Background and Purpose-Transient ischemic attacks (TIAs) are warning signs of stroke. Recently, the hypothesis was raised that TIA bears a significant risk for death and dependence and requires the same complex diagnostic workup as a complete stroke. Methods-We prospectively collected pre-and in-hospital procedures, symptoms, outcome, complications, and therapies from a representative sample of all stroke-treating hospitals (nϭ82) in southwest Germany. Follow-up was attempted 6 months after discharge. End points were death or dependence in activities of daily living (Barthel Index Ͻ95, modified Rankin Scale (mRS) of 3 to 6, or institutionalization in a nursing home). Results-1380 TIA patients and 3855 stroke patients entered the database. During hospital stay, stroke incidence was 8%for TIA patients and another 5% within the first half-year. Similarly, for ischemic stroke (IS) patients these figures were 7% and 6% (PϾ0.05), respectively. Two percent of TIA patients died in hospital (5% afterward) compared with 9% of stroke patients (10% afterward, PϽ0.001). Seventeen percent TIA compared with 38% IS patients (PϽ0.05) were dependent at follow-up. Whereas an estimated preexisting deficit (mRS Ͼ2) was the strongest predictor for death or disability (baseline mRS odds ratio, 4.1; 95% CI, 2.3 to 7.2), admission to a stroke unit was a valid predictor for survival and independence (odds ratio, 0.4; 95% CI, 0.2 to 0.9). Conclusions-These data from a large, multicenter, nonselected, observational study underscore the "not so benign" prognosis for TIA patients. There is a relevant individual risk of early stroke, death, or disability in TIA patients. Management and treatment strategies are similar for both TIA and acute stroke.

Conclusion:Carotid stenting with the use of an emboli-protection device is not inferior to carotid endarterectomy for treatment of severe carotid artery stenosis in patients considered at high risk for carotid endarterectomy.Summary: This is a long awaited publication of the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial. The authors conducted a randomized trial comparing carotid artery stenting with an emboli-protection device versus carotid endarterectomy in 334 patients with coexisting medial or anatomic conditions that may increase the risk of carotid endarterectomy. Patients included in the trial had at least 50% symptomatic carotid artery stenosis, or if the lesion was asymptomatic, a stenosis of at least 80%. The primary end point was somewhat unusual in that it consisted of cumulative incidents of cardiovascular events in 1 year. These included a composite of death, stroke, or myocardial infarction within 30 days after the intervention, or death or ipsilateral stroke between 31 days and 1 year. Recurrent carotid stenosis was not an end point.The primary end point occurred in 20 patients assigned to the carotid stenting with an embolic-protection device group (cumulative incidence, 12.2%) and in 32 patients who underwent carotid endarterectomy (cumulative incidence, 20.1%; absolute difference, Ϫ7.9% ; 95% confidence interval, Ϫ16.4% to 0.7%; P ϭ .004 for non-inferiority, and P ϭ .053 for superiority). In this study, approximately 20% of the patients were Ͼ80 years old and 22% were entered for recurrent carotid stenosis. Less than 30% of the patients had symptomatic stenosis. There were no differences in the cumulative incidence of the primary end point at 1 year in the patients with symptomatic stenosis (16.8% among those who received a stent vs 16.5% among those who underwent endarterectomy, P ϭ .95). For patients with asymptomatic carotid stenosis, the cumulative incidence of the primary end point at 1 year was lower among those who received a stent (9.9%) than among those that underwent carotid endarterectomy (21.5%), P ϭ .02.Comment: This study, first published in USA Today, has now appeared in the New England Journal of Medicine. The differences in the primary end points between the endarterectomy and stented group appear to be primarily driven by the higher number of myocardial infarctions, primarily non-Q wave myocardial infarctions, in the endarterectomy group. Nearly 75% of the patients were treated for asymptomatic stenosis. The applicability of the results of this trial for the overall care of patients with carotid artery disease seems limited. Given the narrow therapeutic index of intervention for asymptomatic carotid stenosis, particularly recurrent carotid stenosis, it is likely the large majority of patients entered into the trial would not have been, in many practices, suitable candidates for any carotid intervention, regardless of whether it was endarterectomy or stent.