Nonfocal Symptoms are More Frequent in Patients with Vertebral Artery than Carotid Artery Stenosis

Abstract

Introduction: In patients with a transient ischemic attack (TIA) or ischemic stroke, the combination of focal and nonfocal symptoms has been associated with a higher risk of cardiovascular events. We hypothesized that nonfocal symptoms are more frequent in patients with symptomatic stenosis of a vertebral artery (VA) than of a carotid artery (CA). Therefore, we assessed the prevalence of nonfocal symptoms in patients with a recent TIA or nondisabling ischemic stroke and studied their relation with symptomatic CA or VA stenosis. Methods: We administered a standardized questionnaire on the occurrence of focal and nonfocal symptoms during the qualifying TIA or nondisabling ischemic stroke and in the preceding 6 months. We included 50 consecutive patients with a recently symptomatic CA stenosis ≥50%, 50 consecutive patients with a recently symptomatic VA stenosis ≥50%, 25 consecutive patients with an anterior circulation event without an ipsilateral CA stenosis ≥50%, and 25 consecutive patients with a posterior circulation event without a relevant VA stenosis ≥50%. Relative risks for the presence of nonfocal symptoms in relation to the presence of a symptomatic stenosis were calculated with univariate and multivariate Poisson regression. Adjustments were made for age, sex, stroke as the qualifying event, and cardiovascular risk factors. A subgroup analysis was performed for patients in whom the vascular territory of the event was confirmed on imaging. Results: During the qualifying ischemic event, focal symptoms were accompanied by nonfocal symptoms in 80 (53%) patients. Nonfocal symptoms occurred more frequently in patients with a VA stenosis (72%) than in patients with a CA stenosis [26%; adjusted relative risk (aRR), 2.9; 95% confidence interval (CI), 1.8-4.6]. A higher prevalence of nonfocal symptoms was found in patients with posterior circulation TIAs and strokes (73%) than in patients with anterior circulation TIAs and strokes (33%; aRR, 2.2; 95% CI, 1.6-3.1). During the preceding 6 months, 45% of patients with and 20% of patients without a symptomatic stenosis had had nonfocal symptoms (aRR, 2.4; 95% CI, 1.3-4.3). Subgroup analysis for the 89 (59%) patients with ischemia visible on imaging gave essentially the same results. Conclusions: More than half of the TIAs or nondisabling ischemic strokes were associated with nonfocal neurological symptoms. Nonfocal symptoms occurred more frequently in patients with a symptomatic VA stenosis than CA stenosis.

Is the Long-Term Prognosis of Transient Ischemic Attack or Minor Ischemic Stroke Affected by the Occurrence of Nonfocal Symptoms?

“…May 2014 a previous hospital-based study 4 but considerably higher than in the population-based Rotterdam study. 5 In the hospitalbased study, 53% of the patients had accompanying nonfocal neurological symptoms.…”

“…5 In the hospitalbased study, 53% of the patients had accompanying nonfocal neurological symptoms. 4 However, half of the patients in that study had posterior circulation TIA or stroke, and half of the patients had a stenosis of ≥50% of the carotid or vertebral artery. Both in our current study and in previous studies, nonfocal or atypical neurological symptoms were more frequent in patients with TIA or stroke in the posterior circulation than in the anterior circulation.…”

“…Both in our current study and in previous studies, nonfocal or atypical neurological symptoms were more frequent in patients with TIA or stroke in the posterior circulation than in the anterior circulation. 4,[9][10][11] In addition, nonfocal symptoms were more frequent in the presence of a stenosis in one of the supplying arteries. 4 Both in our study and in previous studies, the occurrence of nonfocal symptoms was associated with a higher age.…”

“…4,[9][10][11] In addition, nonfocal symptoms were more frequent in the presence of a stenosis in one of the supplying arteries. 4 Both in our study and in previous studies, the occurrence of nonfocal symptoms was associated with a higher age. 5,12 In the population-based Rotterdam study, focal symptoms were accompanied by nonfocal symptoms in just 12% of all patients with focal neurological symptoms.…”

“…1,2 Nevertheless, in hospital-based series, 22% to 53% of patients with a TIA or minor ischemic stroke had accompanying nonfocal symptoms, such as nonrotatory dizziness or confusion. 3,4 In a large population-based study, typical TIAs were accompanied by nonfocal symptoms in 12% of patients. 5 Several studies have suggested that nonfocal neurological symptoms may be less innocuous than often thought.…”