Transient ischemic attacks: predictability of future ischemic stroke or transient ischemic attack events.

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Abstract

The short-term risk of an ischemic stroke after a transient ischemic attack (TIA) is estimated to be approximately 3%-10% at 2 days, 5% at 7 days, and 9%-17% at 90 days, depending on active or passive ascertainment of ischemic stroke. Various risk prediction scores are available to identify high-risk patients. We present here a pragmatic review of the literature discussing the main scoring systems. We also provide the sensitivity, specificity, positive predictive value, and negative predictive value for each scoring system. Our review shows that scoring systems including brain imaging and vascular imaging are better at risk prediction than scores that do not include this information.

Most cited references 54

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Special report from the National Institute of Neurological Disorders and Stroke. Classification of cerebrovascular diseases III.

(1990)

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Addition of brain and carotid imaging to the ABCD² score to identify patients at early risk of stroke after transient ischaemic attack: a multicentre observational study.

Á. Merwick, Hakan Ay, Maria Stack … (2010)

The ABCD² score improves stratification of patients with transient ischaemic attack by early stroke risk. We aimed to develop two new versions of the score: one that was based on preclinical information and one that was based on imaging and other secondary care assessments. We analysed pooled data from patients with clinically defined transient ischaemic attack who were investigated while in secondary care. Items that contribute to the ABCD² score (age, blood pressure, clinical weakness, duration, and diabetes), other clinical variables, carotid stenosis, and abnormal acute diffusion-weighted imaging (DWI) were recorded and were included in multivariate logistic regression analysis of stroke occurrence at early time intervals after onset of transient ischaemic attack. Scores based on the findings of this analysis were validated in patients with transient ischaemic attack from two independent population-based cohorts. 3886 patients were included in the study: 2654 in the derivation sample and 1232 in the validation sample. We derived the ABCD³ score (range 0-9 points) by assigning 2 points for dual transient ischaemic attack (an earlier transient ischaemic attack within 7 days of the index event). C statistics (which indicate discrimination better than chance at >0·5) for the ABCD³ score were 0·78 at 2 days, 0·80 at 7 days, 0·79 at 28 days, and 0·77 at 90 days, compared with C statistics for the ABCD² score of 0·71 at 2 days (p=0·083), 0·71 at 7 days (p=0·012), 0·71 at 28 days (p=0·021), and 0·69 at 90 days (p=0·018). We included stenosis of at least 50% on carotid imaging (2 points) and abnormal DWI (2 points) in the ABCD³-imaging (ABCD³-I) score (0-13 points). C statistics for the ABCD³-I score were 0·90 at 2 days (compared with ABCD² score p=0·035), 0·92 at 7 days (p=0·001), 0·85 at 28 days (p=0·028), and 0·79 at 90 days (p=0·073). The 90-day net reclassification improvement compared with ABCD² was 29·1% for ABCD³ (p=0·0003) and 39·4% for ABCD³-I (p=0·034). In the validation sample, the ABCD³ and ABCD³-I scores predicted early stroke at 7, 28, and 90 days. However, discrimination and net reclassification of patients with early stroke were similar with ABCD³ compared with ABCD². The ABCD³-I score can improve risk stratification after transient ischaemic attack in secondary care settings. However, use of ABCD³ cannot be recommended without further validation. Health Research Board of Ireland, Irish Heart Foundation, and Irish National Lottery. Copyright © 2010 Elsevier Ltd. All rights reserved.

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Patterns and predictors of early risk of recurrence after transient ischemic attack with respect to etiologic subtypes.

Rebecca Sabin, Pilar Delgado, Joan Montaner … (2007)

The risk of recurrent stroke is highest within the first few weeks after a transient ischemic attack (TIA), and it is likely to be related to the underlying pathology. We sought to study the early risk of recurrent stroke by etiologic subtype. We prospectively studied 388 TIA patients. The cause of TIA was classified according to the Trial of ORG 10172 criteria: large-artery atherosclerosis (LAA, n=90), cardioembolism (n=87), small-vessel disease (n=68), undetermined (n=127), and other determined cause (n=16). Patients were followed up at 3 months. Risk factors and clinical symptoms for each subtype were recorded. The duration of symptoms and clinical symptoms varied significantly among the different subtypes. LAA was associated with recurrent short episodes of weakness, whereas speech impairment and cortical symptoms were associated with cardioembolism (P<0.05). The association of vascular risk factors was highest in LAA (P<0.05). New strokes were recorded in 35 (9%) patients. Recurrent stroke risk varied among subtypes (P<0.001): LAA, 20.0%; cardioembolism, 11.5%; undetermined, 4.7%; small-vessel disease, 1.5%; and other cause, 0%. Cox proportional-hazards multivariate analyses did not identify any independent predictor of further cerebral ischemic events for LAA, cardioembolism, undetermined, or small-vessel disease. The risk of early recurrent stroke is highest in patients with LAA. This supports the need for urgent carotid and transcranial imaging for identifying those patients at highest risk. Some risk factors and clinical symptoms are related to some etiologic subtypes, but stronger predictors of stroke recurrence are needed to identify those patients with highest risk for each TIA subtype.

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Author and article information

Journal

Journal ID (iso-abbrev): Ther Clin Risk Manag

Title: Therapeutics and clinical risk management

Publisher: Informa UK Limited

ISSN: 1176-6336

ISSN (Print): 1176-6336

Publication date (Electronic): 2014

Volume: 10

Affiliations

[1 ] Department of Neurology, The University of Arkansas Medical Sciences, Little Rock, AR.

[2 ] Department of Knowledge and Evaluation Research, Mayo Clinic, Rochester, MN.

[3 ] Department of Neurology, The University of Kansas Medical Center, Kansas City, KS, USA.

Article

Publisher Item ID: tcrm-10-027

DOI: 10.2147/TCRM.S54810

PMC ID: 3891764

PubMed ID: 24476667

SO-VID: 161e4c58-9c9c-46ce-8ca7-0832c1073f1e

History

Keywords: ischemic stroke,prediction,systematic review,transient ischemic attack

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Keywords: ischemic stroke, prediction, systematic review, transient ischemic attack

Transient ischemic attacks: predictability of future ischemic stroke or transient ischemic attack events.

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Abstract

Most cited references 54

Special report from the National Institute of Neurological Disorders and Stroke. Classification of cerebrovascular diseases III.

Addition of brain and carotid imaging to the ABCD² score to identify patients at early risk of stroke after transient ischaemic attack: a multicentre observational study.

Patterns and predictors of early risk of recurrence after transient ischemic attack with respect to etiologic subtypes.

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