Validation of the RRE-90 Scale to Predict Stroke Risk after Transient Symptoms with Infarction: A Prospective Cohort Study

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Abstract

Background and Purpose

The risk of stroke after a transient ischemic attack (TIA) for patients with a positive diffusion-weighted image (DWI), i.e., transient symptoms with infarction (TSI), is much higher than for those with a negative DWI. The aim of this study was to validate the predictive value of a web-based recurrence risk estimator (RRE; http://www.nmr.mgh.harvard.edu/RRE/) of TSI.

Methods

Data from the prospective hospital-based TIA database of the First Affiliated Hospital of Zhengzhou University were analyzed. The RRE and ABCD ² scores were calculated within 7 days of symptom onset. The predictive outcome was ischemic stroke occurrence at 90 days. The receiver-operating characteristics curves were plotted, and the predictive value of the two models was assessed by computing the C statistics.

Results

A total of 221 eligible patients were prospectively enrolled, of whom 46 (20.81%) experienced a stroke within 90 days. The 90-day stroke risk in high-risk TSI patients (RRE ≥4) was 3.406-fold greater than in those at low risk (P <0.001). The C statistic of RRE (0.681; 95% confidence interval [CI], 0.592–0.771) was statistically higher than that of ABCD ² score (0.546; 95% CI, 0.454–0.638; Z = 2.115; P = 0.0344) at 90 days.

Conclusion

The RRE score had a higher predictive value than the ABCD ² score for assessing the 90-day risk of stroke after TSI.

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Most cited references 22

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A computerized algorithm for etiologic classification of ischemic stroke: the Causative Classification of Stroke System.

Jens-Erik B Jensen, Amytis Towfighi, Aneesh B Singhal … (2007)

The SSS-TOAST is an evidence-based classification algorithm for acute ischemic stroke designed to determine the most likely etiology in the presence of multiple competing mechanisms. In this article, we present an automated version of the SSS-TOAST, the Causative Classification System (CCS), to facilitate its utility in multicenter settings. The CCS is a web-based system that consists of questionnaire-style classification scheme for ischemic stroke (http://ccs.martinos.org). Data entry is provided via checkboxes indicating results of clinical and diagnostic evaluations. The automated algorithm reports the stroke subtype and a description of the classification rationale. We evaluated the reliability of the system via assessment of 50 consecutive patients with ischemic stroke by 5 neurologists from 4 academic stroke centers. The kappa value for inter-examiner agreement was 0.86 (95% CI, 0.81 to 0.91) for the 5-item CCS (large artery atherosclerosis, cardio-aortic embolism, small artery occlusion, other causes, and undetermined causes), 0.85 (95% CI, 0.80 to 0.89) with the undetermined group broken into cryptogenic embolism, other cryptogenic, incomplete evaluation, and unclassified groups (8-item CCS), and 0.80 (95% CI, 0.76 to 0.83) for a 16-item breakdown in which diagnoses were stratified by the level of confidence. The intra-examiner reliability was 0.90 (0.75-1.00) for 5-item, 0.87 (0.73-1.00) for 8-item, and 0.86 (0.75-0.97) for 16-item CCS subtypes. The web-based CCS allows rapid analysis of patient data with excellent intra- and inter-examiner reliability, suggesting a potential utility in improving the fidelity of stroke classification in multicenter trials or research databases in which accurate subtyping is critical.

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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

Contributors

Yoshihiro Kokubo: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 22 September 2015

Publication date Collection: 2015

Volume: 10

Issue: 9

Electronic Location Identifier: e0137425

Affiliations

[1 ]Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China

[2 ]Department of Neurology, the Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China

National Cardiovascular Center Hospital, JAPAN

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: BS YX. Performed the experiments: LP HF LZ YG YW ST. Analyzed the data: BS LP. Contributed reagents/materials/analysis tools: YX. Wrote the paper: BS LP HF LZ YG YW ST YX.

‡ These authors are co-first authors on this work.

* E-mail: xuyuming@ 123456zzu.edu.cn

Article

Publisher ID: PONE-D-15-14683

DOI: 10.1371/journal.pone.0137425

PMC ID: 4579076

PubMed ID: 26394400

SO-VID: 03c778d2-7a1b-479d-8a5d-f2f933fdea0c

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

History

Date received : 4 April 2015

Date accepted : 17 August 2015

Page count

Figures: 3, Tables: 7, Pages: 11

Funding

This study was funded by the Health Department of Henan Province (201202005) and the Education Department of Henan Province (12A320046). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability All relevant data are within the paper and its Supporting Information files.

Validation of the RRE-90 Scale to Predict Stroke Risk after Transient Symptoms with Infarction: A Prospective Cohort Study

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Abstract

Background and Purpose

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Results

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Stroke MRI

Most cited references 22

A computerized algorithm for etiologic classification of ischemic stroke: the Causative Classification of Stroke System.

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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