ABCD 2 Score Predicts Severity Rather Than Risk of Early Recurrent Events After Transient Ischemic Attack

Diffusion kurtosis imaging in patients with tissue-negative transient ischemic attack

Approximately 50–60% of patients with a clinical transient ischemic attack (TIA) do not have diffusion-weighted imaging (DWI) evidence of cerebral ischemia. The purpose of this study was to assess the added diagnostic value of diffusion kurtosis imaging (DKI) in the evaluation of patients with TIA who have normal DWI findings. From September 2014 to May 2017, a total of 179 consecutive patients with suspected TIA were eligible for enrollment in our study. The inclusion criteria were a confirmed diagnosis of TIA confirmed by a stroke neurologist, MRI (including DWI and DKI) within 24 h after symptom onset, no stroke history, and no DWI lesion. A follow-up DWI was performed to establish stroke recurrence within a period of 90 days. A total of 98 patients who had no lesions on the baseline DWI were included for data analysis. Of these 98 patients, 31 (31.6%) had positive findings on the initial DKI. In 29 of the 31 (93.5%) patients, the location of the abnormality observed on DKI was consistent with the clinical symptoms. During the 90-day follow-up period, 14 (14.3%) patients developed recurrent stroke. The prevalence of recurrent stroke was higher in the DKI-positive group than in the DKI-negative group (29.0% vs. 7.5%, p = 0.01). A comparison between the patients with and without recurrent stroke showed that an abnormality on the baseline DKI was associated with stroke recurrence. Furthermore, 8 of the 9 stroke patients in the DKI-positive group developed a new ischemic lesion in the artery territory corresponding to the initial DKI abnormality. The new findings suggest the predictive value of DKI on the recurrence of stroke in the patients with TIA who have negative findings on conventional DWI.

A nomogram for predicting the in-hospital risk of recurrence among patients with minor non-cardiac stroke

BACKGROUND

Patients with minor stroke suffer a substantial risk of further recurrences, especially in the first two weeks. We aimed to develop and validate a prognostic nomogram to predict in-hospital stroke recurrence among patients with acute minor stroke.

METHODS

A total of 1326 patients with minor non-cardiac stroke (NIHSS) ≤5) from three centers were divided into development cohort (1016 patients from two centers) and validation cohort (310 patients from another center). Recurrent stroke was defined as a new ischemic stroke. A logistic regression model was employed to develop the nomogram to predict in-hospital stroke recurrence in patients with minor stroke using demographic, medical and imaging information. We then validated the nomogram externally. The predictive discrimination and calibration of the nomogram were assessed in the development and validation cohorts by area under the curve (AUC) and calibration plots.

RESULTS

During a median length of stay of 12 days, stroke recurrence occurred in 34 patients (3.3%). Predictors of in-hospital recurrence included prior history of transient ischemic attack, baseline NIHSS score, multiple infarctions, and carotid stenosis. The clinical and imaging-based nomogram B demonstrated adequate calibration and discrimination (AUC = 0.777), which was validated among 273 patients in a separate validation cohort (AUC = 0.753). Our clinical-imaging based nomogram was determined to be superior to the clinical-based nomogram and the RRE90 score in terms of discrimination.

CONCLUSION

A prognostic nomogram that integrates clinical and imaging information to predict the in-hospital risk of stroke recurrence among patients after acute minor stroke was constructed and validated externally. The nomogram demonstrated adequate calibration and discrimination in both the development and validation cohort.

A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis

Importance

Management of transient ischemic attack (TIA) has gained significant attention during the past 25 years after several landmark studies indicated the high incidence of a subsequent stroke.

Objective

To calculate the pooled event rate of subsequent ischemic stroke within 2, 7, 30, and 90 days of a TIA and compare this incidence among the population with TIA recruited before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C).

Data Sources

All published studies of TIA outcomes were obtained by searching PubMed from 1996, to the last update on January 31, 2020, irrespective of the study design, document type, or language.

Study Selection

Of 11 516 identified citations, 175 articles were relevant to this review. Both the classic time-based definition of TIA and the new tissue-based definition were accepted. Studies with a combined record of patients with TIA and ischemic stroke, without clinical evaluation for the index TIA, with diagnosis of index TIA event after ischemic stroke occurrence, with low suspicion for TIA, or duplicate reports of the same database were excluded.

Data Extraction and Synthesis

The study was conducted and reported according to the PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality assessment used the Quality in Prognosis Studies tool. Publication bias was visualized by funnel plots and measured by the Begg-Mazumdar rank correlation Kendall τ2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models.

Main Outcomes and Measures

The proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size.

Results

Systematic review yielded 68 unique studies with 223 866 unique patients from 1971 to 2019. The meta-analysis included 206 455 patients (58% women) during a span of 4 decades. The overall subsequent ischemic stroke incidence rates were estimated as 2.4% (95% CI, 1.8%-3.2%) within 2 days, 3.8% (95% CI, 2.5%-5.4%) within 7 days, 4.1% (95% CI, 2.4%-6.3%) within 30 days, and 4.7% (95% CI, 3.3%-6.4%) within 90 days. There was a recurrence risk of 3.4% among group A in comparison with 2.1% in group B or 2.1% in group C within 2 days; 5.5% in group A vs 2.9% in group B or 3.2% in group C within 7 days; 6.3% in group A vs 2.9% in group B or 3.4% in group C within 30 days, and 7.4% in group A vs 3.9% in group B or 3.9% in group C within 90 days.

Conclusions and Relevance

These findings suggest that TIA continues to be associated with a high risk of early stroke; however, the rate of post-TIA stroke might have decreased slightly during the past 2 decades.

A Nomogram for Predicting Stroke Recurrence Among Young Adults

Background and Purpose—

This study aimed to develop and validate a nomogram for predicting the risk of stroke recurrence among young adults after ischemic stroke.

Methods—

Patients aged between 18 and 49 years with first-ever ischemic stroke were selected from the Nanjing Stroke Registry Program. A stepwise Cox proportional hazards regression model was employed to develop the best-fit nomogram. The discrimination and calibration in the training and validation cohorts were used to evaluate the nomogram. All patients were classified into low-, intermediate-, and high-risk groups based on the risk scores generated from the nomogram.

Results—

A total of 604 patients were enrolled in this study. Hypertension (hazard ratio [HR], 2.038 [95% CI, 1.504–3.942]; P =0.034), diabetes mellitus (HR, 3.224 [95% CI, 1.848–5.624]; P <0.001), smoking status (current smokers versus nonsmokers; HR, 2.491 [95% CI, 1.304–4.759]; P =0.006), and stroke cause (small-vessel occlusion versus large-artery atherosclerosis; HR, 0.325 [95% CI, 0.109–0.976]; P =0.045) were associated with recurrent stroke. Educational years (>12 versus 0–6; HR, 0.070 [95% CI, 0.015–0.319]; P =0.001) were inversely correlated with recurrent stroke. The nomogram was composed of these factors, and successfully stratified patients into low-, intermediate-, and high-risk groups ( P <0.001).

Conclusions—

The nomogram composed of hypertension, diabetes mellitus, smoking status, stroke cause, and education years may predict the risk of stroke recurrence among young adults after ischemic stroke.

Clinical Risk Score for Predicting Recurrence Following a Cerebral Ischemic Event

Introduction: Recurrent stroke has a higher rate of death and disability. A number of risk scores have been developed to predict short-term and long-term risk of stroke following an initial episode of stroke or transient ischemic attack (TIA) with limited clinical utilities. In this paper, we review different risk score models and discuss their validity and clinical utilities.

Methods: The PubMed bibliographic database was searched for original research articles on the various risk scores for risk of stroke following an initial episode of stroke or TIA. The validation of the models was evaluated by examining the internal and external validation process as well as statistical methodology, the study power, as well as the accuracy and metrics such as sensitivity and specificity.

Results: Different risk score models have been derived from different study populations. Validation studies for these risk scores have produced conflicting results. Currently, ABCD² score with diffusion weighted imaging (DWI) and Recurrence Risk Estimator at 90 days (RRE-90) are the two acceptable models for short-term risk prediction whereas Essen Stroke Risk Score (ESRS) and Stroke Prognosis Instrument-II (SPI-II) can be useful for prediction of long-term risk.

Conclusion: The clinical risk scores that currently exist for predicting short-term and long-term risk of recurrent cerebral ischemia are limited in their performance and clinical utilities. There is a need for a better predictive tool which can overcome the limitations of current predictive models. Application of machine learning methods in combination with electronic health records may provide platform for development of new-generation predictive tools.

The cost of stroke in a public hospital in Brazil: a one-year prospective study

OBJECTIVE

Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. To measure the costs of stroke care in a public hospital in Joinville, Brazil.

METHODS

We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement.

RESULTS

We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively.

CONCLUSIONS

Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

Assessment of cerebral infarction after transient cerebral ischemic attack by ABCD2 score combined with the position of intracranial vascular stenosis

This study aims to investigate the value of the ABCD score combined with the position of the offending vessel stenosis in predicting the risk of transient ischemic attack (TIA) to develop into cerebral infarction.The ABCD score and head magnetic resonance imaging + magnetic resonance angiography (MRA) results of 192 patients with TIA were retrospectively analyzed. With the 7th day as the endpoint time, these patients were divided into 3 groups, according to ABCD scores: low-risk group (n = 105), moderate-risk group (n = 60), and high-risk group (n = 27). Blood vessels were screened using head MRA results, and patients were accordingly divided into 2 groups: proximal vascular stenosis group (n = 71) and nonproximal vascular stenosis group (n = 171). Then, the association of the position of the intracranial vascular stenosis and ABCD score with short-term prognosis was analyzed.Based on the ABCD score, the incidence of cerebral infarction after 1 week was significantly higher in the high-risk group (85.7%) than in the moderate-risk group (16.7%) and low-risk group (1.9%), and the differences were statistically significant (P < .05). When the ABCD score was ≥4 points, the incidence of cerebral infarction after 1 week was significantly higher in the proximal vascular stenosis group (59.1%) than in the nonproximal vascular stenosis group (30.8%), and the difference was statistically significant (P < .05). When the ABCD score was <4 points, the incidence of cerebral infarction after 1 week in the proximal stenosis group (2%) was not significantly different from that in the nonproximal stenosis group (1.9%, P > .05).The ABCD score combined with proximal offending vessel stenosis can improve the short-term prediction of cerebral infarction in patients with TIA.

Transient ischemic attack: Incidence and early risk of stroke in northern Portugal from 1998–2000 to 2009–2011

Objective

A decline in TIA incidence would be expected mirroring stroke trends, but patient's awareness of symptoms/signs, improved diagnostic procedures and changes in severity of vascular disease may raise TIA incidence. We aimed to estimate changes in TIA incidence and 30-day stroke risk in Portugal.

Methods

Data from two prospective community-based registers of first-ever TIA in 104,700 (1998–2000) and 118,232 (2009–2011) persons were collected using comprehensive case ascertainment methods. Incidence and stroke risk from TIA onset were compared using different inception cohorts. ABCD2 was used to stratified stroke risk.

Results

Overall, 141 patients were included in 1998–2000 and 174 in 2009–2011. Crude annual incidence rate increased from 67 to 74/100,000 (IRR=1.12; 95% CI, 0.90–1.40), particularly in men under 65 years (IRR=1.79; 95% CI, 1.06–3.04). Male/female IRR increased from 1.20 (0.86–1.68) in 1998–2000 to 1.77 (1.31–2.39) in 2009–2011, after adjustment for age. Better control of vascular risk factors (VRFs) accounted for lower ABCD2 scores in 2009–2011. The 30-day stroke risk was similar in study periods (18.4% vs. 16.7%, p > 0.7), decreasing from 16.1% to 8.2% ( p < 0.042) excluding patients reporting TIA after stroke occurrence and from 12.2% to 4.0% ( p < 0.011) further excluding patients who had stroke in ambulance/hospital. ABCD2 discriminated stroke risk only in 1998–2000; stroke severity decreased while posterior circulation stroke was more common in 2009–2011.

Conclusion

Despite a stable TIA incidence across periods, the risk increased in men compared to women. Better control of VRF accounted for lower ABCD2 scores and secondary prevention reduced stroke risk. Men under 65 years emerge as a preferential target for primary and secondary prevention.

Prominent deep medullary veins: a predictive biomarker for stroke risk from transient ischemic attack?

Background Deep medullary veins (DMVs) are a biomarker of severity and prognosis in patients with acute cerebral infarction. However, their clinical significance remains unclear in patients with transient ischemic attack (TIA). Purpose To determine whether prominent deep medullary veins (PDMVs) are a predictive biomarker for stroke risk after TIA. Material and Methods Clinical and imaging data of 49 patients with TIA and 49 sex- and age-matched controls were studied. PDMVs were defined as DMVs with a score of 3 (TDMVs) or asymmetric DMVs (ADMVs), and the relationship between PDMVs and clinical features was analyzed. The DMV score based on susceptibility weighted imaging (SWI) ranged from 0 (not visible) to 3 (very prominent) and was calculated for both hemispheres separately. A different score in each hemisphere was defined as ADMVs and an equal score was defined as symmetric DMVs. The asymmetry and score of DMVs were compared between the two groups and with respect to the time from TIA onset to imaging analysis. Results Agreement between neuroradiologists for the DMV asymmetry/score on SWI was excellent. The frequency of ADMVs and TDMVs was significantly higher in patients with TIA than controls ( P < 0.05). The patients showed no correlation between the time from TIA onset to imaging and the DMV asymmetry/score ( P > 0.05); PDMVs were not correlated with age, blood pressure, or diabetes. However, PDMVs were associated with the ABCD2 score (≥4), clinical symptoms, and duration of TIA (≥10 min). Conclusion Prominent deep medullary veins is a predictive biomarker for the risk of stroke in many patients having suffered from TIA.

Imaging Parameters and Recurrent Cerebrovascular Events in Patients With Minor Stroke or Transient Ischemic Attack

IMPORTANCE

Neurological worsening and recurrent stroke contribute substantially to morbidity associated with transient ischemic attacks and strokes (TIA-S).

OBJECTIVE

To determine predictors of early recurrent cerebrovascular events (RCVEs) among patients with TIA-S and National Institutes of Health Stroke Scale scores of 0 to 3.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted at 2 tertiary care centers (Columbia University Medical Center, New York, New York, and Tulane University Medical Center, New Orleans, Louisiana) between January 1, 2010, and December 31, 2014. All patients with neurologist-diagnosed TIA-S with a National Institutes of Health Stroke Scale score of 0 to 3 who presented to the emergency department were included.

MAIN OUTCOMES AND MEASURES

The primary outcome (adjudicated by 3 vascular neurologists) was RCVE: neurological deterioration in the absence of a medical explanation or recurrent TIA-S during hospitalization.

RESULTS

Of the 1258 total patients, 1187 had no RCVEs and 71 had RCVEs; of this group, 750 patients (63.2%) and 39 patients (54.9%), respectively, were aged 60 years or older. There were 505 patients with TIA-S at Columbia University; 31 (6.1%) had RCVEs (15 patients had neurological deterioration only, 11 had recurrent TIA-S only, and 5 had both). The validation cohort at Tulane University consisted of 753 patients; 40 (5.3%) had RCVEs (24 patients had neurological deterioration only and 16 had both). Predictors of RCVE in multivariate models in both cohorts were infarct on neuroimaging (computed tomographic scan or diffusion-weighted imaging sequences on magnetic resonance imaging) (Columbia University: not applicable and Tulane University: odds ratio, 1.75; 95% CI, 0.82-3.74; P = .15) and large-vessel disease etiology (Columbia University: odds ratio, 6.69; 95% CI, 3.10-14.50 and Tulane University: odds ratio, 8.13; 95% CI, 3.86-17.12; P < .001). There was an increase in the percentage of patients with RCVEs when both predictors were present. When neither predictor was present, the rate of RCVE was extremely low (up to 2%). Patients with RCVEs were less likely to be discharged home in both cohorts.

CONCLUSIONS AND RELEVANCE

In patients with minor stroke, vessel imaging and perhaps neuroimaging parameters, but not clinical scores, were associated with RCVEs in 2 independent data sets. Prospective studies are needed to validate these predictors.

Acute Stroke and Transient Ischemic Attack in the Outpatient Clinic

Ischemic stroke is cause of substantial death and disability in the United States. Transient ischemic attack, a precursor to ischemic stroke, conveys a high risk of recurrent stroke within 90 days from event. These conditions are highly preventable and treatable. The cause is heterogenous and includes atherothrombosis, cardioembolism, lacunar disease, or cryptogenic, and some uncommon causes, such as arterial dissection and prothrombotic states. The emergent evaluation includes establishing time of onset, vital signs, glucose level, and severity of the deficit.

ABCD2 risk score does not predict the presence of cerebral microemboli in patients with hyper-acute symptomatic critical carotid artery stenosis

Introduction

ABCD² risk score and cerebral microemboli detected by transcranial Doppler (TCD) have been separately shown to the predict risk of recurrent acute stroke. We studied whether ABCD² risk score predicts cerebral microemboli in patients with hyper-acute symptomatic carotid artery stenosis.

Participants and methods

We studied 206 patients presenting within 2 weeks of transient ischaemic attack or minor stroke and found to have critical carotid artery stenosis (≥50%). 86 patients (age 70±1 (SEM: years), 58 men, 83 Caucasian) had evidence of microemboli; 72 (84%) of these underwent carotid endarterectomy (CEA). 120 patients (age 72±1 years, 91 men, 113 Caucasian) did not have microemboli detected; 102 (85%) of these underwent CEA. Data were analysed using X² and Mann–Whitney U tests and receiver operating characteristic (ROC) curves.

Results

140/206 (68%: 95% CI 61.63 to 74.37) patients with hyper-acute symptomatic critical carotid stenosis had an ABCD² risk score ≥4. There was no significant difference in the NICE red flag criterion for early assessment (ABCD² risk score ≥4) for patients with cerebral microemboli versus those without microemboli (59/86 vs 81/120 patients: OR 1.05 ABCD² risk score ≥4 (95% CI 0.58 to 1.90, p=0.867)). The ABCD² risk score was <4 in 27 of 86 (31%: 95% CI 21 to 41) embolising patients and in 39 of 120 (31%: 95% CI 23 to 39) without cerebral microemboli. After adjusting for pre-neurological event antiplatelet treatment (APT), area under the curve (AUC) of ROC for ABCD² risk score showed no prediction of cerebral microemboli (no pre-event APT, n=57: AUC 0.45 (95% CI 0.29 to 0.60, p=0.531); pre-event APT, n=147: AUC 0.51 (95% CI 0.42 to 0.60, p=0.804)).

Conclusions

The ABCD² score did not predict the presence of cerebral microemboli or carotid disease in over one-quarter of patients with symptomatic critical carotid artery stenosis. On the basis of NICE guidelines (refer early if ABCD² ≥4), assessment of high stroke risk based on ABCD² scoring may lead to inappropriate delay in urgent treatment in many patients.

High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack

Background and Purpose

Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD² scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD² scores, in-hospital ischemic events, and in-hospital treatments after TIA admission.

Methods

We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD² scores.

Results

Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD² scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD² score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20).

Conclusions

Higher ABCD² scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of ‘low-risk’ patients.

An institutional study of time delays for symptomatic carotid endarterectomy

OBJECTIVE

The aim of this study was to assess time delays between first cerebrovascular symptoms and carotid endarterectomy (CEA) at a single center and to systematically evaluate causes of these delays.

METHODS

Consecutive adult patients who underwent CEAs between January 2010 and September 2011 at a single university-affiliated center (Centre Hospitalier de l'Université Montréal-Hôtel-Dieu Hospital, Montreal) were identified from a clinical database and operative records. Covariates of interest were extracted from electronic medical records. Timing and nature of the first cerebrovascular symptoms were also documented. The first medical contact and pathway of referral were also assessed. When possible, the ABCD² score (age, blood pressure, clinical features, duration of symptoms, and diabetes) was calculated to calculate further risk of stroke. The nonparametric Wilcoxon test was used to assess differences in time intervals between two variables. The Kruskal-Wallis test was used to assess differences in time intervals in comparing more than two variables. A multivariate linear regression analysis was performed using covariates that were determined to be statistically significant in our sensitivity analyses.

RESULTS

The cohort consisted of 111 patients with documented symptomatic carotid stenosis undergoing surgical intervention. Thirty-nine percent of all patients were operated on within 2 weeks from the first cerebrovascular symptoms. The median time between the occurrence of the first neurologic symptom and the CEA procedure was 25 (interquartile range [IQR], 11-85) days. The patient-dependent delay, defined as the median delay between the first neurologic symptom and the first medical contact, was 1 (IQR, 0-14) day. The medical-dependent delay was defined as the time interval between the first medical contact and CEA. This included the delay between the first medical contact and the request for surgery consultation (median, 3 [IQR, 1-10] days). The multivariate regression model demonstrated that the emergency physician as referral source (P = .0002) was statistically significant for reducing CEA delay. Patients who were investigated as an outpatient (P = .02), first medical contact with a general practitioner (P = .0002), and hospital center I as referral center (P = .045) were also found to be statistically significant to extend CEA delay when the model was adjusted over all covariates. In this center, there was no correlation between ABCD² risk score and waiting time for surgery.

CONCLUSIONS

The majority of our cohort falls short of the recommended 2-week interval to perform CEA. Factors contributing to reduced CEA delay were presentation to an emergency department, in-patient investigations, and a stroke center where a vascular surgeon is available.

The Association Between Emergency Department Crowding and the Disposition of Patients With Transient Ischemic Attack or Minor Stroke

BACKGROUND

Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission.

OBJECTIVES

The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA.

METHODS

This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables.

RESULTS

The study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size.

CONCLUSIONS

These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.

Urgent carotid intervention is safe after thrombolysis for minor to moderate acute ischemic stroke

OBJECTIVE

Carotid intervention shortly after an acute neurologic ischemic event is being performed more frequently in stroke centers to reduce the risk of recurrent stroke. Thrombolysis with recombinant tissue plasminogen activator (tPA) is offered to select patients with ischemic stroke symptoms who present within 4.5 hours. However, there is a paucity of data as to whether tPA followed by urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS) has an increased risk of complications, particularly intracerebral hemorrhage (ICH). We sought to determine the periprocedural complications of urgently performed CEA or CAS following tPA.

METHODS

From January 2009 to January 2015, 762 patients underwent carotid interventions (CEA, n = 440; CAS, n = 322) at a tertiary referral center and 165 patients (21.6%) underwent an urgent CEA or CAS during the index hospitalization for an acute transient ischemic attack or stroke. We compared the effect of intravenous tPA on 30-day complications, including ICH. The χ(2) and Fisher exact tests were used to determine significance between groups.

RESULTS

During the 6-year period, 165 patients underwent urgent carotid interventions (CEA, n = 135; CAS, n = 30) for acute neurologic symptoms. Of these, 19% (31 patients [CEA, n = 25; CAS, n = 6]) had tPA for an acute stroke; the remaining (134 patients [CEA, n = 110; CAS, n = 24]) fell outside of the tPA time window. Most strokes were minor or moderate with a mean National Institutes of Health Stroke Scale (NIHSS) score of 6.6 (range, 0-19). The mean time to intervention for both groups was 2.4 days (0-15 days). The 30-day stroke, death, and myocardial infarction rates were 9.7% (3 of 31) for the tPA group compared with 4.5% (6 of 134) for the no-tPA group (P = .37). Including bleeding complications in these 30-day outcomes, there was no difference between the tPA (3 of 31) and the no-tPA cohorts (8 of 134; P = .43). In the tPA group, there were one ICH, one neck hematoma/death, and an additional death; in the no-tPA group, there were one ICH, two neck hematomas, one stroke, two myocardial infarctions, one ICH/death, and one additional death. No significant increased rates of bleeding were noted within the tPA group (2 of 31) compared with the no-tPA group (4 of 134; P = .32). Moreover, in the tPA cohort, more than half of the patients (17 of 31) underwent revascularization within 72 hours (CEA = 13; CAS = 4) with outcomes similar to those who underwent revascularization after 72 hours.

CONCLUSIONS

Thrombolysis followed by urgent CEA or CAS is not associated with an increased risk of complications in select patients who present with acute neurologic symptoms. Selection of patients is important; there was no ICH and only one death in each group for patients with minor to moderate ischemic stroke (NIHSS score <10).

ABCD2 score and secondary stroke prevention: meta-analysis and effect per 1,000 patients triaged

OBJECTIVE

Patients with TIA have high risk of recurrent stroke and require rapid assessment and treatment. The ABCD2 clinical risk prediction score is recommended for patient triage by stroke risk, but its ability to stratify by known risk factors and effect on clinic workload are unknown.

METHODS

We performed a systematic review and meta-analysis of all studies published between January 2005 and September 2014 that reported proportions of true TIA/minor stroke or mimics, risk factors, and recurrent stroke rates, dichotomized to ABCD2 score </≥4. We calculated the effect per 1,000 patients triaged on stroke prevention services.

RESULTS

Twenty-nine studies, 13,766 TIA patients (range 69-1,679), were relevant: 48% calculated the ABCD2 score retrospectively; few reported on the ABCD2 score's ability to identify TIA mimics or use by nonspecialists. Meta-analysis showed that ABCD2 ≥4 was sensitive (86.7%, 95% confidence interval [CI] 81.4%-90.7%) but not specific (35.4%, 95% CI 33.3%-37.6%) for recurrent stroke within 7 days. Additionally, 20% of patients with ABCD2 <4 had >50% carotid stenosis or atrial fibrillation (AF); 35%-41% of TIA mimics, and 66% of true TIAs, had ABCD2 score ≥4. Among 1,000 patients attending stroke prevention services, including the 45% with mimics, 52% of patients would have an ABCD2 score ≥4.

CONCLUSION

The ABCD2 score does not reliably discriminate those at low and high risk of early recurrent stroke, identify patients with carotid stenosis or AF needing urgent intervention, or streamline clinic workload. Stroke prevention services need adequate capacity for prompt specialist clinical assessment of all suspected TIA patients for correct patient management.

Hospital costs of ischemic stroke and TIA in the Netherlands

OBJECTIVES

There have been no ischemic stroke costing studies since major improvements were implemented in stroke care. We therefore determined hospital resource use and costs of ischemic stroke and TIA in the Netherlands for 2012.

METHODS

We conducted a retrospective cost analysis using individual patient data from a national diagnosis-related group registry. We analyzed 4 subgroups: inpatient ischemic stroke, inpatient TIA, outpatient ischemic stroke, and outpatient TIA. Costs of carotid endarterectomy and costs of an extra follow-up visit were also estimated. Unit costs were based on reference prices from the Dutch Healthcare Insurance Board and tariffs provided by the Dutch Healthcare Authority. Linear regression analysis was used to examine the association between hospital costs and various patient and hospital characteristics.

RESULTS

A total of 35,903 ischemic stroke and 21,653 TIA patients were included. Inpatient costs were €5,328 ($6,845) for ischemic stroke and €2,470 ($3,173) for TIA. Outpatient costs were €495 ($636) for ischemic stroke and €587 ($754) for TIA. Costs of carotid endarterectomy were €6,836 ($8,783). Costs of inpatient days were the largest contributor to hospital costs. Age, hospital type, and region were strongly associated with hospital costs.

CONCLUSIONS

Hospital costs are higher for inpatients and ischemic strokes compared with outpatients and TIAs, with length of stay (LOS) the most important contributor. LOS and hospital costs have substantially declined over the last 10 years, possibly due to improved hospital stroke care and efficient integrated stroke services.

Duration of symptom and ABCD2 score as predictors of risk of early recurrent events after transient ischemic attack: a hospital-based case series study

BACKGROUND

The aim of this study was to refine clinical risk factor stratification and make an optimal intervention plan to prevent ischemic stroke.

MATERIAL/METHODS

Clinical data, including diffusion-weighted imaging (DWI) findings, were collected in a cohort of hospitalized transient ischemic attack (TIA) patients from January 2010 to December 2011. Recurrent cerebrovascular events after TIA, including recurrent TIA, minor stroke, and major stroke, were identified by face-to-face follow-up. A multivariate, ordinal, logistic regression model was used to determine significant predictors of recurrent events.

RESULTS

Of 106 TIA patients, 24 (22.6%) had recurrent TIA and 20 (18.9%) had a stroke within 7 days. Hypertension, dyslipidemia, a history of ischemic stroke or TIA, and ABCD2 score were significantly associated with the recurrent events after TIA (P<0.001, P=0.02, P<0.001, P=0.02). Hypertension (RR=9.21; 95% CI, 3.07-27.61, P<0.001) and duration of symptom (RR=1.10; 95% CI, 1.02-1.17, P=0.01) as an item of ABCD2 score were highly predictive of the severity of recurrent events, whereas ABCD2 score as a whole (P=0.18) proved to be less strongly predictive.

CONCLUSIONS

A history of hypertension and long duration of symptom independently and significantly predict severe recurrent events after TIA within 7 days, but a high ABCD2 score was less strongly predictive of severe recurrent events.

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

BACKGROUND

Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.

OBJECTIVES

Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention?

DATA SOURCES

Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.

REVIEW METHODS

Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.

RESULTS

The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective.

LIMITATIONS

Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.

CONCLUSIONS

Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Can lower risk patients presenting with transient ischaemic attack be safely managed as outpatients?

This study aimed to examine outcome in low risk transient ischaemic attack (TIA) patients presenting to emergency departments (ED) in a regional Australian setting discharged on antiplatelet therapy with expedited neurology review. All patients presenting to Gosford or Wyong Hospital ED with TIA, for whom faxed referrals to the neurology department were received between October 2008 and July 2010, were included in this prospective cohort study. Classification of low risk was based on an age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score <4 and the absence of high risk features, including known carotid disease, crescendo TIA, or atrial fibrillation. Patients with ABCD2 scores > or =4 or with high risk features were discussed with the neurologist on call (a decision regarding discharge or admission was then made at the neurologist's discretion). Patients were investigated with a brain CT scan and/or CT angiography, routine pathology, and an electrocardiogram. All discharged patients were commenced on antiplatelet therapy and asked to follow up with their local medical officer within 7 days. The patients were contacted by the neurology department to arrange follow-up. Our primary outcome was the number of subsequent strokes occurring within 90 days. Of 200 discharged patients for whom referrals were received, three patients had a stroke within 90 days. None of these would have been prevented through hospitalisation. In conclusion, medical assessment, expedited investigation with immediate commencement of secondary prevention and outpatient neurology review may be a reasonable alternative to admission for low risk patients presenting to the ED with TIA.

Transient neurological attack before vertebrobasilar stroke

BACKGROUND

Patients with vertebrobasilar (VB) circulation ischemia can present with nonspecific symptoms, which complicate the distinction of transient ischemic attack (TIA) from other benign disorders. According to previously accepted classifications, typical TIA does not occur with VB symptom such as vertigo, diplopia, or dysarthria in isolation. However, there is a lack of evidence to support this hypothesis.

METHODS

This hospital-based study included 214 consecutive patients with acute ischemic VB stroke. We defined transient neurological attacks (TNAs) as temporary (<24h) episodes with neurological symptoms, and further divided them into TIA, nonspecific TNA, or other specific disorder groups. We investigated the incidence and clinical symptoms of TNAs within 3months prior to the stroke episode, and comparisons were made between patients with and without previous TNA history with respect to their background and stroke profiles.

RESULTS

Among 214 patients with VB stroke, 56 (26.2%) had previous TNAs. Six of them were diagnosed with other specific disorders and excluded from the analysis. The remaining 33 and 17 were diagnosed with TIA and nonspecific TNA, respectively. Twenty-one (42.0%) had attacks with a nonfocal symptom in isolation, and acute infarction in neuroimaging was confirmed in 4 of these patients. Vertigo was the most frequent nonspecific TNA symptom. Patients with prior TNA had a significantly higher rate of atherothrombotic stroke than those without TNA (40.0% vs. 21.5%, P=0.009).

CONCLUSIONS

A considerable fraction of TIAs due to VB circulation ischemia may be overlooked among clinically nonfocal TNAs.

Analysis of multiple risk factors for the recurrence of nondisabling stroke

BACKGROUND

Recurrent stroke is one of severe outcomes of transient ischemic attack (TIA) and minor ischemic stroke (MIS), which are collectively termed as nondisabling stroke. However, the association between multiple risk factors and nondisabling stroke has not been fully studied. Here, we aimed to identify predicative risk factors in TIA and MIS in order to prevent recurrent nondisabling stroke.

METHODS

We used logistic regression methods to analysis risk factors in 620 patients with TIA or MIS between August 2006 and january 2009 and followed up to 90 days. We selected 20 factors, including age, gender, body mass index (BMI), smoking and alcohol history, blood pressure, limb weakness, speech impairment, diabetes, ischemic brain lesions, previous history of stroke (> 24 hours), coronary atherosclerotic heart disease, cardiac function insufficiency, duration of symptoms of at least 1 hour, blood lipids, lysophosphatidic acid, C-reactive protein, atrial fibrillation, and carotid artery plaque in ultrasound examination.

RESULTS

We found that limb weakness, history of cerebrovascular events, and carotid artery plaque in ultrasound examination were risk factors of recurrent stroke within 14 days, whereas the factors for the recurrence within 90 days were duration of symptoms of at least 1 hour, speech impairment, limb weakness, BMI of at least 25 kg/m2, history of cerebrovascular events, and carotid artery plaque in ultrasound examination.

CONCLUSION

Six risk factors are associated with recurrent nondisabling stroke, including symptom duration of at least 1 hour, speech impairment, limb weakness, BMI of at least 25 kg/m2, history of cerebrovascular events, and carotid artery plaque in ultrasound examination. Thus, identification and prevention of these risk factors may reduce recurrent stroke.

Assessment of ABCD² scale in patients with transient ischaemic attack or stroke

BACKGROUND AND PURPOSE

Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in patients with transient ischaemic attack (TIA) or minor ischaemic stroke (MIS).

MATERIAL AND METHODS

Consecutive patients with TIA or MIS referring to Ghaem Hospital, Mashhad presenting within 24 hours from the onset of symptoms were recruited to the prospective cohort study between 2010 and 2011. MIS was defined as an ischaemic stroke with National Institutes of Health Stroke Scale (NIHSS) score < 4. The end-point of the study was a new ischaemic cerebrovascular event or vascular death at 90 days and, additionally, at 3 days after the index TIA or MIS. The decision to admit and of method of treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD2 scoring system for recurrent stroke or TIA was quantified by the area under the curve (AUC), using the c-statistics.

RESULTS

The study included 393 patients with TIA (238 males, 155 females) and 118 patients with MIS (77 males, 41 females). Among 511 patients with minor ischaemic events, 117 strokes (23.2%), 99 TIAs (19.6%), and 11 vascular deaths (2.2%) occurred within 3 months after the index event. The ABCD2 score had a weak predictive value for 3-month and 3-day recurrent stroke in patients with TIA (AUC = 0.599 and 0.591, respectively), but a high predictive value for 3-month and 3-day recurrent stroke in patients with MIS (AUC = 0.727 and 0.728, respectively).

CONCLUSION

The ABCD2 score is highly predictive for short-term recurrent stroke in patients with MIS but not in patients with TIA, although it was originally designed for patients with TIA.

The ABCD(2) Score is Highly Predictive of Stroke in Minor Ischemic Stroke Patients

Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in transient ischemic attack (TIA) and minor ischemic stroke (MIS) patients. Consecutive TIA or MIS patients referred to Ghaem Hospital, Mashhad were enrolled in a prospective cohort study during 2010-2011. Only TIA or MIS patients presenting within 24 h from the onset of symptoms were recruited. MIS was considered as ischemic stroke with NIHSS <4. The end point of the study was a new ischemic cerebrovascular event or vascular death at 90 days and additionally at 3 days. The decision to admit and treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD(2) scoring system for recurrent stroke or TIA was quantified by the area under the cure (AUC) using the c statistics. Three hundred ninety-three TIA patients (238 males, 155 females) and 118 MIS patients (77 males, 41 females) were enrolled in the study. One hundred seventeen strokes (23.2%), 99 TIA (19.6%), and 11 vascular death (2.2%) occurred within 3 months postevent in the whole of our 511 patients with minor ischemic events. The ABCD(2) score had a weak predictive value for 3 months and 3 days recurrent stroke in our TIA patients (AUC = 0.599, AUC = 0.591), but a high predictive value for 3 months and 3 days recurrent stroke in our MIS patients (AUC = 0.727, AUC = 0.728), respectively. The ABCD(2) score is highly predictive of short-term recurrent stroke in MIS patients but not TIA cases, despite its creation for TIA cohorts.

Medical treatment in acute and long-term secondary prevention after transient ischaemic attack and ischaemic stroke

Stroke is a major cause of death and disability worldwide. Without improvements in prevention, the burden will increase during the next 20 years because of the ageing population, especially in developing countries. Major advances have occurred in secondary prevention during the past three decades, which demonstrate the broader potential to prevent stroke. We review the main medical treatments that should be considered for most patients with transient ischaemic attack or ischaemic stroke in the acute phase and the long term, and draw attention to recent developments.