First stroke incidence, causes, treatments, and outcomes for Aboriginal Peoples in South Australia and the Northern Territory: a pilot prospective study.

OBJECTIVE: We performed a pilot stroke incidence study, focused on feasibility and inclusion of the CONSIDER reporting guidelines, to model the design of a future population-based study aiming to definitively determine stroke incidence, antecedents, treatment, and outcomes. STUDY DESIGN: Prospective stroke incidence study (pilot study). SETTING, PARTICIPANTS: All people aged 15 years or older who lived in postcode-defined areas of South Australia and Northern Territory (885 472 people, including 45 127 Aboriginal people [5.1%]) diagnosed with stroke for the first time during 1 October - 31 December 2015 and admitted to public hospitals or stroke and transient ischaemic attack clinics. MAIN OUTCOME MEASURES: Feasibility of a prospective population-based stroke incidence study. RESULTS: Of the 123 participants with first strokes, ten were Aboriginal (8%); the median age of Aboriginal people was 45 years (interquartile range [IQR], 33-55 years), of non-Indigenous people 73 years (IQR, 62-84 years). For Aboriginal people, the age-standardised incidence of stroke was 104 (95% confidence interval [CI], 84-124) per 100 000 person-years, for non-Indigenous people 33 (95% CI, 22-44) per 100 000 person-years. We found that a prospective population-based stroke incidence study in Aboriginal people was feasible, including with respect to establishing an adequate sample size, diagnostic confirmation, identification of incident stroke, confirming stroke subtypes, establishing a stable statistical population, standardising data reporting for comparison with other stroke incidence studies, and ethical research reporting that conforms to CONSIDER guidelines. CONCLUSIONS: A larger, population-based study of the incidence of stroke in Aboriginal people is both feasible and needed to provide robust estimates of stroke incidence, antecedents, treatments and outcomes to help guide strategies for reducing the risk of and outcomes of stroke in Aboriginal people.

Evaluation of a CTA-Triage Based Transient Ischemic Attack Service: A Retrospective Single Center Cohort Study.

OBJECTIVE: We designed a computed tomography angiography (CTA)-based algorithm for patients presenting to hospital with a transient ischemic attack (TIA) which identified high-risk patients, as well as inpatient versus semiurgent outpatient management following MRI, and we hypothesised that this would be effective. METHODS: Patients seen in the ED at the Royal Adelaide Hospital from March 3, 2012 to November 30, 2016 with TIA-like symptoms were assessed for a cardioembolic source (clinical assessment, electrocardiogram) and underwent intra and extracranial CTA. Patients with a referable >50% stenosis were admitted and given dual antiplatelets. Most high-risk cardiac source patients were also admitted and anticoagulated. Other patients were loaded with aspirin, or changed to clopidogrel if on aspirin, and reviewed as outpatients following semiurgent MRI (3-4 days). We assessed the 90-day recurrent stroke risk in this cohort as a whole, and in those with a final cerebrovascular diagnosis. RESULTS: 1167 patients were diagnosed in Emergency as TIA and referred via our algorithm. A total of 150 were admitted, 78 had "high-risk" features. A total of 1017 patients were reviewed in the TIA clinic. The average age of the total cohort was 65.8 years old. Final diagnosis was TIA/minor stroke in 69% admitted patients and 30% clinic patients (P value < .0001). The 90-day recurrent stroke risk in these patients was 2.0% (5.8% admitted vs .7% clinic patients, P value < .0001). In those with noncerebrovascular diagnoses, there were no recurrent strokes within 90 days. CONCLUSIONS: Stroke risk is very low using CTA guided semiurgent clinic review algorithm.

Icatibant as a Potential Treatment of Life-Threatening Alteplase-Induced Angioedema.

Severe orolingual angioedema is a life-threatening complication of alteplase treatment for acute ischemic stroke that occurs during alteplase infusion or in the first 2 hours afterward. Currently, there are no proven therapies, although glucocorticoids, antihistamines, and adrenaline are sometimes used. Intubation is required if significant airway compromise supervenes. The incidence is .2%-5.1%, and risk factors include treatment with angiotensin-converting enzyme inhibitors and total insular infarcts. Here we report a case of alteplase-induced severe angioedema, which resolved briskly following icatibant treatment.

Ischaemic stroke may symptomatically manifest as migraine aura.

Migraine aura is a common stroke mimic. We hypothesised that some patients with typical migraine aura symptoms might have embolic stroke detected as the precipitant. We identified fourteen patients who presented with symptoms consistent with a clinical diagnosis of migraine aura, but demonstrated subsequent evidence of acute infarction on magnetic resonance imaging (MRI). In all patients, migraine aura symptoms were not directly attributable to the vascular lesion on MRI. 50% of patients were classified as having an embolic stroke of undetermined source. Of these, a patent foramen ovale was identified in 4/5 of those who underwent transoesophageal echocardiogram, with large right-to-left shunt demonstrated in three. The results from our cohort suggest that migraine aura can be the presenting feature of acute ischaemic stroke, with local ischaemia presumably triggering a widely migrating cortical wave of spreading depolarization.