Screening for Cognitive Impairment in Bilinguals: What Is the Influence of the Language of Assessment?

BACKGROUND: Bilingualism's impact on cognitive assessment remains underexplored. This study analyzes the efficacy of the Mini-Mental State Examination (MMSE) as a screening tool for bilinguals, specifically examining the influence of language choice on balanced and unbalanced Lebanese bilinguals (Arabic-French) and its implications for diagnosing cognitive impairment. METHODS: Ninety-three bilingual healthy controls (mean age = 67.99 ± 9.3) and 29 Alzheimer's disease patients (mean age = 77.2 ± 5.9), including 26 with mild and 3 with moderate dementia, underwent MMSE assessments in both Arabic and French. The study aimed to assess language impact on cognitive screening outcomes in different bilingual subtypes. RESULTS: Sensitivity in screening for cognitive impairment using the MMSE varied based on language and bilingualism subtype. For unbalanced bilinguals, using the prominent language increased sensitivity. Conversely, in balanced bilinguals, employing the societal majority language enhanced sensitivity. This suggests that the conventional use of the non-prominent language in cognitive screening for foreigners/immigrants may result in a subtle loss of MMSE sensitivity. CONCLUSION: This study emphasizes the critical role of language choice in cognitive assessment for bilinguals. The MMSE's sensitivity is influenced by language selection, with clinical implications for screening procedures. Recommendations include using the prominent language for cognitive screening in dominant bilinguals and the societal majority language for balanced bilinguals. This nuanced approach aims to improve the accuracy and cultural sensitivity of cognitive screening in bilingual populations, addressing the gap in current assessment practices.

Five-Year Risk of Stroke after TIA or Minor Ischemic Stroke.

BACKGROUND: After a transient ischemic attack (TIA) or minor stroke, the long-term risk of stroke and other vascular events is not well known. In this follow-up to a report on 1-year outcomes from a registry of TIA clinics in 21 countries that enrolled 4789 patients with a TIA or minor ischemic stroke from 2009 through 2011, we examined the 5-year risk of stroke and vascular events. METHODS: We evaluated patients who had had a TIA or minor stroke within 7 days before enrollment in the registry. Among 61 sites that participated in the 1-year outcome study, we selected 42 sites that had follow-up data on more than 50% of their enrolled patients at 5 years. The primary outcome was a composite of stroke, acute coronary syndrome, or death from cardiovascular causes (whichever occurred first), with an emphasis on events that occurred in the second through fifth years. In calculating the cumulative incidence of the primary outcome and secondary outcomes (except death from any cause), we treated death as a competing risk. RESULTS: A total of 3847 patients were included in the 5-year follow-up study; the median percentage of patients with 5-year follow-up data per center was 92.3% (interquartile range, 83.4 to 97.8). The composite primary outcome occurred in 469 patients (estimated cumulative rate, 12.9%; 95% confidence interval [CI], 11.8 to 14.1), with 235 events (50.1%) occurring in the second through fifth years. At 5 years, strokes had occurred in 345 patients (estimated cumulative rate, 9.5%; 95% CI, 8.5 to 10.5), with 149 of these patients (43.2%) having had a stroke during the second through fifth years. Rates of death from any cause, death from cardiovascular causes, intracranial hemorrhage, and major bleeding were 10.6%, 2.7%, 1.1%, and 1.5%, respectively, at 5 years. In multivariable analyses, ipsilateral large-artery atherosclerosis, cardioembolism, and a baseline ABCD2 score for the risk of stroke (range, 0 to 7, with higher scores indicating greater risk) of 4 or more were each associated with an increased risk of subsequent stroke. CONCLUSIONS: In a follow-up to a 1-year study involving patients who had a TIA or minor stroke, the rate of cardiovascular events including stroke in a selected cohort was 6.4% in the first year and 6.4% in the second through fifth years. (Funded by AstraZeneca and others.).

Osteitis fibrosa cystica mimicking bone tumor, a case report.

BACKGROUND: We report a case of osteitis fibrosa cystica, a rare benign resorptive bone lesion caused by hyperparathyroidism, that presented on imaging as an aggressive bone tumor. CASE PRESENTATION: The patient is a 51-year-old male complaining of severe sustained pain of the right hip region. Imaging studies were suspicious for a malignant tumor of the right iliac bone. Biopsy under CT guidance was performed and showed remodeled bone trabeculae with numerous osteoclasts, excluding bone tumor and raising the possibility of osteitis fibrosa cystica. Complementary tests disclosed elevated blood level of parathyroid hormone and a partially cystic enlarged left inferior parathyroid gland consistent with adenoma. After parathyroidectomy, the clinical symptoms were relieved and the radiological findings were significantly improved, which confirmed the diagnosis. CONCLUSIONS: Metabolic diseases-associated bone lesions should always be considered in the differential diagnosis of bone tumors, to avoid unnecessary surgeries and treatments.

Impact of Low Ankle-Brachial Index on the Risk of Recurrent Vascular Events.

Background and Purpose- Low ankle-brachial index (ABI) identifies a stroke subgroup with high risk of recurrent stroke, cardiovascular events, and death. However, limited data exist on the relationship between low ABI and stroke in low and middle-income countries. Therefore, we evaluated the prevalence of ABI ≤0.90 (which is diagnostic of peripheral artery disease) in nonembolic stroke patients or transient ischemic attack and assessed the correlation of low ABI with stroke risk, factors, and recurrent vascular events and death. Methods- Patients ≥45 years with acute transient ischemic attack or minor ischemic strokes were recruited consecutively from over 17 low-income and middle-income countries (Latin America [1543 patients], Middle East [1041 patients], North Africa [834 patients], and South Africa [217 patients]). The ABI measurement was performed at a single visit. Stroke recurrence and risk of new vascular events were assessed after 24 months of follow-up. Results- Among 3487 enrolled patients, abnormal ABI (<0.9) was present in 22.3 %. Patients with an ABI of ≤0.9 were more likely ( P<0.05) to be male, older, and have a history of peripheral artery disease, hypertension, and diabetes mellitus. During 2-year follow-up, the rate of major cardiovascular event was higher in patients with ABI <0.9 than those with ABI ≥0.9 (Kaplan-Meier estimates, 22.5%; 95% CI, 19.6-25.8 versus 13.7%; 21.4-15.1; P<0.001), and when ABI was categorized into 4 groups (≤0.6; 95% CI, 0.6-0.9; 0.9-1; 1-1.4), the rate of major cardiovascular event was higher in those with ABI ≤0.6 than the other groups (Kaplan-Meier estimates, 32.6%; 95% CI, 21.0-48.3 for ABI≤0.6 versus 21.7%; 95% CI, 18.8-25.0 for ABI 0.6-0.9 versus 14.3%; 95% CI, 12.4-16.6 for ABI 0.9-1 versus 13.3%; 95% CI, 11.6-15.2 for ABI 1-1.4; P<0.001). Conclusions- Among patients with nonembolic ischemic stroke or transient ischemic attack, those with low ABI had a higher rate of vascular events and death in this population. Screening for ABI in stroke patients may help identify patients at high risk of future events.

Uncovering Demographic, Clinical, Triggering Factors Similarities Between Migraine and Irritable Bowel Syndrome: A Prospective Study.

The objective was to uncover demographical and clinical factors associated with migraine and irritable bowel syndrome (IBS) in a group of patients experiencing both painful disorders and to identify their triggering factors. A prospective study was performed between January 2016 and June 2017. Clinical characteristics and potential generating factors for both pathologies were then assessed using validated questionnaires. Our study showed that the percentage of patients diagnosed with migraine and having IBS was 34.3%. Compared with patients with migraine alone, patients having both diseases were identified with higher prevalence of concomitant chronic/psychiatric diseases, lower frequency of migraine attacks, and lower prevalence of throbbing/distressing/enervating pain and concentration difficulties than patients with migraine alone. Moreover, patients in this subgroup had moderate abdominal pain intensity, and constipation was the predominant stool type. Finally, some dietary and environmental factors seem to be significantly important triggering factors of migraine/IBS pain.

Mortality and Predictors of Death Poststroke: Data from a Multicenter Prospective Cohort of Lebanese Stroke Patients.

BACKGROUND: Despite efforts to reduce stroke mortality rates, the disease remains a leading cause of death in Lebanon highlighting the importance of understanding risk factors and subsequent mortality. We examined mortality rates during the first year after acute stroke and the major short-term (1-month) and long-term (1-year) mortality predictors. METHODS: Data were collected prospectively on hospitalized stroke patients from 8 hospitals in Beirut during a 1-year period. Patients were followed up for 1-year or until death. Mortality rates were assessed at 1-month and at 1-year poststroke and predictors of death were evaluated using Cox proportional hazard model. RESULTS: A total of 191 stroke patients were included. Survival data were completed for over 97% of patients. Cumulative mortality rates were 14.1% at 1-month and 22% at 1-year. Predictors of short-term and long-term mortality in univariate analysis were low socioeconomic status, intensive care unit admission, decreased level of consciousness, stroke severity, and presence of complications. Marital status also predicted short-term mortality, while age greater than 64 years, atrial fibrillation, coronary heart disease, hypertension, Bamford and TOAST classifications and surgery need were also long-term mortality predictors. In multivariate analysis, stroke severity and presence of complications were predictors of death at 1-month and at 1-year. Low socioeconomic status, dependency in daily living activities, and the presence of comorbidities were additional predictors of 1-year mortality. CONCLUSIONS: Approximately 1 over 5 of patients did not survive 1-year after stroke. There is a need for public awareness campaigns to improve stroke knowledge, warning, and prevention which may reduce this high stroke mortality rate in Lebanon.

Longitudinal Extensive Transverse Myelitis in an Immunocompetent Older Individual-A Rare Complication of Varicella-Zoster Virus Reactivation.

Varicella-zoster virus (VZV) is a human neurotropic herpes virus that causes chickenpox in children. After becoming latent in dorsal root ganglia, it can reactivate to cause dermatological manifestations, the most common one being shingles or herpes zoster. Severe neurologic dysfunctions can occur in immunocompromised patients such as encephalitis, meningitis, myelitis and neuropathy. Longitudinal extensive transverse myelitis (LETM) is an unusual neurological complication mainly described in immunocompromised patients, with very few cases described in immunocompetent ones. We hereby report a case of VZV-induced LETM in an immunocompetent older adult-a situation rarely described in the literature. LETM is a rare complication of VZV and its pathogenesis; therapeutic interventions and prognosis are far from being fully clarified. However, a prompt diagnosis is needed to allow a rapid initialization of treatment and ensure a better outcome. Although the therapeutic lines are not clear, immunosuppressive agents may have their place in cases of unsuccessful results and/or relapses following acyclovir coupled with a well conducted methylprednisolone therapy. Further studies are highly needed to improve the current understanding of the disease course and mechanisms, and to optimize therapeutic strategies.

Direct Medical Cost of Hospitalization for Acute Stroke in Lebanon: A Prospective Incidence-Based Multicenter Cost-of-Illness Study.

Stroke is a major social and health problem posing heavy burden on national economies. We provided detailed financial data on the direct in-hospital cost of acute stroke care in Lebanon and evaluated its drivers. This was an observational, quantitative, prospective, multicenter, incidence-based, bottom-up cost-of-illness study. Medical and billing records of stroke patients admitted to 8 hospitals in Beirut over 1 year were analyzed. Direct medical costs were calculated, and cost drivers were assessed using a multivariable linear regression analysis. In total, 203 stroke patients were included (male: 58%; mean age: 68.8 ± 12.9 years). The direct in-hospital cost for all cases was US$1 413 069 for 2626 days (US$538 per in-hospital day). The average in-hospital cost per stroke patient was US$6961 ± 15 663. Hemorrhagic strokes were the most costly, transient ischemic attack being the least costly. Cost drivers were hospital length of stay, intensive care unit length of stay, type of stroke, stroke severity, modified Rankin Scale, third party payer, surgery, and infectious complications. Direct medical cost of acute stroke care represents high financial burden to Lebanese health system. Development of targeted public health policies and primary prevention activities need to take priority to minimize stroke admission in future and to contain this cost.

Specificities of Ischemic Stroke Risk Factors in Arab-Speaking Countries.

BACKGROUND: Stroke is largely preventable, and therefore, a better understanding of risk factors is an essential step in reducing the population stroke rate and resulting disease burden in Arab countries. SUMMARY: We performed 2 separate analyses in 2 similar populations of patients with noncardioembolic ischemic stroke. This first involved 3,635 patients in the Outcomes in Patients with TIA and Cerebrovascular disease (OPTIC) registry (followed for 2 years), with baseline collection of the usual risk factors and 5 socioeconomic variables (unemployment status, residence in rural area, living in fully serviced accommodation, no health-insurance coverage, and low educational level). The second involved patients in the PERFORM trial (n = 19,100 followed up for 2 years), with baseline collection of the usual risk factors and 1 socioeconomic variable (low educational level). The primary outcome was a composite of nonfatal stroke, nonfatal myocardial infarction, or cardiovascular death. Stroke risk factors were more prevalent in patients in Arab countries. The incidence of major cardiovascular events (MACE; age- and gender-adjusted) was higher in Arab countries (OPTIC, 18.5 vs. 13.3%; PERFORM, 18.4 vs. 9.7%; both p ≤ 0.0001). These results remained significant after adjustment on risk factors and were attenuated in OPTIC after further adjustment on socioeconomic variables (hazard ratio 1.24; 95% CI 0.98-1.55; p = 0.07). Key Messages: Patients with ischemic stroke living in Arab countries had a lower mean socioeconomic status, a much higher prevalence of diabetes mellitus, and a higher rate of MACE compared with patients from non-Arab countries. This finding is partly explained by a higher prevalence of risk factors and also by a high prevalence of poverty and low educational level.

Overlap of diseases underlying ischemic stroke: the ASCOD phenotyping.

BACKGROUND AND PURPOSE: ASCOD phenotyping (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; and D, dissection) assigns a degree of likelihood to every potential cause (1 for potentially causal, 2 for causality is uncertain, 3 for unlikely causal but disease is present, 0 for absence of disease, and 9 for insufficient workup to rule out the disease) commonly encountered in ischemic stroke. We used ASCOD to investigate the overlap of underlying vascular diseases and their prognostic implication. METHODS: A single rater applied ASCOD in 405 patients enrolled in the Asymptomatic Myocardial Ischemia in Stroke and Atherosclerotic Disease study. RESULTS: A was present in 90% of patients (A1=43% and A2=15%), C in 52% (C1=23% and C2=14%), and S in 66% (S1=11% and S2=2%). On the basis of grades 1 and 2, 25% of patients had multiple underlying diseases, and 80% when all 3 grades were considered. The main overlap was found between A and C; among C1 patients, A was present in 92% of cases (A1=28%, A2=20%, and A3=44%). Conversely, among A1 patients, C was present in 47% of cases (C1=15%, C2=15%, and C3=17%). Grades for C were associated with gradual increase in the 3-year risk of vascular events, whereas risks were similar across A grades, meaning that the mere presence of atherosclerotic disease qualifies for high risk, regardless the degree of likelihood for A. CONCLUSIONS: ASCOD phenotyping shows that the large overlap among the 3 main diseases, and the high prevalence of any form of atherosclerotic disease, reinforces the need to systematically control atherosclerotic risk factors in all ischemic strokes.

Spectrum of transient visual symptoms in a transient ischemic attack cohort.

BACKGROUND AND PURPOSE: Transient visual symptoms (TVS) are common complaints. They can be related to transient ischemic attacks, but the nature of the symptoms often remains uncertain, and data on prognosis are scarce. We studied the prevalence, presentation, and effect of different types of TVS, paying particular attention to the association with high-risk pathology of embolism. METHODS: A total of 2398 patients with suspected transient ischemic attack admitted to the SOS-TIA clinic between January 2003 and December 2008 underwent immediate evaluation and treatment. RESULTS: Eight hundred twenty-six (34.5%) patients had TVS, including 422 (17.6%) patients with isolated TVS. Transient monocular blindness was the most frequent TVS (36.3%), followed by diplopia (13.4%), homonymous lateral hemianopia (12.3%), bilateral positive visual phenomena (10.8%), and lone bilateral blindness (4.5%). Positive diffusion-weighted imaging was found in 11.8%, 8.1%, 8.1%, and 5.0% of patients with homonymous lateral hemianopia, diplopia, lone bilateral blindness, and transient monocular blindness, respectively. Among 1850 patients (595 patients with TVS) with definite/possible transient ischemic attack or minor stroke, a major source of embolism of cardiac or arterial origin was found less frequently in patients with isolated or nonisolated TVS than in patients without TVS (19.6%; 19.7% versus 28.1%, respectively; P<0.001). However, we found a higher rate of atrial fibrillation in patients with homonymous lateral hemianopia (23.2%) than in patients with other TVS (4.0%; adjusted odds ratio, 6.71; 95% confidence interval, 2.99-15.06) or nonvisual symptoms (9.1%; adjusted odds ratio, 4.39; 95% confidence interval, 2.26-8.50). CONCLUSIONS: Approximately 20% of patients with TVS had a major source of embolism detected, requiring urgent management. Atrial fibrillation was particularly frequent in patients with transient homonymous lateral hemianopia.

Coronary artery disease and risk of major vascular events after cerebral infarction.

BACKGROUND AND PURPOSE: The impact of asymptomatic coronary artery disease on the risk of major vascular events in patients with cerebral infarction is unknown. METHODS: Four hundred five patients with acute cerebral infarction underwent carotid, femoral artery, thoracic, and abdominal aorta ultrasound examination. Of 342 patients with no known coronary heart disease, 315 underwent coronary angiography. We evaluated the 2-year risk of major vascular events (myocardial infarction, resuscitation after cardiac arrest, hospitalization for unstable angina or heart failure, stroke, or major peripheral arterial disease events) in patients with known coronary heart disease (n=63), and in the no known coronary heart disease group (n=315) as a function of coronary angiographic status (n=315). RESULTS: At 2 years, the estimated risk of major vascular events was 11.0% (95% confidence interval, 8.2-14.7). According to baseline coronary angiography, estimated risk was 3.4% in patients with no coronary artery disease (n=120), 8.0% with asymptomatic coronary artery stenosis <50% (n=113), 16.2% with asymptomatic coronary artery stenosis ≥ 50% (n=81), and 24.1% with known coronary heart disease (P<0.0001). Using no coronary artery disease as the reference, the age- and sex-adjusted hazard ratio (95% confidence interval) of vascular events was 2.10 (0.63-6.96) for asymptomatic coronary stenosis <50%, 4.36 (1.35-14.12) for asymptomatic coronary stenosis ≥ 50%, and 6.86 (2.15-21.31) for known coronary artery disease. CONCLUSIONS: In patients with nonfatal cerebral infarction, presence and extent of asymptomatic stenoses on coronary angiography are strong predictors of major vascular events within 2 years.

Verbal fluency in bilingual Lebanese adults: Is the prominent language advantage due to executive processes, language processes, or both?

Although bilingualism is widespread, little data on verbal fluency tasks (VFTs) within bilingualism subtypes and the underlying mechanisms exist. The study's objective was to explore executive and language processes in 10 semantic and letter VFTs and a set of language and executive tests among 100 elderly Arabic-French bilinguals from three bilingualism subgroups: Arabic-dominant, French-dominant, and balanced. We observed a prominent-language advantage for semantic and letter VFTs in French but not for letter VFTs in Arabic. This advantage in the VFT was associated with a sustained rate of late production, a higher percentage of specific words, a higher number of clusters, and a larger cluster size, and was related mainly to language processes. Our results suggest that the strategic search processes underlying VFTs operate on the two phonological output lexicons of bilinguals with similar characteristics in different languages and thus support the hypothesis of a single, centralized, strategic search process.

Bulbar Symptoms as an Unusual Presentation of Multiple Sclerosis: A Case Report.

Multiple sclerosis (MS) is a complex multifactorial disease with different clinical manifestations. Bulbar symptoms such as dysarthria and dysphagia are common in MS patients with advanced secondary progressive disease. However, they are not common at disease onset. We present the case of a 17-year-old male who initially presented with vomiting, dysarthria, and dysphagia. The investigations led to the diagnosis of MS, with an active lesion in the brainstem, more specifically in the area postrema region. Differential diagnoses were eliminated. The patient received intravenous methylprednisolone resulting in amelioration of symptoms. Treatment with fingolimod was started after discharge. The recognition of MS with atypical onsets is important to make an early accurate diagnosis and prescribe appropriate treatment for a disease known to be one of the most common causes of neurologic disability in young adults. LEARNING POINTS: Multiple sclerosis can have atypical presentations.Bulbar symptoms such as dysarthria and dysphagia can be initial symptoms of multiple sclerosis, although uncommon.Clinicians should be able to recognize multiple sclerosis with atypical onsets in order to make an early accurate diagnosis.

Atherogenic dyslipidemia in patients with transient ischemic attack.

BACKGROUND AND PURPOSE: There is mounting evidence that atherogenic dyslipidemia (ie, low high-density lipoprotein cholesterol combined with high triglyceride concentrations) is an independent predictor of high cardiovascular risk and possibly of stroke. METHODS: All patients included in the SOS-TIA cohort underwent an initial standardized evaluation, including medical history, physical examination, routine blood biochemistry, and diagnostic testing, and were followed for 1 year. Lipid profile was evaluated under fasting conditions. Atherogenic dyslipidemia was defined as high-density lipoprotein cholesterol blood concentration ≤ 40 mg/dL and triglycerides ≥ 150 mg/dL. RESULTS: Among 1471 consecutive patients with transient ischemic attack (TIA) or minor stroke, overall prevalence of atherogenic dyslipidemia was 5.8%, but varied from 4.6% to 11.1%, depending on final diagnosis (possible TIA or TIA with a cerebral ischemic lesion, respectively). Prevalence of atherogenic dyslipidemia was independently associated with male sex, diabetes, and body mass index, but not with ABCD2 score. Atherogenic dyslipidemia also strongly associated with symptomatic intracranial stenosis ≥ 50% (adjusted odds ratio, 2.77; 95% CI, 1.38-5.55), but not with symptomatic extracranial stenosis ≥ 50% (adjusted odds ratio, 1.20; 95% CI, 0.64-2.26). Despite appropriate secondary prevention treatment, 90-day stroke risk was greater in patients with versus without atherogenic dyslipidemia (4.8% versus 1.7%; P=0.04). CONCLUSIONS: The atherogenic dyslipidemia phenotype in patients with TIA may be associated with intracranial artery stenosis and higher risk of early recurrent stroke. Additional data are needed to confirm these findings and to assess the best way to reduce important residual risk in such patients.

Outcomes of mechanical endovascular therapy for acute ischemic stroke: a clinical registry study and systematic review.

BACKGROUND AND PURPOSE: Recanalization is a powerful predictor of stroke outcome in patients with arterial occlusion. Intravenous recombinant tissue plasminogen activator is limited by its recanalization rate, which may be improved with mechanical endovascular therapy (MET). However, the benefit and safety of MET remain to be determined. The aim of this study was to give reliable estimates of efficacy and safety outcomes of MET. METHODS: We analyzed data from our prospective clinical registry and conducted a systematic review of all previous studies using MET published between January 1966 and November 2009. RESULTS: From April 2007 to November 2009, 47 patients with acute stroke were treated with MET at Bichat Hospital. The literature search identified 31 previous studies involving a total of 1066 subjects. In the meta-analysis, including our registry data, the overall recanalization rate was 79% (95% CI, 73-84). Meta-analysis of clinical outcomes showed a pooled estimate of 40% (95% CI, 34-46; 27 studies) for favorable outcome, 28% (95% CI, 23-33; 28 studies) for mortality, and 8% (95% CI, 6-10; 27 studies) for symptomatic intracranial hemorrhage. The likelihood of a favorable outcome increased with the use of thrombolysis (OR, 1.99; 95% CI, 1.23-3.22) and with proportion of patients with isolated middle cerebral artery occlusion (OR per 10% increase, 1.14; 95% CI, 1.04-1.25). CONCLUSIONS: MET is associated with acceptable safety and efficacy in stroke patients, and it may be a therapeutic option in those presenting with isolated middle cerebral artery occlusion.

Yield of systematic transcranial Doppler in patients with transient ischemic attack.

OBJECTIVE: Urgent evaluation and treatment of transient ischemic attack (TIA) patients in a dedicated TIA clinic may reduce the 90-day stroke risk by 80%. ABCD2 (Age, Blood pressure, Clinical features, Duration, Diabetes) score and magnetic resonance imaging abnormalities help to identify patients at high risk of stroke. Our aim was to determine whether the use of transcranial Doppler (TCD) examination on arrival at the TIA clinic yields additional information that facilitates the identification of patients at high risk of stroke recurrence. METHODS: Between January 2003 and December 2007, 1,881 patients were admitted to SOS-TIA clinic (a TIA clinic with around-the-clock access). Clinical and vascular assessment included TCD performed by a neurologist immediately after admission. Stroke prevention measures were initiated on arrival, in accordance with guidelines. All patients were followed for 1 year after presentation to the SOS-TIA clinic. RESULTS: A total of 1,823 TCD examinations were performed within 4 hours of admission. Intracranial narrowing or occlusion was found in 8.8% of patients, and was independently associated with age, hypertension, and diabetes. After 1-year follow-up on best preventive therapy, the incidence of recurrent vascular events (intracranial revascularization for TIA recurrence, stroke, myocardial infarction, and vascular death combined) was 7.0% in patients with intracranial narrowing or occlusion and 2.4% in those without (log-rank, p = 0.007). The hazard ratio of combined outcome for the presence of intracranial narrowing or occlusion was 2.29 (95% confidence interval [CI], 1.15-4.56; p = 0.02) in multivariate analysis including age, gender, hypertension, and diabetes, and was 2.50 (95%CI, 1.24-5.05; p = 0.01) in multivariate analysis including ABCD2 score > or =4. INTERPRETATION: Immediate TCD examination on arrival at the TIA clinic is feasible and could help to identify patients at high risk of vascular events recurrence. This study supports a systematic intracranial vascular examination in the initial management of TIA.

Impact of a combined intravenous/intra-arterial approach in octogenarians.

BACKGROUND: Intravenous (IV) alteplase is not currently recommended in octogenarian patients, and the benefit/risk ratio of endovascular (intra-arterial, IA) therapy remains to be determined. The aim of this study was to determine the impact of a combined IV-IA approach in octogenarians. METHODS: From a single-centre interventional study, we report age-specific outcomes of patients treated by a combined IV-IA thrombolytic approach. Patients ≥80 years with documented arterial occlusion treated by conventional IV thrombolysis constituted the control group. RESULTS: Among 84 patients treated by the IV-IA approach, those ≥80 years (n = 25) had a similar rate of early neurological improvement to that of patients <80 years, whereas the 90-day favourable outcome rate was lower in octogenarians (adjusted odds ratio, OR, 0.21; 95% confidence interval, CI, 0.06-0.75). No difference in symptomatic intracranial haemorrhage was observed whereas a higher rate of 90-day mortality (adjusted OR, 3.27; 95% CI, 0.76-14.14) and asymptomatic intracranial haemorrhage (adjusted OR, 6.39; 95% CI, 1.54-26.63) were found in patients ≥80 years old. Among octogenarians, and compared to IV-thrombolysis-treated patients (n = 24), patients treated by the IV-IA approach had a higher rate of recanalization (76 vs. 33%, p = 0.003) associated with increased early neurological improvement (32 vs. 8%, p = 0.07). Although there was a higher rate of asymptomatic intracranial haemorrhage (44 vs. 8%, p = 0.005) observed in the IV-IA group, no difference existed in symptomatic intracranial haemorrhage rates and 90-day favourable outcome. CONCLUSION: The IV-IA approach in octogenarians was associated with lower efficacy at 3 months and higher mortality and asymptomatic haemorrhagic complications than in patients <80 years old. Definite recommendations cannot be given, but an endovascular approach may cause more harm than positive effects in patients over 80 years and should not be considered outside an approved protocol.

Urodynamics in patients with multiple sclerosis: is it necessary? A randomized-controlled trial.

BACKGROUND: The need for complete urodynamic evaluation in Multiple Sclerosis (MS) patients with Lower Urinary Tract Symptoms (LUTS) is not fully established in the literature. The objective was to evaluate the effect of urodynamics in MS patients with LUTS on treatment outcomes. METHODS: MS patients with LUTS were recruited. On their first visit, urinary symptoms, symptom bother and urologic quality-of-life were evaluated using standardized questionnaires. On their second visit, patients were randomized into two groups: Group A underwent uroflowmetry, and Group B underwent a urodynamic study. Patients received treatment based on the whole evaluation and then were evaluated at 1, 3 and 6 months. RESULTS: Fifty MS patients with LUTS were randomized to 25 patients in each group. All scores decreased significantly after 6 months of treatment in both groups (p < 0.05). However, no differences were found between the two groups at baseline and at 1, 3 and 6 months of treatment (p > 0.05) concerning treatment outcomes. CONCLUSION: A detailed clinical and non-invasive evaluation of MS patients with LUTS seems to be sufficient for prescribing an effective treatment. A urodynamic study does not influence the response to the prescribed treatment in terms of LUTS severity, bother or urologic quality-of-life.

Does ABCD2 score below 4 allow more time to evaluate patients with a transient ischemic attack?

BACKGROUND AND PURPOSE: The National Institute for Clinical Excellence (NICE) recommends that patients with a transient ischemic attack and ABCD(2) score > or =4 and those with >2 transient ischemic attacks within 1 week be admitted for urgent complete etiologic evaluation within 24 hours and that those with an ABCD(2) score <4 be evaluated less urgently within 1 week. METHODS: Using data from 1176 patients with a definite or possible transient ischemic attack or minor stroke included in the SOS-TIA registry (January 2003 to June 2007), we studied the usefulness of the conventional ABCD(2) score cutoff as well as the NICE criteria for urgent admission to a stroke unit defined as presence of symptomatic internal carotid artery stenosis > or =50%, symptomatic intracranial artery stenosis > or =50%, or major cardiac source of embolism. RESULTS: Among 697 patients with an ABCD(2) score <4, 20% required immediate consideration for emergency treatment (eg, symptomatic internal carotid stenosis > or =50% in 9.1% of patients, symptomatic intracranial stenosis in 5.0%, atrial fibrillation in 5.9%, other major cardiac source of embolism in 2.1%) in comparison to 31.6% of 497 patients with an ABCD(2) score > or =4. The sensitivity and specificity of ABCD(2) score > or =4 or NICE criteria for discriminating between patients requiring admission or not were <62% with low positive predictive values (<30%) and high negative predictive values (> or =80%). CONCLUSIONS: One in 5 patients with an ABCD(2) score <4 had high-risk disease requiring urgent treatment decision-making. When triaging on an ABCD(2) score, we recommend adding systematic carotid ultrasound (or a default angiographic CT scan) and electrocardiography within 24 hours before postponing complete transient ischemic attack evaluation.