Risk factors and outcomes for ischemic stroke
Stroke continues to have a great impact on public health in the United States. Stroke is frequent, recurring, and is more often disabling than fatal. The annual incidence of new strokes in the United States is nearly one half million, with over 3 million stroke survivors alive today. Identifying risk factors for initial ischemic stroke, as well as characterizing the determinants of outcome (stroke recurrence and mortality) after ischemic stroke, is the basis for stroke prevention strategies. Modifiable and nonmodifiable risk factors for ischemic stroke have been identified and include age; gender; race/ethnicity; heredity; hypertension; cardiac disease, particularly atrial fibrillation; diabetes mellitus; hypercholesterolemia; cigarette smoking; and alcohol abuse. New risk factors, such as hypercoagulable states and patient foramen ovale, are currently being investigated. Follow-up studies have quantified case-fatality rates, early recurrence risk, and long-term mortality and recurrence risks. Despite advances in stroke prevention strategies and treatments, stroke recurrence is still the major threat to any stroke survivor. A major goal set by the Public Health Service in its National Health Promotion and Disease Prevention Objectives for the year 2000 is “to reduce stroke deaths to no more than 20 per 100,000.” Part of this can be achieved if the risk of stroke recurrence is reduced. However, the frequency and determinants of stroke recurrence are poorly understood. Data from epidemiologic studies can help identify risk factors and outcomes after ischemic stroke, as well as the selection of high-risk individuals for focused risk-factor modification. Current information on these topics is discussed. 
Morning increase in onset of ischemic stroke.
The time of onset of ischemic stroke was determined for 1,167 of 1,273 patients during the collection of data by four academic hospital centers between June 30, 1983, and June 30, 1986. More strokes occurred in awake patients from 10:00 AM to noon than during any other 2-hour interval. The incidence of stroke onset declined steadily during the remainder of the day and early evening. The onset of stroke is least likely to occur in the late evening, before midnight. 
Tissue Plasminogen Activator for Acute Ischemic Stroke
Thrombolytic therapy for acute ischemic stroke has been approached cautiously because there were high rates of intracerebral hemorrhage in early clinical trials. We performed a randomized, double-blind trial of intravenous recombinant tissue plasminogen activator (t-PA) for ischemic stroke after recent pilot studies suggested that t-PA was beneficial when treatment was begun within three hours of the onset of stroke.
The trial had two parts. Part 1 (in which 291 patients were enrolled) tested whether t-PA had clinical activity, as indicated by an improvement of 4 points over base-line values in the score of the National Institutes of Health stroke scale (NIHSS) or the resolution of the neurologic deficit within 24 hours of the onset of stroke. Part 2 (in which 333 patients were enrolled) used a global test statistic to assess clinical outcome at three months, according to scores on the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS.
In part 1, there was no significant difference between the group given t-PA and that given placebo in the percentages of patients with neurologic improvement at 24 hours, although a benefit was observed for the t-PA group at three months for all four outcome measures. In part 2, the long-term clinical benefit of t-PA predicted by the results of part 1 was confirmed (global odds ratio for a favorable outcome, 1.7; 95 percent confidence interval, 1.2 to 2.6). As compared with patients given placebo, patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales. Symptomatic intracerebral hemorrhage within 36 hours after the onset of stroke occurred in 6.4 percent of patients given t-PA but only 0.6 percent of patients given placebo (P<0.001). Mortality at three months was 17 percent in the t-PA group and 21 percent in the placebo group (P = 0.30).
Despite an increased incidence of symptomatic intracerebral hemorrhage, treatment with intravenous t-PA within three hours of the onset of ischemic stroke improved clinical outcome at three months. 
Combined Intestinal Ischemia, Cerebral Stroke and Thrombosis of Thoracoabdominal Aorta and Splenic Artery in a Thrombophilic Woman: A Case Report
Aim: To present an uncommon, life-threatening case of intestinal ischemia complicated by cerebral stroke, thoraco-abdominal aorta and splenic artery thrombosis, in a woman with thrombophilia presenting common clinical signs.
Presentation of Case: A 42-year-old woman was admitted to hospital for lower abdominal pain, vomiting and fever. Emergency abdominal surgery evidenced intestinal ischemia requiring 80 cm ileum resection. The day following surgery, the patient lost consciousness and was admitted to the stroke unit. Thereafter, the patient was transferred to the intensive care unit due to respiratory failure. A brain-thoracic-abdominal CT-angiography showed occlusion of left medium cerebral artery, a thrombotic formation in thoracic and abdominal aorta, and partial occlusion of splenic artery. Homocysteine levels were 56.8mmol/l, screening for homozygosis mutation MTHFRC677T positive. Resolution of systemic thrombosis lasted one month. Patient was finally transferred to a rehabilitation center.
Discussion: Vascular disease and ischemic stroke have rarely been reported in subjects with thrombophilia and MTHFR polymorphisms. Our patient, affected by thrombophilia and high homocysteine levels, faced multiple vascular and cerebral complications. High concentration of homocysteine, with consequent vessel deposits, was detrimental for endothelium and vessel walls, due to action on blood coagulation factors and lipoproteins, with increased platelet adhesion and aggregation.
Conclusion: This case report represents an uncommon, sudden, life-threatening complication in thrombophilic patients, in spite of the common clinical signs presented. This clinical report should alert physicians to the importance of carrying out a careful clinical examination in the presence of thrombophilic patients presenting with apparently common clinical signs, such as abdominal pain, vomiting and fever. 
Ischemic Stroke: A Complication of Tuberculous Meningitis
We report a case of a 45-year old Hispanic male who was diagnosed with tuberculous meningitis (TBM) presented to the emergency department (ED) with altered mental status, confusion, and violent behavior. Computed tomography (CT) scan of the head was normal and repeated lumbar puncture (LP) did not yield new findings. Magnetic resonance imaging (MRI) of head showed multiple ischemic infarcts. Non-tPA stroke protocol was followed and anti-TB medicines were continued. With continuous cardiac monitoring, echocardiogram (ECHO) was normal so arrhythmia was less likely. Soon he was more responsive and alert with no further episodes of agitation and behavioral changes. Then, he was able to walk with assistance and was discharged to acute rehabilitation facility. 
 Sacco, R.L., 1995. Risk factors and outcomes for ischemic stroke. Neurology, 45(2 Suppl 1), p.S10.
 Marler, J.R., Price, T.R., Clark, G.L., Muller, J.E., Robertson, T., Mohr, J.P., Hier, D.B., Wolf, P.A., Caplan, L.R. and Foulkes, M.A., 1989. Morning increase in onset of ischemic stroke. Stroke, 20(4), pp.473-476.
 National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, 1995. Tissue plasminogen activator for acute ischemic stroke. New England Journal of Medicine, 333(24), pp.1581-1588.
 Giordano, C., Penna, O., Amato, A., Bruno, R., Tripodi, V. F., Vadalà, E. G., Pennisi, N. C., Mondello, E. and Fodale, V. (2015) “Combined Intestinal Ischemia, Cerebral Stroke and Thrombosis of Thoracoabdominal Aorta and Splenic Artery in a Thrombophilic Woman: A Case Report”, Journal of Advances in Medicine and Medical Research, 10(12), pp. 1-7. doi: 10.9734/BJMMR/2015/20540.
 Azharuddin, M., Lalani, I., Du, D. and Ghali, W. (2016) “Ischemic Stroke: A Complication of Tuberculous Meningitis”, International Neuropsychiatric Disease Journal, 8(3), pp. 1-6. doi: 10.9734/INDJ/2016/29820.