Bilateral internal carotid artery agenesis coexisting with bovine aortic arch: case report and literature review.

This case study aims to elucidate the rare occurrence of bilateral internal carotid artery agenesis combined with a bovine aortic arch. The main objectives are to explore the incidence, embryological origins, clinical manifestations, and associated anomalies of this unique vascular condition. The study involves a detailed investigation of a 55-year-old male with a history of recurrent transient ischemic attacks (TIAs) using MRI and CT scan. The patient's medical history, clinical examination, and imaging results were systematically analyzed to provide a thorough understanding of the anatomical variations. The main findings include the rare coexistence of bilateral ICA agenesis and a bovine aortic arch, making this the 39th documented occurrence of bilateral ICA agenesis and the first recorded instance of its association with a bovine aortic arch. Also, the study highlighted the demographic characteristics, clinical presentations, and associated anomalies observed in the 38 documented cases of bilateral internal carotid artery agenesis. This case report contributes valuable insights into the rarity of bilateral internal carotid artery agenesis and its unprecedented association with a bovine aortic arch. The findings emphasize the importance of heightened anatomical awareness in clinical practice, particularly. Recognizing and understanding such variations is crucial for accurate diagnosis, appropriate management, and improved patient outcomes. Further research in this area is warranted to deepen our understanding of these complex vascular anomalies.

Vascular vertigo and dizziness: managing and treating outpatients.

OBJECTIVE: Due the lack of data on the treatment of Vascular Vertigo and Dizziness, this study aimed to report how we managed and treated those outpatients according to the recently introduced American Heart Association and Stroke Association guidelines. METHODS: We conducted a longitudinal case series from May 2022 to February 2023. We included patients who met the Bárány Society's Vascular Vertigo and Dizziness classification and were eligible for therapy in accordance with the American Heart Association and Stroke Association guidelines, featuring aspects of the stroke group and transient attack group. RESULTS: Overall, 41 patients (51.2% female; median age 72 years) were enrolled; 10 (24.3%) had ischemic strokes, 30 (73.1%) had transient ischemic attack, and 1 (2.4%) had a probable isolated labyrinthine infarction. The patients received dual antiplatelet (48.7%), single antiplatelet therapy (48.7%), and anticoagulant therapy (2.4%). No new crises occurred in 95.2% of the patients, and the transient ischemic attack group showed a significant decrease in discomfort from imbalance on the visual analog scale. CONCLUSIONS: Antiplatelets and anticoagulants are safe and effective in treating Vascular Vertigo and Dizziness as they prevent new ischemic events and increase the flow of the posterior circulation, reducing vertigo/dizziness attacks and imbalance complaints.

Incidental Finding of Atrial Myxoma in a Patient Presenting With Transient Ischemic Attack (TIA): A Case Report.

Atrial myxomas are benign primary cardiac tumors. They can present with nonspecific symptoms, ranging from constitutional symptoms and embolic phenomena such as transient ischemic attacks (TIAs) or strokes to sudden cardiac death. Early diagnosis may be a challenge due to the nonspecific presentation of atrial myxoma. A high degree of suspicion is needed in patients with TIA having no known cardiovascular risk factors. Although benign, if left untreated, it can lead to serious complications ranging from embolic phenomena and obstructive symptoms to sudden cardiac death. An echocardiogram is of fundamental importance in diagnosing atrial myxoma, and surgical resection is the ultimate treatment of choice. Here, we discuss a case of TIA as the initial presentation of atrial myxoma.

Beta-2 Glycoprotein I IgA Isotype: An Important Consideration in Secondary Hypertension.

Anti-beta-2 glycoprotein I antibodies are an important player in hypercoagulable states, including those that lead to antiphospholipid syndrome. Traditionally, assays have only detected IgG and IgM isotypes of this antibody. However, newer assays also detect the IgA isotype. The problem lies in the largely unknown significance of this IgA isotype. This paper describes a middle-aged male who presented with hypertensive emergency and was later found to have IgA anti-beta-2 glycoprotein I antibodies. He was treated with multiple anti-hypertensives, aspirin, and statin therapy. In addition to the case, we discuss the implications of this IgA isotype and how it may relate to antiphospholipid syndrome, despite not currently being included in the laboratory diagnostic criteria for the disease.

Unresponsiveness to Chiari Malformation Type I Surgery Can Be Related to the Accompanying Chiari Network.

Surgical treatment is indicated for Chiari malformation type 1 (CMI) with tonsillar descent (TD) of >5 mm and other clinical manifestations. However, some patients remain unresponsive to surgery; this is an active topic of discussion. A patient presented to the emergency department with dizziness and an impaired gait. He had a history of hypertension. Magnetic resonance investigations revealed a 9-mm TD and cervical syringomyelia. There was no evidence of interatrial septum pathology on transthoracic echocardiography performed preoperatively. Although his complaints were attributed to CMI and surgery was performed, his symptoms remained persistent. Two years later, when the patient's dizziness increased, a posterior fossa transient ischemic attack (TIA) was suspected. A large patent foramen ovale (PFO) and Chiari network (CN) were also detected on transesophageal echocardiography. His complaints were resolved following PFO closure. Our case suggests that neurosurgeons should be informed about the results of the companionship of a PFO and CN. Before deciding on CMI surgery for patients with only dizziness complaints, a detailed investigation of accompanying cardiac pathologies is paramount to ensure accurate diagnosis and treatment.

A Rare Case of Exercise-Induced Transient Global Amnesia as an Exclusive Presenting Symptom of Hippocampus Infarct.

Transient global amnesia (TGA) is a rare condition characterized by a temporary loss of the ability to form new memories. Retrograde episodic memory loss may also occur but to a lesser extent. Although TGA is generally benign, its sudden onset and similarity to more dangerous conditions like transient ischemic attack (TIA) or cerebral vascular accident (CVA) can be concerning. We present the case of a 70-year-old female who experienced confusion and general memory loss after a vigorous workout on her stationary exercise bike. After displaying considerable amnestic symptoms, she was admitted to the hospital for further medical attention and underwent a magnetic resonance imaging (MRI) that concluded a TGA diagnosis. This case report aims to investigate the prognosis associated with risk factors and refine the diagnostic criteria of TGA. We explore whether TGA caused by exercise, leading to unilateral or bilateral hippocampal lesions, is linked to cognitive decline. It is not yet clear if the development of TGA with unilateral infarct or bilateral hippocampal lesions results in different clinical presentations or varying prognoses. Further research is needed to determine the long-term risks of cognitive decline associated with resulting infarcts and clinical presentations.

Adventitia Layer-Focused Microsurgical Flow Reconstruction for Long-Segment Tubular Stenosis of the Cervical Segment (C1) Internal Carotid Artery: Clinical Valuable Experience in 20 Cases.

To evaluate the efficacy of perivascular sympathectomy in managing adventitia layer-related long-segment tubular stenosis of cervical segment (C1) internal carotid arteries (ICAs) in a cohort where conventional medical and endovascular interventions were not viable options, we retrospectively analyzed 20 patients (8 males, 12 females, aged 41-63 years) who underwent perivascular sympathectomy for long-segment (>5 cm) tubular cervical ICA stenosis (non-atherosclerotic, non-intima related, and nondolichoarteriopathic) between 2017 and 2023. The procedure aimed to alleviate symptoms such as hemiparesis, pulsatile tinnitus, and migraines associated with transient ischemic attacks (TIAs). Preoperative and postoperative symptoms were assessed, and patient follow-up was conducted by MR angiography and perfusion studies. Postoperatively, 10 out of 11 migraine sufferers (90.9%) reported complete cessation of symptoms, while one patient (9.09%) experienced reduction in frequency and intensity. In cases of tinnitus, six out of nine patients (66.6%) reported complete resolution, two (22.2%) had reduced symptoms, and one (11.1%) saw no change. Regarding motor function, all 12 patients (100%) with initial hemiparesis (30-40% loss of motor function) showed complete recovery postoperatively. There was no TIA attack among the patients after the procedure in the mean two-year follow-up. Perivascular sympathectomy has shown promising results in alleviating symptoms and preventing recurrent cerebrovascular events in long-segment tubular stenosis of cervical ICAs.

Transient recurrent episodes of abducens nerve palsy and cheiro-oral syndrome in a sub-occlusive carotid bulb atherosclerotic stenosis.

We report the case of a male in his 50s with a history of smoking admitted to our hospital for three transient recurrent episodes of less than 60 min of cheiro-oral paresthesias and binocular horizontal diplopia with convergent strabismus. On admission, his neurological examination was normal. Cerebral magnetic resonance imaging showed no cerebral lesion. Computed tomography angiography showed a sub-occlusive right carotid bulb atherosclerotic stenosis, the absence of abnormality of the subclavian arteries and the origin of the vertebral arteries, and no stenosis of the basilar artery or posterior cerebral arteries. Routine blood tests were normal with glycated hemoglobin of 6.5%. The patient underwent right carotid endarterectomy. One year after carotid endarterectomy, the patient has had no other cerebrovascular events.

Understanding Focal Seizures in Adults: A Comprehensive Review.

Focal or partial seizures are a common neurological disorder affecting adults. This review aims to provide an in-depth understanding of focal seizures in adults, including their classification, clinical presentation, etiology, diagnosis, and management. This article seeks to enhance awareness and knowledge among medical professionals and the general public by exploring the latest research and clinical insights. Standard electroencephalography (EEG) and recordings in presurgical electrode depth in humans provide a clear definition of patterns similar to focal seizures. Models of animals with partial seizures and epilepsy mimic seizure patterns with comparable characteristics. However, the network factors supporting interictal spikes, as well as the start, development, and end of seizures remain obscure. According to recent research, inhibitory networks are heavily implicated at the beginning of seizures, and extracellular potassium alterations help start and maintain seizure continuation. An increase in network synchronization, which may be caused by both excitatory and inhibitory pathways, is correlated with the cessation of a partial seizure. Recent research on temporal lobe focal seizures in human and animal models leads to the hypothesis that the active blocking of subcortical arousal processes brings on unconsciousness. Brainstem, basal forebrain, and thalamic arousal networks' neuronal firing is diminished during focal limbic seizures, and cortical arousal can be recovered when subcortical arousal circuits are engaged. These results suggest that thalamic neurostimulation may be therapeutic to restore arousal and consciousness during and after seizures. Targeted subcortical stimulation may increase arousal and consciousness when current treatments cannot halt seizures, enhancing safety and psychosocial function for epileptic patients. We embark on an investigation into adult focal seizures in this thorough review that goes beyond a cursory knowledge of their clinical symptoms.

Impact of Vascular Service Centralization on the Carotid Endarterectomy Pathway: A Study at the Bedfordshire, Luton, and Milton Keynes Vascular Network.

Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50% internal carotid artery (ICA) stenosis supplying index hemispheric territory. The recommended period for CEA is 14 days post-index event; this period carries a heightened risk for second ischemic events. However, implementation of this stringent timeline often encounters delays stemming from multifaceted factors. The centralization of vascular services, designed to enhance patient care, introduces a paradigm shift. Centralization's efficacy in improving patient outcomes, particularly in the CEA pathway, is a subject of ongoing investigation. Our study aims to discern the impact of centralized services on the timeliness of CEA for symptomatic carotid artery stenosis, shedding light on this complex interplay of factors. Methods This retrospective study analyzed CEA data at the Bedfordshire, Luton, and Milton Keynes Vascular Network between January 2021 and June 2023. Eligible patients exhibited symptomatic carotid artery stenosis, with asymptomatic cases; those unfit for surgery or receiving best medical therapy only were excluded. Patients were categorized by their primary referral location: Hub, Spoke-1, or Spoke-2. Demographic and referral data were collected, and timelines from symptom onset to surgery were recorded. Continuous variables were expressed as means and standard deviations, and categorical variables as counts and percentages. Box plots illustrated the relationship between referral origin and surgery timing, and the Classification and Regression Tree (CART) assessed second events. Statistical significance was determined using Fisher's exact and chi-square tests, with p<0.05 indicating significance. Results A total of 148 patients underwent CEA after implementing exclusion criteria. 35.5% (n=53) of patients were referred from the Hub, while 45.6% (n=67) and 18.8% (n=28) were from Spoke-1 and Spoke-2, respectively. 40% (n=59) received CEA within the recommended timeframe, and 15.4% (n=23) experienced a second ischemic event pre-surgery. Time from TIA clinic review to referral was 5.5±8 days and 16.4±20 days from vascular referral to surgery. Patterns of delays were observed, with Spoke-2 exhibiting the most significant delays. Notably, amaurosis fugax and embolic stroke correlated with recurrent ischemic events, emphasizing the importance of timely care in CEA. Conclusion Our study underscores the significant benefits and challenges of the Hub and Spoke model in vascular surgery. The growing referral delays from Spoke sites are concerning, emphasizing the need for a multi-disciplinary team approach within Spoke sites to ensure efficient and standardized care delivery.

[Reversible cerebral vasoconstriction syndrome and ischemic stroke]. / Sindrom obratimogo tserebral'nogo vazospazma i ishemicheskii insul't.

The article describes a 45-year-old female patient with recurrent transient ischemic attacks and ischemic stroke due to spontaneous spasm of the middle cerebral artery, the anterior cerebral artery and distal part of the internal cerebral artery on the left, verified by MR angiography and CT angiography. It is assumed that the spasm caused damage to the vascular wall, an increase in its permeability, the development of edema, inflammation and subsequent fibrosis, therefore a complete restoration of the arterial lumen did not occur.

Symptomatic Common Carotid Artery Stenosis Managed With Carotid Endarterectomy.

Extracranial carotid artery disease is typical at the carotid bifurcation and internal carotid artery (ICA) and is rarely symptomatic from isolated common carotid artery (CCA) stenosis. We present the case of a 60-year-old female patient who presented with a transient ischemic attack (TIA) with significant stenosis of the ipsilateral CCA only, without any involvement of the ICA or bifurcation. This was treated with carotid endarterectomy (CEA) with desirable postoperative outcomes; at up to six months postoperative follow-up, this patient had no recurrence of symptoms. We draw attention to the current gap in the literature with regard to a lack of specific guidelines for optimal evidence-based surgical treatment for this specific condition, with recent advances within certain vascular societies.

Follow-Up Diffusion-Weighted Image Reveals Delayed Appearance of Ischemic Lesions in Suspected Transient Ischemic Attack.

INTRODUCTION: In patients suspected of transient ischemic attack (TIA), it is not uncommon to find no lesion on the diffusion-weighted image (DWI) on admission but a delayed appearance on the follow-up DWI. METHODS: Enrolled patients met the following criteria: (1) MRI performed within 24 hours of onset and seven days after admission; (2) National Institutes of Health Stroke Scale (NIHSS) score ≦4 on admission; (3) pre-stroke modified Rankin scale (mRS) score of 0-1. Patients were divided as follows: no lesion on the first DWI and a new lesion on the second DWI (delayed-specified ischemic stroke; DSIS); and no lesion on either the first or second DWI (well-screened TIA; WSTIA). We compared both groups regarding the clinical background and the outcome at three months. RESULTS: We identified 144 cases (male 70%; median age 64 years; DSIS, n=34) between October 2012 and March 2019. DSIS was older (71 vs. 60 years, p=0.006) and had a higher NIHSS score on admission (1 vs. 0, p=0.041), a higher rate of large vessel occlusion (LVO) (17% vs. 2%, p=0.008), and symptom duration over one hour (82% vs. 64%, p=0.041). A favorable outcome mRS score of 0-1 at three months was less frequent in DSIS (85% vs. 96%, p=0.004). Age/10 (OR 1.62, 95%CI 1.17-2.24; p=0.004) and LVO (OR 10.84, 95%CI 1.87-63.06; p=0.008) were independent factors for DSIS. CONCLUSIONS: In suspected TIA with age or LVO but no lesion in the initial DWI, the second DWI should be considered to identify the delayed appearance of an ischemic stroke.

Comprehensive Management of Takayasu Arteritis Using Immunologic and Antithrombotic Interventions With Cerebral Circulation Support: A Case Report.

A 20-year-old woman with bilateral common carotid artery stenosis was diagnosed with Takayasu arteritis (TA). She suffered from a recurrent stroke, and repeated transient ischemic attacks (TIAs) occurred due to middle cerebral artery (MCA) stenosis. The clinical course indicated that TA contributed to MCA stenosis despite the negative results for serological inflammation markers. Immunotherapy with tocilizumab and methotrexate effectively reduced disease activity and improved symptoms. Bed rest and hydration prevented further TIAs and ischemic stroke progression. Long-term monitoring of neurological symptoms and angiography findings is essential to evaluate disease severity and treatment efficacy in TA patients with negative inflammatory markers.

Limb shaking movement as a rare manifestation of transient ischemic attacks caused by carotid stenosis disease: A case report.

A limb shaking TIA is a less common form of TIA that manifests as involuntary movement and is frequently confused with focal motor epilepsy. A 64-year-old female presented with a 7-month history of episodic involuntary shaking movements affecting her left arm and leg before admission. These attacks primarily occurred after she rose from a sitting or lying down position to a standing position, and were relieved by simply returning to a sitting or lying position. A neurological examination revealed no motor or sensory deficits in either extremity. Her magnetic resonance angiogram (MRA) and carotid Doppler revealed right ICA stenosis in her brain. It is important to distinguish this limb shaking TIA from other conditions such as focal motor seizures. Importantly, early detection and treatment of the associated carotid artery occlusion can not only prevent the patient's TIA episode, but also lower the risk of future stroke.

GLP-1 Receptor Agonists and Risk of Adverse Cerebrovascular Outcomes in Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

CONTEXT: The effect of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on ischemic/hemorrhagic stroke and transient ischemic attacks (TIA) in type 2 diabetes mellitus (T2DM) remains undetermined. OBJECTIVE: To pool effects of GLP-1RAs on adverse cerebrovascular outcomes and investigate impact of baseline variables on these effects. METHODS: PubMed, Embase, Web of Science, Cochrane Library, and clinical trial registry websites were searched for randomized controlled trials (RCTs) ≥24 weeks duration in adults with T2DM (PROSPERO: CRD42022331547). Adjudicated cerebrovascular events in GLP-1RA treatment vs control arms were pooled together to calculate risk ratios (RR) using fixed-effects model. Subgroup analysis was performed based on individual drugs, treatment duration, and baseline patient characteristics. Quality of evidence was assessed using GRADE framework. RESULTS: We identified 28 RCTs involving 74 148 patients (57% male; median [range], age 58 [52-67] years, BMI 32 [25.4-37.2] kg/m2, T2DM duration 9 [3.5-15.4] years, treatment duration 52 [24-259] weeks). GLP-1RA use in T2DM was associated with significantly decreased risk of adverse cerebrovascular outcomes vs placebo/active comparator (RR, 0.83; 95% CI, 0.76-0.91; I2 = 0%). Pooling data from cardiovascular outcome trials (n = 8), GLP-1RA treatment vs placebo was associated with reduced risk of nonfatal stroke (RR, 0.85; 95% CI, 0.76-0.94; I2 = 0%) but not fatal stroke (RR, 0.80; 95% CI, 0.61-1.05; I2 = 0%). GLP-1RA use was associated with reduced risk of ischemic stroke (RCTs = 12; RR, 0.73; 95% CI, 0.60-0.89; I2 = 0%), composite of ischemic stroke/TIA (RCTs = 16; RR, 0.76; 95% CI, 0.65-0.90; I2 = 0%), but not hemorrhagic stroke (RCTs = 3; RR, 0.92; 95% CI, 0.51-1.64; I2 = 0%). Treatment benefits differed according to baseline eGFR and diabetes duration (P interaction < .1). Benefits were statistically significant for dulaglutide, subcutaneous/oral semaglutide (P < .05). Sensitivity analysis, excluding shorter-acting lixisenatide, eliminated the heterogeneity between individual GLP-1RA effects. CONCLUSION: GLP-1RAs, particularly longer-acting formulations, reduced ischemic cerebrovascular events in T2DM. Observed benefits were significantly higher in patients with shorter T2DM duration and higher eGFR.

Schimke immunoosseous dysplasia: an ultra-rare disease. a 20-year case series from the tertiary hospital in the Czech Republic.

BACKGROUND: Schimke immunoosseous dysplasia (SIOD) is an ultra-rare inherited disease affecting many organ systems. Spondyloepiphyseal dysplasia, T-cell immunodeficiency and steroid resistant nephrotic syndrome are the main symptoms of this disease. CASE PRESENTATION: We aimed to characterize the clinical, pathological and genetic features of SIOD patients received at tertiary Pediatric Nephrology Center, University Hospital Motol, Prague, Czech Republic during the period 2001-2021. The mean age at diagnosis was 21 months (range 18-48 months). All patients presented with growth failure, nephropathy and immunodeficiency. Infections and neurologic complications were present in most of the affected children during the course of the disease. CONCLUSIONS: Although SIOD is a disease characterized by specific features, the individual phenotype may differ. Neurologic signs can severely affect the quality of life; the view on the management of SIOD is not uniform. Currently, new therapeutic methods are required.

Incidence of Acute Myocardial Infarction in Patients Presenting With Cerebrovascular Accident in a Tertiary Care Centre in Eastern India.

Acute myocardial infarction in individuals who have had a cerebrovascular accident or transient ischemic attack (CVA-TIA) is a medical emergency, which must be examined and treated as soon as possible. Physicians face a significant problem in managing this scenario because early treatment of one ailment would surely postpone treatment of the other. Early detection and treatment will have an impact on the patient's morbidity and mortality in the future, as well as aid in the patient's rehabilitation. On the basis of ECG alterations and cardiac biomarkers, a prospective observational study was conducted in 103 diagnosed CVA patients to investigate the incidence of myocardial infarction. Infarct and hemorrhagic CVA cases were evenly distributed. According to the age-based distribution, the highest rate of myocardial infarction (8%, 8) was observed in those aged 51-60 years. The male-to-female ratio is 1.86:1. Thirty-two patients had diabetes, among them 75% had only elevated creatine kinase MB (CKMB) with no myocardial infarction (MI), whereas 59 patients had hypertension of which 70% had only elevated CK-MB with no MI. ST-elevation myocardial infarction (STEMI) with high CKMB accounted for 14.78% (15) of the cases, but the majority (71%, 73) of the cases had elevated CKMB with no MI, and the rest presented with normal CKMB. Elevated CKMB with or without STEMI serves as a poor prognosticating factor. Therefore, these patients should be managed on a priority basis for a better outcome.

Takayasu Arteritis Presenting As Epileptic Seizure: A Case Report.

Takayasu's arteritis is a chronic granulomatous large-vessel vasculitis condition that affects the large and medium-sized arteries, primarily the heart and its major vessels. The first symptoms and indicators of Takayasu arteritis differ because the afflicted arteries are heterogeneous. Furthermore, vascular lesions might be difficult to identify at first, further complicating diagnosis. Takayasu arteritis presenting as epileptic seizures is rare. Here, we discuss a 20-year-old female who presented with a brief period of unresponsiveness, followed by a tonic stiffening, limb jerks, a postictal period of fatigue, and temporal memory loss. During the acute phase of Takayasu arteritis, high-dose glucocorticoid therapy and immunosuppressive therapy were used to control inflammatory reactions. Her symptoms gradually improved, and she was discharged from the hospital after serial monitoring; her follow-up visits revealed no recurrence.

No rebound effect after a course of clopidogrel in patients with acute TIA or minor stroke.

BACKGROUND AND PURPOSE: Previous studies demonstrated that discontinuation of clopidogrel in patients after ACS was associated with a rebound increase in risk of recurrent events. In this study, we aimed to investigate the rebound effect after discontinuation of clopidogrel therapy in patients with TIA or stroke. METHODS: All patients with minor stroke or TIA were recruited from the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial. Patients were divided into two groups: patients who discontinued clopidogrel and switched to aspirin therapy   (Clopidogrel Discontinuation Group) and patients who continued one mono-antiplatelet therapy (non-Clopidogrel Discontinuation Group) during 90-180  days. The outcomes included risks of recurrent ischemic stroke, recurrent TIA, and composite events during 90-180  days. The prevalence of each outcome was compared between two groups for every 30 days. Further subgroup analysis was conducted in patients with and without CYP2C19 loss-of-function alleles. RESULTS: Among the 3456 patients included, a total of 10 patients in the Clopidogrel Discontinuation Group and 11 patients in the non-Clopidogrel Discontinuation Group presented ischemic stroke recurrence during the 90-180-day period. The inter-group comparisons were not significant in each 30 days. Similar results were found for recurrent stroke, recurrent TIA, and composite events in these two groups, which were also found in CYP2C19 subgroup analysis. CONCLUSIONS: No rebound increase in the risk of ischemic stroke and composite events was found during the 90 days after discontinuation of clopidogrel therapy in patients with TIA or minor stroke in the CHANCE trial. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00979589.