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Shahjouei S, Li J, Koza E, Abedi V, Sadr AV, Chen Q, Mowla A, Griffin P, Ranta A, Zand R. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2136644. [PMID: 34985520 PMCID: PMC8733831 DOI: 10.1001/jamanetworkopen.2021.36644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome. OBJECTIVE To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting. DATA SOURCES MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020. STUDY SELECTION Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer. DATA EXTRACTION AND SYNTHESIS The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models. MAIN OUTCOMES AND MEASURES Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days). RESULTS The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.
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Affiliation(s)
- Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
- Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Alireza Vafaei Sadr
- Department de Physique Theorique and Center for Astroparticle Physics, University Geneva, Geneva, Switzerland
| | - Qiushi Chen
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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Shahjouei S, Sadighi A, Chaudhary D, Li J, Abedi V, Holland N, Phipps M, Zand R. A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 78:77-87. [PMID: 33044505 DOI: 10.1001/jamaneurol.2020.3627] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Shima Shahjouei
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Alireza Sadighi
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Durgesh Chaudhary
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania.,Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Neil Holland
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Michael Phipps
- Department of Neurology, University of Maryland, Baltimore
| | - Ramin Zand
- Department of Neurology, Geisinger Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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Purroy F, Vicente-Pascual M, Arque G, Baraldes-Rovira M, Begue R, Gallego Y, Gil MI, Gil-Villar MP, Mauri G, Quilez A, Sanahuja J, Vazquez-Justes D. Sex-Related Differences in Clinical Features, Neuroimaging, and Long-Term Prognosis After Transient Ischemic Attack. Stroke 2021; 52:424-433. [PMID: 33493055 PMCID: PMC7834662 DOI: 10.1161/strokeaha.120.032814] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Differences in sex in the incidence, presentation, and outcome of events after ischemic stroke have been studied in depth. In contrast, only limited data are available after transient ischemic attack (TIA). We aim to assess sex-related differences in the presentation, cause, neuroimaging features, and predictors of long-term prognosis in patients with TIA.
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Affiliation(s)
- Francisco Purroy
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Mikel Vicente-Pascual
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Gloria Arque
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Mariona Baraldes-Rovira
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Robert Begue
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Yhovany Gallego
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - M Isabel Gil
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - M Pilar Gil-Villar
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Gerard Mauri
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Alejandro Quilez
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Jordi Sanahuja
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
| | - Daniel Vazquez-Justes
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P., M.V.-P., M.B.-R., Y.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.). Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Spain (F.P., M.V.-P., G.A., R.B., M.I.G., M.P.G.-V., G.M., A.Q., J.S., D.V.-J.)
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Uehara T, Minematsu K, Ohara T, Kimura K, Okada Y, Hasegawa Y, Tanahashi N, Suzuki A, Takagi S, Nakagawara J, Arii K, Nagahiro S, Ogasawara K, Uchiyama S, Matsumoto M, Iihara K, Toyoda K. Incidence, predictors, and etiology of subsequent ischemic stroke within one year after transient ischemic attack. Int J Stroke 2016; 12:84-89. [PMID: 27649736 DOI: 10.1177/1747493016669884] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Incidence and predictors of ischemic stroke in patients with transient ischemic attack (TIA) have not been fully clarified outside Europe and North America. Aims We undertook the present prospective, multicenter study to clarify the incidence, predictors, and etiology of ischemic stroke within one year of TIA onset in Japan. Methods The study subjects were patients within seven days of TIA onset who were enrolled in a prospective register from 57 hospitals between June 2011 and December 2013. The primary endpoint was occurrence of ischemic stroke. Results Of 1365 consecutive patients, 1245 were followed for one year after TIA onset; 101 (8.1%) experienced ischemic stroke during follow-up. The leading subtype of ischemic stroke was small-vessel occlusion (SVO) followed by large-artery atherosclerosis (LAA) attributable to intracranial artery diseases. When dividing ischemic stroke events between those occurring within the first 90 days after TIA onset and those occurring after the first 90 days, the leading subtype of ischemic stroke within the first 90 days after TIA onset was SVO, followed by LAA attributable to intracranial artery diseases. In comparison, the subtypes most commonly seen beyond the first 90 days after TIA onset were cardioembolic and LAA attributable to intracranial artery disease. The one-year risk of ischemic stroke increased significantly as ABCD2 score increased, at 6.2% for 0-3 points, 7.2% for 4-5 points, and 11.6% for 6-7 points. Conclusions The one-year ischemic stroke risk after TIA was about 8% and was associated with the ABCD2 score. The most common subtype of subsequent ischemic stroke was SVO.
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Affiliation(s)
- Toshiyuki Uehara
- 1 Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuo Minematsu
- 1 Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoyuki Ohara
- 1 Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazumi Kimura
- 2 Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Yasushi Okada
- 3 Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yasuhiro Hasegawa
- 4 Department of Neurology, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Norio Tanahashi
- 5 Department of Neurology and Cerebrovascular Medicine, Saitama Medical University Saitama International Medical Center, Hidaka, Japan
| | - Akifumi Suzuki
- 6 Department of Stroke Science, Research Institute for Brain and Blood Vessels-Akita, Akita, Japan
| | | | - Jyoji Nakagawara
- 8 Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Kazumasa Arii
- 9 Department of Neurology, Ebara Hospital, Tokyo, Japan
| | - Shinji Nagahiro
- 10 Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Kuniaki Ogasawara
- 11 Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | | | - Masayasu Matsumoto
- 13 Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, Japan
| | - Koji Iihara
- 14 Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- 1 Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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