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Chaudhary D, Abedi V, Li J, Schirmer CM, Griessenauer CJ, Zand R. Clinical Risk Score for Predicting Recurrence Following a Cerebral Ischemic Event. Front Neurol 2019; 10:1106. [PMID: 31781015 PMCID: PMC6861423 DOI: 10.3389/fneur.2019.01106] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/02/2019] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Durgesh Chaudhary
- Neuroscience Institute, Geisinger Health System, Danville, PA, United States
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA, United States.,Biocomplexity Institute, Virginia Tech, Blacksburg, VA, United States
| | - Jiang Li
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA, United States
| | - Clemens M Schirmer
- Neuroscience Institute, Geisinger Health System, Danville, PA, United States.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Neuroscience Institute, Geisinger Health System, Danville, PA, United States.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Ramin Zand
- Neuroscience Institute, Geisinger Health System, Danville, PA, United States
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Penn AM, Croteau NS, Votova K, Sedgwick C, Balshaw RF, Coutts SB, Penn M, Blackwood K, Bibok MB, Saly V, Hegedus J, Yu AYX, Zerna C, Klourfeld E, Lesperance ML. Systolic blood pressure as a predictor of transient ischemic attack/minor stroke in emergency department patients under age 80: a prospective cohort study. BMC Neurol 2019; 19:251. [PMID: 31653207 PMCID: PMC6815025 DOI: 10.1186/s12883-019-1466-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elevated blood pressure (BP) at emergency department (ED) presentation and advancing age have been associated with risk of ischemic stroke; however, the relationship between BP, age, and transient ischemic attack/minor stroke (TIA/MS) is not clear. METHODS A multi-site, prospective, observational study of 1084 ED patients screened for suspected TIA/MS (symptom onset < 24 h, NIHSS< 4) between December 2013 and April 2016. Systolic and diastolic BP measurements (SBP, DBP) were taken at ED presentation. Final diagnosis was consensus adjudication by stroke neurologists; patients were diagnosed as either TIA/MS or stroke-mimic (non-cerebrovascular conditions). Conditional inference trees were used to define age cut-points for predicting binary diagnosis (TIA/MS or stroke-mimic). Logistic regression models were used to estimate the effect of BP, age, sex, and the age-BP interaction on predicting TIA/MS diagnosis. RESULTS Over a 28-month period, 768 (71%) patients were diagnosed with TIA/MS: these patients were older (mean 71.6 years) and more likely to be male (58%) than stroke-mimics (61.4 years, 41%; each p < 0.001). TIA/MS patients had higher SBP than stroke-mimics (p < 0.001). DBP did not differ between the two groups (p = 0.191). SBP was predictive of TIA/MS diagnosis in younger patients, after accounting for age and sex; an increase of 10 mmHg systolic increased the odds of TIA/MS 18% (odds ratio [OR] 1.18, 95% CI 1.00-1.39) in patients < 60 years, and 23% (OR 1.23, 95% CI 11.12-1.35) in those 60-79 years, while not affecting the odds of TIA/MS in patients ≥80 years (OR 0.99, 95% CI 0.89-1.07). CONCLUSIONS Raised SBP in patients younger than 80 with suspected TIA/MS may be a useful clinical indicator upon initial presentation to help increase clinicians' suspicion of TIA/MS. TRIAL REGISTRATION ClinicalTrials.gov NCT03050099 (10-Feb-2017) and NCT03070067 (3-Mar-2017). Retrospectively registered.
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Affiliation(s)
- Andrew M Penn
- Stroke Rapid Assessment Unit, Island Health, Victoria, BC, Canada
| | - Nicole S Croteau
- Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC, V8R1J8, Canada.,Department of Mathematics and Statistics, University of Victoria, Victoria, BC, Canada
| | - Kristine Votova
- Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC, V8R1J8, Canada. .,Division of Medical Sciences, University of Victoria, Victoria, BC, Canada.
| | - Colin Sedgwick
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
| | - Robert F Balshaw
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Shelagh B Coutts
- Departments of Clinical Neurosciences, Radiology, and Community Health Services, Hotchkiss Brain Institute, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Melanie Penn
- Stroke Rapid Assessment Unit, Island Health, Victoria, BC, Canada
| | - Kaitlin Blackwood
- Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC, V8R1J8, Canada
| | - Maximilian B Bibok
- Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC, V8R1J8, Canada
| | - Viera Saly
- Stroke Rapid Assessment Unit, Island Health, Victoria, BC, Canada
| | - Janka Hegedus
- Stroke Rapid Assessment Unit, Island Health, Victoria, BC, Canada.,Departments of Clinical Neurosciences, Radiology, and Community Health Services, Hotchkiss Brain Institute, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Amy Y X Yu
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Charlotte Zerna
- Departments of Clinical Neurosciences, Radiology, and Community Health Services, Hotchkiss Brain Institute, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Evgenia Klourfeld
- Departments of Clinical Neurosciences, Radiology, and Community Health Services, Hotchkiss Brain Institute, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Mary L Lesperance
- Department of Mathematics and Statistics, University of Victoria, Victoria, BC, Canada
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3
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Betts MB, Milev S, Hoog M, Jung H, Milenković D, Qian Y, Tai MH, Kutikova L, Villa G, Edwards C. Comparison of Recommendations and Use of Cardiovascular Risk Equations by Health Technology Assessment Agencies and Clinical Guidelines. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:210-219. [PMID: 30711066 DOI: 10.1016/j.jval.2018.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 05/14/2018] [Accepted: 08/11/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To identify risk equations for cardiovascular diseases (CVDs) in primary and secondary prevention settings that are used or recommended by health technology assessment (HTA) organizations and in clinical guidelines (CGs). METHODS A targeted literature review was conducted using a two-stage search strategy. First, HTA reviews of manufacturers' drug submissions, reports from established HTA organizations (Europe, Canada, and Australia), and CGs from countries with and without HTA organizations, including the United States, were identified. Documents published between September 30, 2006 and September 30, 2016, were examined for cardiovascular risk equations, recommendations, and commentaries. Next, publications associated with risk equations and cited by HTA and CG documents were retrieved. This literature was examined to extract commentaries and risk equation study characteristics. RESULTS The review identified 47 risk equations, 25 in the primary CVD prevention setting (i.e., patients with no CVD history), including 5 for CVD prevention in diabetes and 22 solely in secondary prevention settings; 11 were identified for heart failure, 3 for stroke or transient ischemic attack, 2 for stable angina, and 11 for acute coronary syndrome or related conditions. A small set of primary prevention equations was found to be commonly used by HTAs, whereas secondary prevention equations were less common in HTA documents. CGs provided more risk equations as options than HTA documents. CONCLUSIONS Although there is an abundance of risk equations developed for primary and secondary prevention, there remains a need for additional research to provide sufficient clinical and HTA guidance for risk estimation, particularly in high-risk or secondary prevention settings.
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Affiliation(s)
| | | | | | | | | | - Yi Qian
- Amgen, Inc., Thousand Oaks, CA, USA
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4
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Lodha N, Harrell J, Eisenschenk S, Christou EA. Motor Impairments in Transient Ischemic Attack Increase the Odds of a Subsequent Stroke: A Meta-Analysis. Front Neurol 2017. [PMID: 28638365 PMCID: PMC5461338 DOI: 10.3389/fneur.2017.00243] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background and purpose Transient ischemic attack (TIA) increases the risk for a subsequent stroke. Typical symptoms include motor weakness, gait disturbance, and loss of coordination. The association between the presence of motor impairments during a TIA and the chances of a subsequent stroke has not been examined. In the current meta-analysis, we examine whether the odds of a stroke are greater in TIA individuals who experience motor impairments as compared with those who do not experience motor impairments. Methods We conducted a systematic search of electronic databases as well as manual searches of the reference lists of retrieved articles. The meta-analysis included studies that reported an odds ratio relating motor impairments to a subsequent stroke, or the number of individuals with or without motor impairments who experienced a subsequent stroke. We examined these studies using rigorous meta-analysis techniques including random effects model, forest and funnel plots, I2, publication bias, and fail-safe analysis. Results Twenty-four studies with 15,129 participants from North America, Australia, Asia, and Europe qualified for inclusion. An odds ratio of 2.11 (95% CI, 1.67–2.65, p = 0.000) suggested that the chances of a subsequent stroke are increased by twofolds in individuals who experience motor impairments during a TIA compared with those individuals who have no motor impairments. Conclusion The presence of motor impairments during TIA is a significantly high-risk clinical characteristic for a subsequent stroke. The current evidence for motor impairments following TIA relies exclusively on the clinical reports of unilateral motor weakness. A comprehensive examination of motor impairments in TIA will enhance TIA prognosis and restoration of residual motor impairments.
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Affiliation(s)
- Neha Lodha
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, United States
| | - Jane Harrell
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, United States
| | - Stephan Eisenschenk
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Evangelos A Christou
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, United States
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5
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Long B, Koyfman A. Best Clinical Practice: Controversies in Transient Ischemic Attack Evaluation and Disposition in the Emergency Department. J Emerg Med 2017; 52:299-310. [DOI: 10.1016/j.jemermed.2016.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 02/07/2023]
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Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department. Ann Emerg Med 2016; 68:354-370.e29. [DOI: 10.1016/j.annemergmed.2016.06.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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7
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Cocho D, Monell J, Planells G, Ricciardi A, Pons J, Boltes A, Espinosa J, Ayats M, Garcia N, Otermin P. Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2014.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P, Dennis M. 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. Health Technol Assess 2014; 18:1-368, v-vi. [PMID: 24791949 DOI: 10.3310/hta18270] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Miriam Brazzelli
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hector Miranda
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zahid Quayyum
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Duncan Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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9
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Cocho D, Monell J, Planells G, Ricciardi AC, Pons J, Boltes A, Espinosa J, Ayats M, Garcia N, Otermin P. Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death. Neurologia 2014; 31:18-23. [PMID: 25261166 DOI: 10.1016/j.nrl.2014.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/25/2014] [Accepted: 05/29/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. METHODS Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. RESULTS We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. CONCLUSIONS In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.
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Affiliation(s)
- D Cocho
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España.
| | - J Monell
- Servicio de Cardiología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - G Planells
- Servicio de Urgencias Médicas, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - A C Ricciardi
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - J Pons
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - A Boltes
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - J Espinosa
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - M Ayats
- Servicio de Cardiología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - N Garcia
- Servicio de Urgencias Médicas, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - P Otermin
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
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Gupta HV, Farrell AM, Mittal MK. Transient ischemic attacks: predictability of future ischemic stroke or transient ischemic attack events. Ther Clin Risk Manag 2014; 10:27-35. [PMID: 24476667 PMCID: PMC3891764 DOI: 10.2147/tcrm.s54810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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.
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Affiliation(s)
- Harsh V Gupta
- Department of Neurology, The University of Arkansas Medical Sciences, Little Rock, AR
| | - Ann M Farrell
- Department of Knowledge and Evaluation Research, Mayo Clinic, Rochester, MN
| | - Manoj K Mittal
- Department of Neurology, The University of Kansas Medical Center, Kansas City, KS, USA
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Durrani-Tariq S, Eskin B, Allegra JR. Admission rates of ED patients with transient ischemic attack have increased since 2000. Am J Emerg Med 2013; 31:1349-51. [PMID: 23906624 DOI: 10.1016/j.ajem.2013.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 06/01/2013] [Accepted: 06/06/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE A study published in December 2000 showed that 5% of patients presenting with transient ischemic attacks (TIAs) developed a stroke within 48 hours. This finding has been corroborated in several other studies. We hypothesize that, influenced by this, emergency department (ED) physicians have been more reluctant to discharge TIA patients resulting in an increase in the percentage of TIA patients admitted. METHODS This is a retrospective cohort of consecutive ED visits. This study is conducted in 6 New Jersey EDs with annual ED visits from 25000 to 65000. Consecutive patients seen by ED physicians between January 1, 2000, and December 31, 2010, were included. We identified TIA visits using the International Classification of Diseases, Ninth Revision, code. We analyzed the admission rates for TIA testing for significant differences using the Student t test and calculated 95% confidence intervals. RESULTS Of the 2622659 visits in the database, 8216 (0.3%) were for TIA. Females comprised 57%. There was a statistically significant increase in the annual admission rates for TIA patients from 2000 to 2010, from 70% to 91%, respectively (difference, 22%; 95% confidence interval, 18%-26% [P < .001]). Separate analysis by sex showed similar increased admission rates for females and males. CONCLUSIONS We found that the admission rate for TIAs increased significantly from 2001 to 2010. This change in physicians' practice may be due to the body of evidence that TIA patients have a significant short-term risk of stroke.
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Affiliation(s)
- Siama Durrani-Tariq
- Morristown Medical Center Residency in Emergency Medicine, Emergency Medical Associates Research Foundation, Morristown, NJ, USA
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12
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Lemmens R, Smet S, Thijs VN. Clinical scores for predicting recurrence after transient ischemic attack or stroke: how good are they? Stroke 2013; 44:1198-203. [PMID: 23482596 DOI: 10.1161/strokeaha.111.000141] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Robin Lemmens
- Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium.
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Chatzikonstantinou A, Wolf ME, Schaefer A, Hennerici MG. Risk Prediction of Subsequent Early Stroke in Patients with Transient Ischemic Attacks. Cerebrovasc Dis 2013; 36:106-9. [DOI: 10.1159/000352060] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 05/10/2013] [Indexed: 11/19/2022] Open
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Assessment of ABCD² scale in patients with transient ischaemic attack or stroke. Neurol Neurochir Pol 2012; 46:421-7. [PMID: 23161185 DOI: 10.5114/ninp.2012.31351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Ghandehari K, Ahmadi F, Ebrahimzadeh S, Shariatinezhad K, Ghandehari K. The ABCD(2) Score is Highly Predictive of Stroke in Minor Ischemic Stroke Patients. Transl Stroke Res 2012; 3:273-8. [PMID: 24323783 DOI: 10.1007/s12975-012-0146-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 02/08/2012] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Kavian Ghandehari
- Neuroscience Research Center, Mashhad University of Medical Sciences (MUMS), Mashhad, Iran,
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Stroke. Neurology 2012. [DOI: 10.1007/978-0-387-88555-1_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Prasad K, Kaul S, Padma MV, Gorthi SP, Khurana D, Bakshi A. Stroke management. Ann Indian Acad Neurol 2011; 14:S82-96. [PMID: 21847335 PMCID: PMC3152174 DOI: 10.4103/0972-2327.83084] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Indexed: 01/13/2023] Open
Affiliation(s)
- Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Cancelli I, Janes F, Gigli GL, Perelli A, Zanchettin B, Canal G, D'Anna L, Russo V, Barbone F, Valente M. Incidence of Transient Ischemic Attack and Early Stroke Risk. Stroke 2011; 42:2751-7. [DOI: 10.1161/strokeaha.110.612705] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The importance of transient ischemic attack (TIA) lies on the short-term risk of stroke, and the ABCD2 score may improve early stroke risk prediction. However, population-based studies are still needed. We aimed to provide data on TIA incidence and to evaluate the ABCD2 predictive ability for early recurrent stroke in a population-based study.
Methods—
This study is part of a 2-year prospective community-based registry of all cerebrovascular events in the district of Udine (153 312 inhabitants), Friuli Venezia Giulia region, northeast of Italy, between April 1, 2007 and March 31, 2009. Multiple overlapping sources for finding cases were used, combining hot and cold pursuit.
Results—
We identified 178 TIA, 161 (90.4%) of which were incident. The crude overall annual TIA incidence rate per 1000 residents was 0.52 (95% confidence interval [CI], 0.45–0.61). Incidence rate was 0.45 (95% CI, 0.31–0.65) when standardized to the 2007 Italian population and 0.25 (95% CI, 0.16–0.39) when standardized to the European standard population. Estimates of stroke risk after the index TIA within 2, 7, 30, and 90 days were, respectively, 2.5% (95% CI, 0.7–6.2), 5.6% (95% CI, 2.6–10.3), 6.2% (95% CI, 3.0–11.1), and 11.2% (95% CI, 6.8–17.1). ABCD2 score was strongly associated with stroke occurrence after index TIA: the areas under the receiver operating characteristic curve at 2, 7, 30, and 90 days were, respectively, 0.85 (95% CI, 0.72–0.97), 0.69 (95% CI, 0.56–0.82), 0.69 (95% CI, 0.56–0.85), and 0.76 (95% CI, 0.67–0.86). No patients with an ABCD2 score <4 had a stroke within the 90-day follow-up period.
Conclusions—
This study adds new data on TIA incidence and prognosis and it further validates the ability of the ABCD2 score to identify patients at early risk for stroke.
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Affiliation(s)
- Iacopo Cancelli
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Francesco Janes
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Gian Luigi Gigli
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Anna Perelli
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Barbara Zanchettin
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Giessica Canal
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Lucio D'Anna
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Valentina Russo
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Fabio Barbone
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
| | - Mariarosaria Valente
- From the Department of Neurosciences (I.C., F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., M.V.), “S. Maria della Misericordia” University Hospital, Udine, Italy; Department of Experimental and Clinical Medicine (F.J., G.L.G., A.P., B.Z., G.C., L.D., V.R., F.B., M.V.), University of Udine Medical School, Udine, Italy
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Bhatt A, Jani V. The ABCD and ABCD2 Scores and the Risk of Stroke following a TIA: A Narrative Review. ISRN NEUROLOGY 2011; 2011:518621. [PMID: 22389822 PMCID: PMC3263538 DOI: 10.5402/2011/518621] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 04/10/2011] [Indexed: 12/03/2022]
Abstract
The California, ABCD, and ABCD2 risk scores (ABCD system) were developed to help stratify short-term stroke risk in patients with TIA (transient ischemic attack). Beyond this scope, the ABCD system has been extensively used to study other prognostic information such as DWI (diffusion-weighted imaging) abnormalities, large artery stenosis, atrial fibrillation and its diagnostic accuracy in TIA patients, which are independent predictors of subsequent stroke in TIA patients. Our comprehensive paper suggested that all scores have and equivalent prognostic value in predicting short-term risk of stroke; however, the ABCD2 score is being predominantly used at most centers. The majority of studies have shown that more than half of the strokes in the first 90 days, occur in the first 7 days. The majority of patients studied were predominantly classified to have a higher ABCD/ABCD2 > 3 scores and were particularly at a higher short-term risk of stroke or TIA and other vascular events. However, patients with low risk ABCD2 score < 4 may have high-risk prognostic indicators, such as diffusion weighted imaging (DWI) abnormalities, large artery atherosclerosis (LAA), and atrial fibrillation (AF). The prognostic value of these scores improved if used in conjunction with clinical information, vascular imaging data, and brain imaging data. Before more data become available, the diagnostic value of these scores, its applicability in triaging patients, and its use in evaluating long-term prognosis are rather secondary; thus, indicating that the primary significance of these scores is for short-term prognostic purposes.
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Affiliation(s)
- Archit Bhatt
- Spectrum Health, Grand Rapids, MI 49503, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI 49503, USA
| | - Vishal Jani
- Department of Neurology, Michigan State University, East Lansing, MI 48824-1046, USA
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Bonifati DM, Lorenzi A, Ermani M, Refatti F, Gremes E, Boninsegna C, Filipponi S, Orrico D. Carotid stenosis as predictor of stroke after transient ischemic attacks. J Neurol Sci 2011; 303:85-9. [DOI: 10.1016/j.jns.2011.01.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 12/06/2010] [Accepted: 01/07/2011] [Indexed: 11/30/2022]
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Transient ischemic attack evaluation models: hospitalization, same-day clinics, or rapid evaluation units. Am J Ther 2011; 18:45-50. [PMID: 20634680 DOI: 10.1097/mjt.0b013e3181e4a671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transient ischemic attack (TIA) has been well established as a risk factor for future stroke. Therefore, the diagnosis of TIA may serve as a golden opportunity for providing early time sensitive therapies to this high-risk group. Currently, there is no standardized algorithm for triaging suspected TIA, leading to errors in diagnosis, significant delays in evaluation and treatment, and greater morbidity and mortality. There are several proposed methods for triaging patients: hospitalization, same-day clinics, and rapid evaluation units. We review the benefits and limitations for each model, focusing on stroke risk reduction, costs, and feasibility.
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Harrison JK, Sloan B, Dawson J, Lees KR, Morrison DS. The ABCD and ABCD2 as predictors of stroke in transient ischemic attack clinic outpatients: a retrospective cohort study over 14 years. QJM 2010; 103:679-85. [PMID: 20601651 DOI: 10.1093/qjmed/hcq108] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The ABCD and ABCD2 scores have been validated for use as predictors of stroke in community populations up to 90 days after a transient ischemic attack (TIA). TIA outpatient clinics may see a selective group of patients who have not had an early stroke but may be at raised risk in the medium to long term and therefore benefit from preventive treatment. AIM To describe the prognostic values of the ABCD and ABCD2 scores on long-term stroke risk. DESIGN Retrospective cohort study of TIA clinic outpatients followed for up to 14 years. METHODS Absolute and relative stroke risks, Kaplan-Meier survival curves and cumulative stroke incidence were calculated. Receiver Operating Characteristic curves (ROCs) and areas under the curve were calculated for both scores. RESULTS Seven hundred and ninety-five patients were included and 138 (17.3%) experienced a stroke within 13.8 years follow-up after first TIA clinic visit, a crude risk of 26.3 per 1000 person-years. Compared with baseline scores of 0-2, risk ratios for ABCD of 3-4 were 2.95 (95% CI 1.52-6.40), and for 5-6 were 3.42 (95% CI 1.72-7.54); for the ABCD2, risk ratios for 3-4 were 2.68 (95% CI 1.37-5.84), and for 5-7 were 3.55 (95% CI 1.80-7.79). Scores of > or = 3 for either ABCD or ABCD2 predicted raised stroke risks at 90 days, 1, 5 and 10 years. Areas under the curve were 0.619 (95% CI 0.571-0.668) and 0.630 (95% CI 0.582-0.677) for the ABCD and ABCD2 scores, respectively. CONCLUSION ABCD and ABCD2 scores of > or = 3 may be clinically useful in identifying TIA outpatients at raised risk of stroke in the medium to long term.
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Affiliation(s)
- J K Harrison
- Division of Community Based Sciences, Faculty of Medicine, University of Glasgow, Glasgow G12 8RZ, UK
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Srikanth V, Sanders L, Phan TG. Current validity of the ABCD2 score for acute risk stratification of transient ischaemic attack patients is uncertain. Intern Med J 2010; 40:469-70; author reply 470-1. [DOI: 10.1111/j.1445-5994.2010.02200.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lou M, Safdar A, Edlow JA, Caplan L, Kumar S, Schlaug G, Searls DE, Goddeau RP, Selim M. Can ABCD score predict the need for in-hospital intervention in patients with transient ischemic attacks? Int J Emerg Med 2010; 3:75-80. [PMID: 20606814 PMCID: PMC2885258 DOI: 10.1007/s12245-010-0176-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Accepted: 03/01/2010] [Indexed: 12/15/2022] Open
Abstract
Background The ABCD2 score is increasingly being used to triage patients with transient ischemic attack (TIA). Whether the score can predict the need for in-hospital intervention (IHI), other than initiation of antiplatelets and statins, is unknown. Aims The ability of the ABCD2 score to predict IHI would strengthen the rationale to use it as a decision-making tool. We thus conducted this study to investigate the relationship between the ABCD2 score and IHI. Methods We analyzed prospectively collected data from consecutive TIA patients over 12 months. We determined ABCD2 upon admission and collected the results of in-hospital evaluation, treatments initiated during hospitalization, and follow-up status. We defined IHI as arterial revascularization or anticoagulation required during admission. We used chi-square for trend to examine the association between ABCD2 and IHI. Results We studied 121 patients. Fourteen (12%) had small infarcts on diffusion magnetic resonance imaging; 38 (31%) had a new risk factor recognized during admission [hyperlipidemia (n = 9), hypertension (1), diabetes (1), carotid stenosis ≥ 50% (16), other arterial occlusive lesions (7), and potential cardioembolic source (4)]. Their percentages increased with higher ABCD2 scores. However, among 12 patients (10%) with IHI, ABCD2 score categories were equally distributed (10% in 0–3, 9% in 4–5, and 10% in 6–7; p = 0.8). One patient (0.8%) worsened during hospitalization; none had a stroke during follow-up. Conclusion Patients with an ABCD2 score ≤ 3 had an equal chance of requiring IHI as those with a score of 4–7. The decision to admit TIA patients based on the ABCD2 score alone is not supported by our experience and requires further study.
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Affiliation(s)
- Min Lou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, Hangzhou, People’s Republic of China
| | - Adnan Safdar
- Department of Neurology–Stroke Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue–Palmer 127, Boston, MA 02215 USA
| | - Jonathan A. Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Louis Caplan
- Department of Neurology–Stroke Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue–Palmer 127, Boston, MA 02215 USA
| | - Sandeep Kumar
- Department of Neurology–Stroke Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue–Palmer 127, Boston, MA 02215 USA
| | - Gottfried Schlaug
- Department of Neurology–Stroke Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue–Palmer 127, Boston, MA 02215 USA
| | - D. Eric Searls
- Department of Neurology–Stroke Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue–Palmer 127, Boston, MA 02215 USA
| | - Richard P. Goddeau
- Department of Neurology–Stroke Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue–Palmer 127, Boston, MA 02215 USA
| | - Magdy Selim
- Department of Neurology–Stroke Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue–Palmer 127, Boston, MA 02215 USA
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Chandratheva A, Geraghty OC, Luengo-Fernandez R, Rothwell PM. ABCD
2
Score Predicts Severity Rather Than Risk of Early Recurrent Events After Transient Ischemic Attack. Stroke 2010; 41:851-6. [PMID: 20299668 DOI: 10.1161/strokeaha.109.570010] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Arvind Chandratheva
- From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Oxford University Department of Clinical Neurology, John Radcliffe Hospital, and the Health Economics Research Centre (R.L.-F.), Oxford University Department of Public Health, Oxford, England
| | - Olivia C. Geraghty
- From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Oxford University Department of Clinical Neurology, John Radcliffe Hospital, and the Health Economics Research Centre (R.L.-F.), Oxford University Department of Public Health, Oxford, England
| | - Ramon Luengo-Fernandez
- From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Oxford University Department of Clinical Neurology, John Radcliffe Hospital, and the Health Economics Research Centre (R.L.-F.), Oxford University Department of Public Health, Oxford, England
| | - Peter M. Rothwell
- From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Oxford University Department of Clinical Neurology, John Radcliffe Hospital, and the Health Economics Research Centre (R.L.-F.), Oxford University Department of Public Health, Oxford, England
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Tsivgoulis G, Heliopoulos I. Potential and Failure of the ABCD
2
Score in Stroke Risk Prediction After Transient Ischemic Attack. Stroke 2010; 41:836-8. [DOI: 10.1161/strokeaha.110.579169] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Georgios Tsivgoulis
- From the Department of Neurology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ioannis Heliopoulos
- From the Department of Neurology, Democritus University of Thrace, Alexandroupolis, Greece
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Giles MF, Rothwell PM. Systematic review and pooled analysis of published and unpublished validations of the ABCD and ABCD2 transient ischemic attack risk scores. Stroke 2010; 41:667-73. [PMID: 20185786 DOI: 10.1161/strokeaha.109.571174] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The ABCD system was derived to predict early risk of stroke after transient ischemic attack. Independent validations have reported conflicting results. We therefore systematically reviewed published and unpublished data to determine predictive value and generalizability to different clinical settings and users. METHODS Validations of the ABCD and ABCD2 scores were identified by searching electronic databases, reference lists, relevant journals, and conference abstracts. Unpublished tabulated data were obtained where available. Predictive value, expressed as pooled areas under the receiver operator characteristic curves (AUC), was calculated using random-effects meta-analysis, and analyses for heterogeneity were performed by categorization according to study setting and method. RESULTS Twenty cohorts were identified reporting the performance of the ABCD system in 9808 subjects with 456 strokes at 7 days. Among the 16 studies of both the ABCD and ABCD2 scores, pooled AUC for the prediction of stroke at 7 days were 0.72 (0.66 to 0.78) and 0.72 (0.63 to 0.82), respectively (P diff=0.97). The pooled AUC for the ABCD and ABCD2 scores in all cohorts reporting relevant data were 0.72 (0.67 to 0.77) and 0.72 (0.63 to 0.80), respectively (both P<0.001). Predictive value varied significantly between studies (P<0.001), but 75% of the variance was accounted for by study method and setting, with the highest pooled AUC for face-to-face clinical evaluation and the lowest for retrospective extraction of data from emergency department records. CONCLUSION Independent validations of the ABCD system showed good predictive value, with the exception of studies based on retrospective extraction of nonsystematically collected data from emergency department records.
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Affiliation(s)
- Matthew F Giles
- Stroke Prevention Research Unit, NIHR Biomedical Research Centre, Oxford University Department of Clinical Neurology, John Radcliffe Hospital, Oxford , UK.
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Asimos AW, Johnson AM, Rosamond WD, Price MF, Rose KM, Catellier D, Murphy CV, Singh S, Tegeler CH, Felix A. A Multicenter Evaluation of the ABCD2 Score's Accuracy for Predicting Early Ischemic Stroke in Admitted Patients With Transient Ischemic Attack. Ann Emerg Med 2010; 55:201-210.e5. [DOI: 10.1016/j.annemergmed.2009.05.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Revised: 03/24/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
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Ong MEH, Chan YH, Lin WP, Chung WL. Validating the ABCD2 Score for predicting stroke risk after transient ischemic attack in the ED. Am J Emerg Med 2010; 28:44-8. [DOI: 10.1016/j.ajem.2008.09.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Revised: 09/03/2008] [Accepted: 09/13/2008] [Indexed: 12/17/2022] Open
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Chandratheva A, Mehta Z, Geraghty OC, Marquardt L, Rothwell PM. Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009; 72:1941-7. [PMID: 19487652 DOI: 10.1212/wnl.0b013e3181a826ad] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Several recent guidelines recommend assessment of patients with TIA within 24 hours, but it is uncertain how many recurrent strokes occur within 24 hours. It is also unclear whether the ABCD2 risk score reliably identifies recurrences in the first few hours. METHODS In a prospective, population-based incidence study of TIA and stroke with complete follow-up (Oxford Vascular Study), we determined the 6-, 12-, and 24-hour risks of recurrent stroke, defined as new neurologic symptoms of sudden onset after initial recovery. RESULTS Of 1,247 first TIA or strokes, 35 had recurrent strokes within 24 hours, all in the same arterial territory. The initial event had recovered prior to the recurrent stroke (i.e., was a TIA) in 25 cases. The 6-, 12-, and 24-hour stroke risks after 488 first TIAs were 1.2% (95% confidence interval [CI]: 0.2-2.2), 2.1% (0.8-3.2), and 5.1% (3.1-7.1), with 42% of all strokes during the 30 days after a first TIA occurring within the first 24 hours. The 12- and 24-hour risks were strongly related to ABCD2 score (p = 0.02 and p = 0.0003). Sixteen (64%) of the 25 cases sought urgent medical attention prior to the recurrent stroke, but none received antiplatelet treatment acutely. CONCLUSION That about half of all recurrent strokes during the 7 days after a TIA occur in the first 24 hours highlights the need for emergency assessment. That the ABCD2 score is reliable in the hyperacute phase shows that appropriately triaged emergency assessment and treatment are feasible.
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Affiliation(s)
- A Chandratheva
- Stroke Prevention Research Unit, Oxford University Department of Clinical Neurology, UK
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Fothergill A, Christianson TJH, Brown RD, Rabinstein AA. Validation and refinement of the ABCD2 score: a population-based analysis. Stroke 2009; 40:2669-73. [PMID: 19520983 DOI: 10.1161/strokeaha.109.553446] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Transient ischemic attacks are a frequent diagnosis in the emergency department setting, yet expert opinion as to the proper follow-up and need for hospitalization differs widely. Recently, an effort has been made to risk-stratify patients presenting with transient ischemic attacks through scoring systems such as the ABCD and ABCD2 scales. The aim of our study was to independently validate these scores using a population-based cohort. METHODS Using the data from the Rochester Stroke and Transient Ischemic Attack Registry and resources of the Rochester Epidemiology Project, medical records of all residents of Rochester, Minn, with a diagnosis of incident transient ischemic attack from 1985 through 1994 were examined (N=284). Patients were scored on the ABCD and ABCD2 scales and new scores were created by adding hyperglycemia and a history of hypertension. The end points of stroke and death were collected previously and were verified through the Rochester Epidemiology Project data. RESULTS Although our study did find that scores >4 had a statistically significant predictive value for future stroke, a substantial proportion of strokes within 7 days (9 of 36 cases [25%]) occurred in patients with low or intermediate risk scores (< or =4) on the ABCD2 scale. Including history of hypertension and hyperglycemia on presentation increased the sensitivity of the score to identify patients who had a stroke within 7 days. CONCLUSIONS Reliance on the ABCD and ABCD2 scores misses some patients who will have a stroke within 7 days of a transient ischemic attack. Adding hyperglycemia and a history of hypertension to the predictive model could be useful, but the value of these additions need to be evaluated further.
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Affiliation(s)
- Amy Fothergill
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Crimmins DS, Levi CR, Gerraty RP, Beer CD, Hill KM. Acute stroke and transient ischaemic attack management - time to act fast. Intern Med J 2009; 39:325-31. [DOI: 10.1111/j.1445-5994.2009.01935.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Shah KH, Metz HA, Edlow JA. Clinical Prediction Rules to Stratify Short-Term Risk of Stroke Among Patients Diagnosed in the Emergency Department With a Transient Ischemic Attack. Ann Emerg Med 2009; 53:662-73. [DOI: 10.1016/j.annemergmed.2008.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 07/30/2008] [Accepted: 08/01/2008] [Indexed: 11/28/2022]
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Cumbler E, Glasheen JJ. Risk stratification tools for transient ischemic attack: which patients require hospital admission? J Hosp Med 2009; 4:247-51. [PMID: 19388066 DOI: 10.1002/jhm.411] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Stroke and transient ischemic attack (TIA) arise from identical etiologies and many fatal or disabling strokes are preceded by a TIA. Ten percent of patients presenting with a TIA will suffer a stroke within 3 months with half occurring in the first 48 hours. Still, many patients with a TIA do not receive timely evaluation or therapy. Hospitalization offers the opportunity for rapid evaluation and secondary prevention, reduced time to thrombolysis for early second strokes, and can be cost effective for high risk patients. Stratification tools are now available which allow individualized assessment of risk for early second strokes based on patient characteristics on presentation. The use of scoring systems such as the ABCD(2) score to predict risk of stroke after TIA are useful in making an evidence-based judgment regarding need for hospitalization. High-risk patients have an 8.1% risk for stroke in the 48 hours after a TIA and warrant hospital admission. Intermediate-risk patients have a 4.1% risk of early second stroke and may be considered for admission, observation, or expedited clinic evaluation. Low-risk patients have a 2-day stroke risk of only 1% and are likely appropriate for prompt outpatient evaluation. TIA is a medical emergency, similar to unstable angina, and high risk patients should receive treatment and prevention measures instituted with comparable urgency.
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Affiliation(s)
- Ethan Cumbler
- Hospital Medicine Group, Division of General Internal Medicine, Department of Medicine, University of Colorado-Denver School of Medicine, Denver, CO, USA.
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Ay H, Arsava EM, Johnston SC, Vangel M, Schwamm LH, Furie KL, Koroshetz WJ, Sorensen AG. Clinical- and imaging-based prediction of stroke risk after transient ischemic attack: the CIP model. Stroke 2008; 40:181-6. [PMID: 18948609 DOI: 10.1161/strokeaha.108.521476] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Predictive instruments based on clinical features for early stroke risk after transient ischemic attack suffer from limited specificity. We sought to combine imaging and clinical features to improve predictions for 7-day stroke risk after transient ischemic attack. METHODS We studied 601 consecutive patients with transient ischemic attack who had MRI within 24 hours of symptom onset. A logistic regression model was developed using stroke within 7 days as the response criterion and diffusion-weighted imaging findings and dichotomized ABCD(2) score (ABCD(2) >/=4) as covariates. RESULTS Subsequent stroke occurred in 25 patients (5.2%). Dichotomized ABCD(2) score and acute infarct on diffusion-weighted imaging were each independent predictors of stroke risk. The 7-day risk was 0.0% with no predictor, 2.0% with ABCD(2) score >/=4 alone, 4.9% with acute infarct on diffusion-weighted imaging alone, and 14.9% with both predictors (an automated calculator is available at http://cip.martinos.org). Adding imaging increased the area under the receiver operating characteristic curve from 0.66 (95% CI, 0.57 to 0.76) using the ABCD(2) score to 0.81 (95% CI, 0.74 to 0.88; P=0.003). The sensitivity of 80% on the receiver operating characteristic curve corresponded to a specificity of 73% for the CIP model and 47% for the ABCD(2) score. CONCLUSIONS Combining acute imaging findings with clinical transient ischemic attack features causes a dramatic boost in the accuracy of predictions with clinical features alone for early risk of stroke after transient ischemic attack. If validated in relevant clinical settings, risk stratification by the CIP model may assist in early implementation of therapeutic measures and effective use of hospital resources.
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Affiliation(s)
- Hakan Ay
- AA Martinos Center for Biomedical Imaging and Stroke Service, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Room 2301, Charlestown MA 02129, USA.
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Abstract
A major challenge facing the physician evaluating patients with transient ischemic attack is determining which patients are at highest short-term risk of stroke. A number of stratification schemes have been recently developed incorporating easily obtainable clinical information about the individual patient. Further, emerging data suggest a role for brain and vascular imaging in risk stratification. Many aspects of acute management of transient ischemic attack, such as which patients should be hospitalized and choice of acute antithrombotic therapy, remain controversial because of a lack of evidence from controlled trials. For longer-term prevention, there is much firmer evidence from multiple large randomized trials, and these data are reviewed in this article.
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Affiliation(s)
- Brett Cucchiara
- Department of Neurology, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
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Bray J, Bladin C, Coughlan K, Patil A. Lessons learnt in implementation of ABCD score in an emergency department. Stroke 2008; 39:e111; author reply e112. [PMID: 18483417 DOI: 10.1161/strokeaha.107.518431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Affiliation(s)
- Rossella Sciolla
- From the Neurology Department (R.S., F.M.), University of Turin, ASO San Luigi, Orbassano, Turin, Italy
| | - Fabio Melis
- From the Neurology Department (R.S., F.M.), University of Turin, ASO San Luigi, Orbassano, Turin, Italy
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Giles MF, Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2007; 6:1063-72. [PMID: 17993293 DOI: 10.1016/s1474-4422(07)70274-0] [Citation(s) in RCA: 467] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Stroke is often preceded by transient ischaemic attack (TIA), but studies of stroke risk after TIA are logistically difficult and have yielded conflicting results. However, reliable estimation of this risk is necessary for planning effective service provision, clinical trials, and public education. We therefore did a systematic review of all studies of stroke risk early after TIA. METHODS All studies of stroke risk within 7 days of TIA were identified by use of electronic databases and by hand searches of reference lists, relevant journals, and conference abstracts. Stroke risks at 2 days and 7 days after TIA were calculated overall and analyses for heterogeneity were done, if possible, after categorisation by study method, setting, population, and treatment. FINDINGS 18 independent cohorts were included, which reported stroke risk in 10 126 TIA patients. The pooled stroke risk was 5.2% (95% CI 3.9-6.5) at 7 days, but there was substantial heterogeneity between studies (p<0.0001), with risks ranging from 0% to 12.8%. However, the risks reported in individual studies over different durations of follow-up were highly correlated (0-7 days vs 8-90 days, r=0.89, p<0.0001), and the heterogeneity between studies was almost fully explained by study method, setting, and treatment. The lowest risks were seen in studies of emergency treatment in specialist stroke services (0.9% [95% CI 0.0-1.9], four studies) and the highest risks in population-based studies without urgent treatment (11.0% [8.6-13.5], three studies). Results were similar for stroke risk at 2 days. INTERPRETATION The reported early risks of stroke after TIA were highly heterogeneous, but this could be largely accounted for by differences in study method, setting, and treatment, with lowest risks in studies of emergency treatment in specialist stroke services.
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Affiliation(s)
- Matthew F Giles
- Stroke Prevention Research Unit, Oxford University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK.
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