The edition · Neurology
TIA carries a sustained dementia risk; plasma p-tau217 misleads in about 1 in 12; shunting for normal pressure hydrocephalus improved gait in pooled trials
A population cohort of 113,081 people after TIA leads a neurology edition on diagnosis and treatment decisions where the evidence is observational or small, and says how far each can be pushed.
The edition in brief
In an Ontario cohort of 113,081 matched patients with a first TIA, dementia was diagnosed in 19.3% over a mean 7.1 years; the rate was 2.71 vs 2.03 per 100 person-years against matched controls, with a hazard ratio of 1.75 in the first year and 1.34 overall, converging towards the risk seen after stroke by 5 years. In 706 participants at Mayo Clinic, plasma p-tau217 results were discordant with amyloid PET or CSF markers in 8.5%; false negatives (5.6%) outnumbered false positives (2.8%), and discordance was linked to age, sleep apnoea, body mass index and renal function. A meta-analysis of 21 phase 3 trials (12,610 people) found ARIA-E in 5.4% and ARIA-H in 10.27% of those receiving anti-amyloid antibodies, with ApoE e4 homozygosity the strongest risk factor (OR 5.12 for ARIA-E). A case-crossover study of 57,547 adults found emergency visits for falls were more frequent in the week before a first seizure (OR 2.6). A meta-analysis of four randomised trials (224 patients) found CSF shunting for idiopathic normal pressure hydrocephalus improved gait speed (SMD 0.73) but increased positional headache, with imprecise subdural haematoma data. A pearl on checking for seizures in unexplained falls closes the edition.
Dementia risk after TIA stays raised for years and nears the post-stroke risk
Consider screening cognition at follow-up after TIA; dementia risk stays raised well beyond the first year.
Plasma p-tau217 disagreed with reference biomarkers in 8.5%, mostly false negatives
Check kidney function, BMI and clinical stage when reading plasma p-tau217, and consider confirmatory testing when the result conflicts with the picture.
ARIA with anti-amyloid antibodies: 5.4% ARIA-E, 10.3% ARIA-H, driven by ApoE e4
Use ApoE genotype and baseline MRI findings to counsel on ARIA risk before anti-amyloid therapy, and follow the product's monitoring schedule.
Falls in the days before a first seizure: a possible missed sign
Think about seizures in unexplained falls and ask about earlier falls in first-seizure presentations.
In the older patient with a fall and a slow gait, ask about the triad
Observe gait and ask about urinary and cognitive symptoms in older patients with falls and unexplained slow walking.
Shunting for idiopathic normal pressure hydrocephalus improved gait in pooled randomised trials
Consider early specialist referral for suspected idiopathic NPH, with counselling that benefit is mainly gait and independence and that subdural bleeding risk is uncertain.
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