Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association.

At least 240 000 individuals experience a transient ischemic attack each year in the United States. Transient ischemic attack is a strong predictor of subsequent stroke. The 90-day stroke risk after transient ischemic attack can be as high as 17.8%, with almost half occurring within 2 days of the index event. Diagnosing transient ischemic attack can also be challenging given the transitory nature of symptoms, often reassuring neurological examination at the time of evaluation, and lack of confirmatory testing. Limited resources, such as imaging availability and access to specialists, can further exacerbate this challenge. This scientific statement focuses on the correct clinical diagnosis, risk assessment, and management decisions of patients with suspected transient ischemic attack. Identification of high-risk patients can be achieved through use of comprehensive protocols incorporating acute phase imaging of both the brain and cerebral vasculature, thoughtful use of risk stratification scales, and ancillary testing with the ultimate goal of determining who can be safely discharged home from the emergency department versus admitted to the hospital. We discuss various methods for rapid yet comprehensive evaluations, keeping resource-limited sites in mind. In addition, we discuss strategies for secondary prevention of future cerebrovascular events using maximal medical therapy and patient education.

Care of the Patient With Acute Ischemic Stroke (Prehospital and Acute Phase of Care): Update to the 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association.

The year 2020 was the year of the nurse, celebrating nurse scholarship, innovation, and leadership by promoting scientific nursing research, improving nursing practice, advancing nursing education, and providing leadership to influence health policy. As architects of stroke care, neuroscience nurses play a vital role in collaborating and coordinating care between multiple health professionals. Nurses improve accessibility and equity through telestroke, emergency medical services, and mobile stroke units and are integral to implementing education strategies by advocating and ensuring that patients and caregivers receive stroke education while safely transitioning through the health care system and to home. Stroke care is increasingly complex in the new reperfusion era, requiring nurses to participate in continuing education while attaining levels of competency in both the acute and recovery care process. Advanced practice nurses are taking the lead in many organizations, serving as prehospital providers on mobile stroke units, participating as members of the stroke response team, and directing stroke care protocols in the emergency department. This scientific statement is an update to the 2009 "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient." The aim is to provide a comprehensive review of the scientific evidence on nursing care in the prehospital and hyperacute emergency hospital setting, arming nurses with the necessary tools to provide evidenced-based high-quality care.

Telemedicine in neurology: Telemedicine Work Group of the American Academy of Neurology update.

PURPOSE: While there is strong evidence supporting the importance of telemedicine in stroke, its role in other areas of neurology is not as clear. The goal of this review is to provide an overview of evidence-based data on the role of teleneurology in the care of patients with neurologic disorders other than stroke. RECENT FINDINGS: Studies across multiple specialties report noninferiority of evaluations by telemedicine compared with traditional, in-person evaluations in terms of patient and caregiver satisfaction. Evidence reports benefits in expediting care, increasing access, reducing cost, and improving diagnostic accuracy and health outcomes. However, many studies are limited, and gaps in knowledge remain. SUMMARY: Telemedicine use is expanding across the vast array of neurologic disorders. More studies are needed to validate and support its use.

Electroencephalographic findings in acute subdural hematoma.

The aim was to determine the electroencephalographic (or electroencephalogram [EEG]) findings predictive of functional outcome in a subset of patients with acute subdural hematoma (SDH) with epileptiform activity on their EEG. Twenty-four patients who underwent evacuation for acute or acute-on-chronic SDH and with epileptiform activity on EEG were identified retrospectively. Their EEGs were reviewed and the findings categorized along with clinical information, the preoperative computed tomography (CT) scan, and functional outcome. Twenty-one patients (87%) had epileptiform discharges on EEG; 13 of them (62%) had midline epileptiform discharges and 9 of them (43%) had periodic lateralized epileptiform discharges (PLEDs). Both types of epileptiform discharges were significantly associated with the degree of midline shift on neuroimaging (P = 0.01, P = 0.04, respectively). Poor early outcomes were associated with the presence of bilateral (P = 0.03), midline (P = 0.04), and bilateral independent multifocal discharges (P = 0.09) on EEG. The EEG findings in this group of patients were complex. Epileptiform discharges were common, and specific types were associated with midline shift on neuroimaging and poor functional outcome at hospital discharge. Improvement in follow-up EEG examinations over time was predictive of good long-term functional outcome.

A PRESsing dissection.

BACKGROUND: Intracranial dissections have been associated with baroreceptor reflex failure. When this occurs labile hypertension may be observed with its own complications, including but not limited to the clinico-radiographic entity, posterior reversible encephalopathy syndrome (PRES). METHODS: Case report and literature review. RESULTS: We describe a case of carotid dissection resulting in PRES. CONCLUSIONS: We believe failure of the baroreceptor reflex due to carotid dissection resulted in hypertension and subsequent posterior reversible encephalopathy syndrome.

Renal failure and posterior reversible encephalopathy syndrome in patients with thrombotic thrombocytopenic purpura.

BACKGROUND: Little is known of the nature of the neurologic manifestations in thrombotic thrombocytopenic purpura (TTP). We have recently reported posterior reversible encephalopathy syndrome (PRES) as the predominant brain abnormality in patients with TTP. Posterior reversible encephalopathy syndrome has been associated with a variety of medications and pathologic states including increased arterial blood pressure and renal failure. The factors that predispose patients with TTP to PRES are not known. OBJECTIVES: To ascertain whether the presence and degree of hypertension and typical laboratory abnormalities seen in hospitalized patients with TTP are predictors of PRES. Design, Setting, and Patients We performed a retrospective analysis of brain imaging in 46 hospitalized patients with acute TTP seen at St Mary's and Rochester Methodist hospitals in Rochester, Minnesota, from January 1997 to June 2007. Head computed tomographic scans and brain magnetic resonance images were evaluated independently by 2 investigators. We then performed statistical analysis to determine whether the presence of PRES was associated with the presence of hypertension or abnormal laboratory data, including renal function. RESULTS: Forty-seven incidences of patients having TTP and neuroimaging were evaluated over a 10-year period. Thirty-three patients (70%) had brain magnetic resonance imaging performed. Of the patients who had acute abnormalities on brain magnetic resonance imaging, 13 (48%) were found to have PRES. Degree of hypertension was not associated with PRES on brain magnetic resonance imaging (P = .55). There was no association between hematocrit or platelet nadir, maximum blood urea nitrogen, D dimer, fibrinogen, lactate dehydrogenase, or total bilirubin levels and occurrence of PRES. The only variable highly associated with PRES on neuroimaging was the glomerular filtration rate (P = .02). CONCLUSION: The occurrence of PRES in patients with acute TTP is associated with worse renal function.

Brain lesions are most often reversible in acute thrombotic thrombocytopenic purpura.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a rare hematologic disorder that frequently presents with neurologic involvement. However, the yield and prognostic value of acute brain neuroimaging in patients with TTP has not been studied. Our aim was to evaluate brain imaging findings in consecutive patients with TTP and assess their impact on prognosis. METHODS: We retrospectively collected clinical, laboratory, and neuroradiologic information in 47 episodes of acute TTP studied with brain imaging at our medical center between 1997 and 2007. Head CT and brain MRI were evaluated independently by 2 investigators. We then performed statistical analysis to determine whether the presence of acute lesions on brain imaging was associated with worse functional outcome as assessed by the modified Rankin score upon discharge and long-term follow-up. RESULTS: Ten patients (25%) of those who had a head CT had acute changes, half of them indicating posterior reversible encephalopathy syndrome (PRES). Most cases studied with brain MRI had acute changes (82%). More than half of those had evidence of PRES (48%). Atypical variants of PRES were seen in 2 patients with isolated basal ganglia involvement. Acute ischemia and hemorrhage were uncommon. Most patients with acute changes on brain imaging recovered favorably, and radiologic lesions were not associated with worse functional outcome. CONCLUSIONS: Posterior reversible encephalopathy syndrome is the most common brain imaging abnormality in severe manifestations of thrombotic thrombocytopenic purpura. Large infarctions and hemorrhage are infrequent. Consequently, abnormal brain neuroimaging does not seem to impact patient outcome, and full neurologic recovery is possible even in comatose patients with extensive brain abnormalities on MRI.