWI is closely related to markers of severity of the ischaemic event. These results justify larger studies of the clinical usefulness of DWI in subacute minor stroke. [ABSTRACT FROM AUTHOR]

Background Fabry disease ( FD) is an X-linked lysosomal storage disorder frequently associated with cerebrovascular disease. In recent years, the prevalence of FD has been reported to be up to 4% in cryptogenic young stroke patients. However, there have been no population-based studies in unselected patients with transient ischaemic attack (TIA) or stroke across the full range of ages. Methods We determined the prevalence of FD mutations in consecutive patients from a population-based study of acute TIA or ischaemic stroke ( Oxford Vascular Study). Analysis included amplifying of the α-galactosidase A gene by polymerase chain reaction, denaturing high-performance liquid chromatography ( dHPLC) analysis and sequencing using standard automated sequencing protocols [ Mutation Surveyor software ( Softgenetics)] where the dHPLC indicated a possible mutation. Results Samples of 1046 consecutive patients (52% women; mean age 73.2 years; 15% age <60 years; 572 stroke; 474 TIA) were tested. No patient had a known gene mutation causing FD, giving an upper 95% confidence interval around the estimated frequency of 0.35% overall and 2.37% in the 154 patients aged under 60 years. However, in 5 (0.48%) samples, a known polymorphism or sequence variation in the gene was identified that can be associated with lower than normal enzyme activity in plasma without causing the full clinical manifestation of FD. Conclusions Fabry disease is rare in an unselected group of UK patients with TIA or stroke. Larger studies in unselected younger patients with cryptogenic stroke are required to determine whether routine screening is justified in this group. [ABSTRACT FROM AUTHOR]

The article discusses a research study on the association of familial history (FH) of stroke with acute coronary syndromes (ACS) in women. FH data of patients with stroke/ischemic attack or ACS were analyzed according to sex of probands and female first-degree relatives (FDRs) along with the review of their coronary angiograms. Conclusions indicated that FH of stroke is common, both in patients who are in stroke/transient ischemic attack and ACS patients while stroke in female FDRs can point to increased risk of ACS.

Objective: Patch angioplasty during carotid endarterectomy (CEA) can reduce the risk of perioperative stroke or late carotid artery recurrent stenosis and subsequent ischaemic stroke. We aimed to update our previous systematic review of randomized controlled trials (RCTs) of routine or selective carotid patch angioplasty compared with CEA with primary closure, and of different materials used for carotid patch angioplasty. Methods: We identified new RCTs published during 2002-2010 by searching Medline, Embase and the Cochrane Stroke Group Trials Register. We also hand-searched six relevant journals. Pooled estimates of treatment effects combined with our previous review (1966-2001) were calculated on the basis of a weighted estimate of the odds ratio (OR) with the Peto method. Results: Twenty-three eligible RCTs were identified in both periods. Ten RCTs involving 2,157 operations compared primary closure with routine patch closure. Patch closure significantly reduced the combined risk of perioperative stroke and later stroke during long-term follow-up [OR = 0.49, 95% confidence interval (CI) = 0.27-0.90, p = 0.001; 7 RCTs]. Patching also reduced the risks of perioperative arterial occlusion (OR = 0.18, 95% CI = 0.08-0.41, p < 0.0001; 7 RCTs) and recurrent stenosis during long-term followup (OR = 0.24, 95% CI = 0.17-0.34, p < 0.001; 8 RCTs). Conclusion: Meta-analysis of relatively small RCTs suggests that carotid patch angioplasty reduces the combined perioperative and long-term risk of stroke and the risk of restenosis. More data are needed. [Copyright &y& Elsevier]

Background: Aspirin plus clopidogrel (A+C) may be more effective than aspirin only (AO) acutely after TIA and minor stroke, but the risk of bleeding in the acute phase is uncertain. We determined this risk, focusing particularly on aspirin-naïve patients. Methods: We studied consecutive referrals to the EXPRESS study clinic from 1/4/02 to 31/3/08. A 30- to 90-day course of A+C was given to patients presenting acutely. Bleeding events were identified by face-to-face follow-up, diagnostic coding, and blood transfusion data. Unpublished data from the FASTER pilot trial were also studied. Results: Among 633 EXPRESS patients treated with aspirin (+/– clopidogrel), there were 12 spontaneous bleeds (6 minor, 6 major/life-threatening) within 90 days after assessment, with a higher risk for A+C vs. AO (8/247 vs. 4/386, p = 0.047 overall; 5/247 vs. 1/386, p = 0.03 for major/life-threatening bleeds). The excess of major/life-threatening bleeds on A+C vs. AO was seen in aspirin-naïve patients, (4/137 vs. 0/273, p = 0.01), but not in prior-aspirin patients (1/110 vs. 1/113, p = 0.98). All symptomatic bleeds in the FASTER pilot also occurred in aspirin-naïve patients randomized to A+C (6/104 vs. 0/94, p = 0.03). In a pooled analysis, major/life-threatening bleeding on A+C occurred in 9/241 aspirin-naïve patients (90-day risk = 4.8%, 1.6–8.0) versus 1/204 prior-aspirin patients (p = 0.009). Conclusion: Although based on relatively few outcomes, the high risk of major bleeding on A+C acutely after TIA or minor stroke in aspirin-naïve patients is a cause for concern. The potential risk to patients is sufficient to mandate detailed monitoring of bleeding risk in ongoing trials and stratify results by whether patients were aspirin-naïve. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: In certain patients in routine practice, blood pressure (BP) measurements differ substantially from week to week or month to month. Although often assumed to be random, such variability could provide information on underlying pathology or prognosis. In order to be informative, however, visit-to-visit BP variability would have to be neither random (i.e. it should be reproducible over time within individuals) nor artefactual (i.e. it should not be an artefact of the method/timing of measurement, for example). Methods: We quantified visit-to-visit variability in BP and explored potential confounding factors by analysing repeat measurements obtained every few months during follow-up in two large trials in patients with a transient ischaemic attack (TIA) or minor ischaemic stroke: the UK-TIA Aspirin Trial (effect of aspirin, effect of season and day of the week of measurement) and the European Carotid Surgery Trial (ECST – effect of carotid endarterectomy). By comparing different periods of follow-up, we also determined the reproducibilities of mean and several different measures of variability for both systolic (SBP) and diastolic BP (DBP). Results: The mean absolute difference between adjacent SBP readings was 14.7 mm Hg in the UK-TIA Trial and 16.0 mm Hg in ECST. Visit-to-visit variability in both SBP and DBP were independent of the potentially confounding factors studied, but reproducibility of all the variability measures was statistically significantly greater than zero. Reproducibility (intraclass correlation) of standard deviation of SBP was 0.32 (p < 0.0001) in the UK-TIA Trial and 0.18 (p = 0.0007) in ECST. Consequently, classification of patients with high (top quintile) or low (bottom quintile) variability was consistent over time (observed/expected = 2.21, 95% confidence interval 1.71–2.85, p < 0.0001, and 1.65, 1.23–2.21, p = 0.0007, respectively). Reproducibility increased with the number of measurements used to calculate variability, and was independent of any correlation with mean BP. Conclusions: Visit-to-visit variability in BP in these populations was reproducible, independently of any correlation with mean BP, demonstrating that visit-to-visit intra-individual BP variability is not random. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The Prevention of cerebrovascular and cardiovascular Events of ischemic origin with teRutroban in patients with a history oF ischemic strOke or tRansient ischeMic attack (PERFORM) study is an international double-blind, randomized controlled trial designed to investigate the superiority of the specific TP receptor antagonist terutroban (30 mg/day) over aspirin (100 mg/day), in reducing cerebrovascular and cardiovascular events in patients with a recent history of ischemic stroke or transient ischemic attack. Here we describe the baseline characteristics of the population. Methods and Results: Parameters recorded at baseline included vital signs, risk factors, medical history, and concomitant treatments, as well as stroke subtype, stroke-associated disability on the modified Rankin scale, and scores on scales for cognitive function and dependency. Eight hundred and two centers in 46 countries recruited a total of 19,119 patients between February 2006 and April 2008. The population is evenly distributed and is not dominated by any one country or region. The mean ± SD age was 67.2 ± 7.9 years, 63% were male, and 83% Caucasian; 83% had hypertension, and about half the population smoked or had quit smoking. Ninety percent of the qualifying events were ischemic stroke, 67% of which were classified as atherothrombotic or likely atherothrombotic (pure or coexisting with another cause). Modified Rankin scale scores showed slight or no disability in 83% of the population, while the scores on the Mini-Mental State Examination, Isaacs’ Set Test, Zazzo’s Cancellation Test, and the instrumental activities of daily living scale showed a good level of cognitive function and autonomy. Conclusions: The PERFORM study population is homogeneous in terms of demographic and disease characteristics. With 19,119 patients, the PERFORM study is powered to test the superiority of terutroban over aspirin in the secondary prevention of cerebrovascular and cardiovascular events in patients with a recent history of ischemic stroke or transient ischemic attack. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To determine the overall operative risk of cardiovascular events in patients with combined cardiac and carotid artery disease undergoing staged carotid artery stenting (CAS) and coronary artery bypass grafting (CABG). Design: Systematic review of operative risks reported in all published studies of CAS plus CABG procedures. Results: Eleven eligible, published studies were identified which reported data on 760 CAS plus CABG procedures. The majority of patients (87%) were neurologically asymptomatic and 82% had unilateral carotid stenoses. Overall mortality was 5.5% (95% confidence interval, CI: 3.4–7.6), the risk of suffering an ipsilateral stroke was 3.3% (95% CI: 1.6–5.1) and the risk of suffering ‘any’ stroke was 4.2% (95% CI: 2.4–6.1), while the 30-day risk of myocardial infarction (MI) was only 1.8% (95% CI: 0.5–3.0). However, the 30-day death and ipsilateral stroke rate was 7.5% (95% CI: 4.5–10.5) and the 30-day risk of death and any stroke was 9.1% (95% CI: 6.1–12.0), while the 30-day of death/stroke/MI was 9.4% (7.0–11.8). Cumulative risks in studies where patients underwent CABG within 48h of CAS were not higher than in comparable studies where CABG was delayed by more than 2 weeks. Conclusions: In a cohort of predominantly asymptomatic patients with unilateral carotid disease, the 30-day risk of death/any stroke was 9.1%. These data are comparable to previous systematic reviews evaluating the roles of staged and synchronous carotid endarterectomy (CEA) plus CABG, and suggest that staged CAS plus CABG is an attractive and less invasive alternative to CEA plus CABG. However, it remains questionable whether the observed 9% risks can be justified in any asymptomatic patient with unilateral carotid disease. [Copyright &y& Elsevier]

Abstract: Objectives: To update our previous systematic review of outcomes following synchronous carotid endarterectomy (CEA) and off-pump coronary artery bypass grafting (OFF-CABG). Design: A systematic review of operative risks reported in published studies of synchronous CEA plus OFF-CABG procedures. Results: We identified 12 eligible studies, including data on 324 synchronous CEA plus OFF-CABG procedures. Operative mortality was 1.5% (95% confidence interval (CI): 0.3–2.8), the risk of death or ipsilateral stroke was 1.6% (0.4–2.8%), risk of death or any stroke was 2.2% (95% CI: 0.7–3.7) and the risk of death, stroke or myocardial infarction was 3.6% (95% CI: 1.6–5.5). Conclusions: Limited published data on 324 patients suggest that early outcomes after synchronous CEA plus OFFCABG are better than those following staged or synchronous CEA plus CABG where the cardiac procedure was performed on-pump. This may, however, be attributed to publication bias, case selection or the fact that the aorta was not manipulated or cannulated, rather than CEA being primarily responsible for the lower stroke risk. Colleagues with unpublished experience of CEA plus OFF-CABG are encouraged to submit their data to further inform the debate. [Copyright &y& Elsevier]

Stroke is the leading cause of disability in the adult population of western industrialized countries. Despite significant improvements of acute stroke care, two thirds of stroke survivors have to cope with persisting neurologic deficits. Adjuvant brain stimulation is a novel approach to improving the treatment of residual deficits after stroke. Transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and epidural electrical stimulation have been used in first trials on small cohorts of stroke patients. Effect sizes in the order of 8% to 30% of functional improvement have been reported, but a publication bias toward presenting “promising” but not negative results is likely. Many questions regarding underlying mechanisms, optimal stimulation parameters, combination with other types of interventions, among others, are open. This review addresses six controversies related to the experimental application of brain stimulation techniques to stroke patients. Cortical stimulation after stroke will need to be individually tailored and a thorough patient stratification according to type and extent of clinical deficit, lesion location, lesion size, comorbidities, time in the recovery process, and perhaps also age and gender will be necessary. There is consensus that cortical stimulation in stroke patients is still experimental and should only be applied in the frame of scientific studies. [Copyright &y& Elsevier]

Background: Diabetes is associated with an increased risk of incident stroke and both early and late recurrent stroke after transient ischaemic attack. Some small studies have suggested that atherosclerotic plaques from diabetics have a higher prevalence of unstable features than plaques from non-diabetics but results have been inconsistent. Method: We made detailed histological assessments of 526 plaques from consecutive patients undergoing carotid endarterectomy for recently symptomatic stenosis and related these to the presence of diabetes and impaired glucose tolerance (IGT). Results: 53 (10.1%) patients had diabetes, 26 (5%) had IGT and 447 (84.9%) had normal glucose tolerance (NGT). The overall prevalence of unstable plaque features was similar across these groups. However, whereas plaques removed >60 days after last symptoms in patients with NGT had less surface thrombus (OR = 0.61, 95% CI = 0.40–0.92, p = 0.02), fewer plaque macrophages (OR = 0.78, 95% CI = 0.51–1.19, p < 0.001) and less marked overall instability (OR = 0.57, 95% CI = 0.35–0.88, p = 0.009) than plaques removed more acutely, these features tended to be more persistent in patients with diabetes/IGT (OR = 1.08, 95% CI = 0.42–2.77, OR = 1.16, 95% CI = 0.46–2.96 and OR = 1.51, 95% CI = 0.60–3.77, respectively). Conclusion: Overall, the prevalence of unstable histology features in recently symptomatic carotid plaques is similar in patients with diabetes, IGT and NGT. However, surface thrombus and plaque macrophages appear to persist for longer after ischaemic symptoms in plaques from patients with diabetes/IGT compared to plaques from patients with NGT. This may contribute to the increased risk of recurrent stroke that is associated with diabetes/IGT. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Carotid bifurcation stenosis is an important cause of ischaemic stroke, particularly in patients with recent transient ischaemic attack or minor stroke. Large randomised trials of endarterectomy have shown that surgery reduces the risk of stroke in patients with ≥50% recently symptomatic carotid stenosis, but more recent research has shown that the effectiveness of surgery is highly dependent on timing and on patient selection. Early surgery has been shown to be essential to reduce the high risk of stroke in the first few weeks after a TIA or minor stroke, and targeting treatment on the basis of timing and individual risk modelling has been shown to be useful in selecting patients with most to gain from endarterectomy for symptomatic stenosis. This article reviews current understanding of the high-risk period after TIA and minor stroke and recent developments in the identification of the high-risk patient – both in the acute phase and in the long-term. [Copyright &y& Elsevier]

Diffusion-weighted imaging (DWI) is mainly used in acute stroke, and signal evolution in the acute phase has been studied extensively. However, patients with a minor stroke frequently present late. Recent studies suggest that DWI may be helpful at this stage, but only very few published data exist on the evolution of the DW-signal in the weeks and months after a stroke. We performed a follow-up study of DWI in the late stages after a minor stroke. 28 patients who presented 48 hours to 14 days after a minor stroke underwent serial MRI at baseline, 4 weeks, 8 weeks, 12 weeks, 6 months and ≥9 months after their event. Signal intensity within the lesion was determined on T2-weighted images, DW-images and the Apparent Diffusion Coefficient (ADC) map at each time-point, and ratios were calculated with contralateral normal values (T2r, DWIr, ADCr). T2r was increased in all patients from the beginning, and showed no clear temporal evolution. ADCr normalized within 8 weeks in 83% of patients, but still continued to increase for up to 6 months after the event. The DW-signal decreased over time, but was still elevated in 6 patients after ≥6 months. The evolution of ADCr and DWIr showed statistically highly significant inter-individual variation (p < 0.0001), which was not accounted for by age, sex, infarct size or infarct location. The ADC and the DW-signal may continue to evolve for several months after a minor ischaemic stroke. Signal evolution is highly variable between individuals. Further studies are required to determine which factors influence the evolution of the ADC and the DW-signal. [ABSTRACT FROM AUTHOR]

Background: Weak associations between total and LDL cholesterol and ischaemic stroke compared with coronary heart disease (CHD) are at odds with the similar effectiveness of statin drugs in preventing ischaemic stroke and CHD, suggesting that other lipid sub-fractions that are affected by statins might be better predictors of ischaemic stroke. Apolipoprotein B levels are reduced by statins and are a stronger predictor of CHD than total and LDL cholesterol in patients both on and off statins. However, there are very few published data on apolipoproteins and stroke risk and no studies in patients with previous transient ischaemic attack (TIA). Methods: We performed a prospective cohort study of the associations of baseline total cholesterol, LDL, HDL, apolipoproteins A1 and B (apo A1; apo B) and risk of ischaemic stroke in 261 patients with previous TIA. Cox proportional hazards models were used to determine crude and multivariate-adjusted hazard ratios (HR) above versus below median values at 10-years follow-up. Results: The apo B/apo A1 ratio was the strongest independent predictor of ischaemic stroke (HR = 2.94, 95% CI 1.43–5.88, p = 0.003) followed by apo B (HR = 2.26, 95% CI 1.16–4.38, p = 0.02). The associations between total cholesterol, LDL, HDL, LDL/HDL ratio and apo A1 and ischaemic stroke risk did not reach statistical significance. Conclusions: Apo B and the apo B/apo A1 ratio are predictive of ischaemic stroke in patients with previous TIA. Further studies are required to determine whether the prognostic value of apolipoprotein levels is maintained in patients on statins. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

We have reliable data on the degree of stenosis above which endarterectomy for symptomatic carotid stenosis is beneficial, but benefit is also influenced by other factors, particularly age, sex, the timing of surgery, plaque surface morphology and the nature of the presenting symptomatic event(s). This review will consider the selection of patients for carotid surgery based on the factors that influence the likely risk of stroke on medical treatment. In order to take into account all of the relevant factors, a risk prediction model is considered. [ABSTRACT FROM AUTHOR]

Background: Randomized trials of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis have demonstrated that benefit is decreased in women, due partly to a high operative risk, which is independent of age. However, it is uncertain whether these trial-based observations are generalisable to routine clinical practice. Methods: We performed a systematic review of all publications reporting data on the association between age and/or sex and procedural risk of stroke and/or death following CEA from 1980 to 2004. Results: 62 eligible papers reported relevant data. Females had a higher rate of operative stroke and death (25 studies, OR = 1.31, 95% CI = 1.17–1.47, p < 0.001) than males, but no increase in operative mortality (15 studies, OR = 1.05, 95% CI = 0.81–0.86, p = 0.78). Compared with younger patients, operative mortality was increased at ≥75 years (20 studies, OR = 1.36, 95% CI = 1.07–1.68, p = 0.02), at age ≥80 years (15 studies, OR = 1.80, 95% CI = 1.26–2.45, p < 0.001) and in older patients overall (35 studies, OR = 1.50, 95% CI = 1.26–1.78, p < 0.001). In contrast, risk of non-fatal stroke did not increase with age and so the combined perioperative risk was only slightly increased at age ≥75 years (21 studies, OR = 1.18, 95% CI = 0.94–1.44, p = 0.06), at age ≥80 years (10 studies, OR = 1.14, 95% CI = 0.92–1.36, p = 0.34) and in older patients overall (36 studies, OR = 1.17, 95% CI = 1.04–1.31, p = 0.01). Conclusions: The effects of age and sex on the operative risk of CEA in published case series are consistent with those observed in the trials. Operative risk of stroke is increased in women and operative mortality is increased in patients aged ≥75 years. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article presents a study which compares the recurrent of cerebral ischaemic lesions on diffusion-weighted imaging (DWI) in patients with carotid stenosis in Great Britain. It uses patients who were recruited from 2003 to 2004 and who experienced transient ischaemic attack (TIA) or minor stroke. It likewise uses a DWI and a questionnaire to examine and recorded the recurrent of the lesions. The results show that asymptomatic lesions on DWI occur in the chronic phase after TIA or minor.

Abstract Objective: To estimate the very early stroke risk after a transient ischaemic attack (TIA) or minor stroke and thereby inform the planning of effective stroke prevention services. Design: Population based prospective cohort study of patients with TIA or stroke. Setting: Nine general practices in Oxfordshire, England, from April 2002 to April 2003. Participants: All patients who had a TIA (n = 87) or minor stroke (n = 87) during the study period and who presented to medical attention. Main outcome measures: Risk of recurrent stroke at seven days, one month, and three months after TIAs and minor strokes. Results: The estimated risk of recurrent stroke was 8.0% (95% confidence interval 2.3% to 13.7%) at seven days, 11.5% (4.8% to 18.2%) at one month, and 17.3% (9.3% to 25.3%) at three months after a TIA. The risks at these three time periods after a minor stroke were 11.5% (4.8% to 11.2%), 15.0% (7.5% to 22.5%), and 18.5% (10.3% to 26.7%). Conclusions: The early risks of stroke after a TIA or minor stroke are much higher than commonly quoted. More research is needed to determine whether these risks can be reduced by more rapid instigation of preventive treatment. [ABSTRACT FROM AUTHOR]

Discusses the need for reliable data on risks and risks factors in cerebrovascular complications of therapeutic neck manipulation. Increase in arterial dissections; Proportion of chiropractic vertebral artery dissections that are asymptomatic; Difficulty of interpretating observations.

Limb shaking is an under-recognised form of transient ischaemic attack (TIA), which can easily be confused with focal motor seizures. However, it is important to distinguish limb shaking TIAs and focal seizures, as patients with this form of TIA almost invariably have severe carotid occlusive disease and are at high risk of stroke. A patient with limb shaking TIAs is presented in whom the diagnosis was missed. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To determine the role of carotid artery disease in the pathophysiology of stroke after coronary artery bypass (CABG). Design: Systematic review of the literature. Results: The risk of stroke after CABG was 2% and remained unchanged between 1970-2000. Two-thirds occurred after day 1 and 23% died. 91% of screened CABG patients had no significant carotid disease and had a <2% risk of peri-operative stroke. Stroke risk increased to 3% in predominantly asymptomatic patients with a unilateral 50–99% stenosis, 5% in those with bilateral 50–99% stenoses and 7–11% in patients with carotid occlusion. Significant predictive factors for post-CABG stroke included; (i) carotid bruit (OR 3.6, 95% CI 2.8–4.6), (ii) prior stroke/TIA (OR 3.6, 95% CI 2.7–4.9) and (iii) severe carotid stenosis/occlusion (OR 4.3, 95% CI 3.2–5.7). However, the systematic review indicated that 50% of stroke sufferers did not have significant carotid disease and 60% of territorial infarctions on CT scan/autopsy could not be attributed to carotid disease alone. Conclusions: Carotid disease is an important aetiological factor in the pathophysiology of post-CABG stroke. However, even assuming that prophylactic carotid endarterectomy carried no additional risk, it could only ever prevent about 40–50% of procedural strokes. [Copyright &y& Elsevier]

Background & Aims: Oropharyngeal dysphagia is an important disability that occurs after stroke; it contributes to aspiration pneumonia and death, and current modalities for rehabilitation of dysphagia have uncertain efficacy. We therefore examined the role of pharyngeal electrical stimulation (PES) in expediting human swallowing recovery after experimental (virtual) and actual (stroke) brain lesions. Methods: First, healthy subjects (n = 13) were given 1-Hz repetitive transcranial magnetic stimulation to induce a unilateral virtual lesion in pharyngeal motor cortex followed by active or sham (control) PES. Motor-evoked potentials and swallow accuracy were recorded before and after the lesion to assess PES response. Thereafter, 50 acute dysphagic stroke patients underwent either a dose-response study, to determine optimal parameters for PES (n = 22), or were assigned randomly to groups given either active or sham (control) PES (n = 28). The primary end point was the reduction of airway aspiration at 2 weeks postintervention. Results: In contrast to sham PES, active PES reversed the cortical suppression induced by the virtual lesion (F 7,70 = 2.7; P = .015) and was associated with improvement in swallowing behavior (F 3,42 = 5; P = .02). After stroke, 1 PES treatment each day (U = 8.0; P = .043) for 3 days (U = 10.0) produced improved airway protection compared with controls (P = .038). Active PES also reduced aspiration (U = 54.0; P = .049), improved feeding status (U = 58.0; P = .040), and resulted in a shorter time to hospital discharge (Mantel–Cox log-rank test, P = 0.038). Conclusions: This pilot study of PES confirms that it is a safe neurostimulation intervention that reverses swallowing disability after virtual lesion or stroke. [Copyright &y& Elsevier]

Background & Aims: Excitatory brain stimulation with repetitive transcranial magnetic stimulation (rTMS) has been proposed as a treatment for dysphagia after stroke. Moreover, 1-Hz rTMS can induce a “virtual lesion” in the human pharyngeal motor cortex that suppresses brain activity and temporarily disrupts swallowing. We thus examined if rTMS could reverse the disrupted brain and swallowing functions following a unilateral virtual lesion in the pharyngeal motor cortex, such that rTMS might be developed as a therapy. Methods: Healthy subjects (n = 23) were given varying conditions of 5-Hz rTMS over the pharyngeal motor cortex to determine the most effective excitatory parameters. Thereafter, a unilateral virtual lesion was made in the pharyngeal motor cortex using 1-Hz rTMS, followed by contralateral active or sham 5-Hz rTMS. Motor evoked potentials and serial swallowing reaction times were recorded before and for 60 minutes postlesion to assess reversibility of the disruption to the brain and swallowing. Results: The greatest increase in pharyngeal motor cortex excitability was seen following 250 pulses of 5-Hz rTMS (F(1,11) = 10.3, P = .008), an effect that lasted over 2 hours. In contrast to sham rTMS, active contralateral 5-Hz rTMS completely abolished the cortical suppression induced by the virtual lesion, with effects occurring for up to 50 minutes in both unlesioned (F(1,11) = 6, P = .03) and lesioned (F(1,11) = 67, P < .001) hemispheres. Active rTMS also reversed the changes in swallowing behavior (F(1,8) = 9, P = .018), restoring function to prelesional levels. Conclusions: Contralesional-targeted neurostimulation modulates brain activity and swallowing motor behavior after experimental disruption and might be usefully applied in stroke-affected patients as a therapy for dysphagia. [Copyright &y& Elsevier]

The article answers a question regarding the comparison between a unified risk score and a previously developed ABCD and California scores for predicting two, seven and 90 day strok risk in patients with transient ischemic attack. Patients classified at high risk should be prioritized for immediate evaluation, targeted intervention and inpatient observation to minimize their risk of future stroke and maximize their chances of access to early thrombolysis.

The article reports on a study to determine whether a simple risk score can predict stroke during the first seven days after probable or definite transient ischemic attack (TIA). Three cohort studies were conducted in family practices in Oxfordshire, Great Britain. It was indicated that a simple risk score based on age, blood pressure, clinical characteristics and duration of symptoms can predict a seven day stroke risk.

Discusses research being done on transient ischemic attack (TIA) and minor stroke. Reference to study by M. F. Giles et al, presented at the British Geriatrics Society Communications to the Autumn Meeting in Harrogate, England from October 6 to 8, 2004; Determinants of delay in seeking medical attention by older people after a TIA or minor stroke; Methodology and result of the study.

Discusses research being done on transient ischemic attack and stroke clinics. Reference to study by M. F. Gilles et al, presented at the British Geriatrics Society Communications to the Autumn Meeting in Harrogate, England from October 6 to 8, 2004; Evaluation of the services of TIA and stroke clinics; Methodology and result of the study.

Discusses research being done on transient ischemic attack and ischemic stroke in older people. Reference to study by M. F. Giles et al, presented at the British Geriatrics Society Communications to the Autumn Meeting in Harrogate, England from October 6 to 8, 2004; Prevalence of significant carotid stenosis; Benefit from carotid endarterectomy for symptomatic carotid stenosis.

Presents an abstract of the study "Rates and Non-Fatal Acute Cerebrovascular Versus Coronary Vascular Events: Implications for Provision of Acute Services," by A. J. Coull, L. E. Silver , P. M. Rothwell.

Summary: Background: UK stroke mortality data suggest that the incidence of haemorrhagic stroke has fallen in the past 20 years, but these data do not include deaths of individuals aged 75 years or over. Trends in the older population might differ, since cause varies with age. Our aim was to investigate changes in the population-based incidence of intracerebral haemorrhage according to age and likely aetiology. Methods: We used data from the Oxford Community Stroke Project (OCSP; 1981–86) and the Oxford Vascular Study (OXVASC; 2002–06) to investigate changes in the incidence of intracerebral haemorrhage with time, above and below age 75 years, together with associated risk factors and premorbid medications. Incidences were standardised to the 2001 census population of England and Wales. Findings: In the population aged under 75 years the incidence of intracerebral haemorrhage decreased substantially (rate ratio 0·53, 95% CI 0·29–0·95; p=0·03), but the number of cases of intracerebral haemorrhage at all ages were similar in OXVASC and OCSP (52 vs 55 cases) as the proportion of cases occurring at 75 years and over tended to increase (2·0, 0·8–4·6; p=0·09). The incidence of intracerebral haemorrhage associated with premorbid hypertension (blood pressure ≥160/100 mm Hg) fell overall (0·37, 0·20–0·69; p=0·002), but the incidence of intracerebral haemorrhage associated with antithrombotic use was increased (7·4, 1·7–32; p=0·007). Above age 75 years the proportion of cases who were non-hypertensive with lobar bleeds and presumed to have had mainly amyloid-related haemorrhages, also increased (4·0, 1·1–17; p=0·003). Interpretation: There has been a substantial fall in hypertension-associated intracerebral haemorrhage over the past 25 years, but not in the overall number of cases of intracerebral haemorrhage in older age-groups, in part due to a rise in intracerebral haemorrhage associated with antithrombotic use. These trends, along with the expected increase in prevalence of amyloid angiopathy with the ageing population, suggest that, in contrast to projections based on mortality data below age 75 years, absolute number of cases of intracerebral haemorrhage might increase in future. [Copyright &y& Elsevier]