A comparison of risk factors for recurrent TIA and stroke in patients diagnosed with TIA
Abstract
Background: Some spells consistent with TIA may be benign, such as those produced by migraine or migraine accompaniments in the elderly. Distinguishing these from embolic or thrombotic events may be difficult.
Methods: Emergency department physicians identified patients who presented with a presumed TIA at one of 16 hospitals in Northern California from March 1997 through February 1998. Recurrent TIAs and strokes were recorded for 90 days afterwards.
Results: Of 1,707 patients in whom TIA had been diagnosed in the emergency department, 191 (11.2%) had a recurrent TIA and 180 (10.5%) had a stroke during 90-day followup. Independent risk factors for recurrent TIA were age >60 years (odds ratio 1.9; 95% CI 1.2 to 2.9; p = 0.003), history of multiple TIAs (odds ratio 2.9; 2.1 to 4.0; p < 0.001), duration of spell ≤10 minutes (odds ratio 2.3; 1.6 to 3.3; p < 0.001), and sensory abnormality associated with the spell (odds ratio 1.9; 1.4 to 2.6; p < 0.001). Independent risk factors for stroke from a previous analysis were age, duration >10 minutes, diabetes, weakness, and speech impairment. Among the 30 patients with isolated sensory symptoms lasting ≤10 minutes, the risk of recurrent TIA was 40% and none had a stroke.
Conclusions: In patients in whom TIA has been diagnosed in the emergency department, risk factors for subsequent stroke and recurrent TIA are different. A subset of patients with presumed TIA has a benign short-term course with multiple brief TIAs more frequently characterized by sensory symptoms.
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Received: July 22, 2002
Accepted: October 4, 2002
Published online: January 28, 2003
Published in print: January 28, 2003
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We congratulate Johnston et al on their study of risk factors for recurrent cerebral ischemic events in patients presenting with transient ischemic attack (TIA).[1]
The authors focus on a distinct subgroup of patients with isolated sensory symptoms with a high risk of recurrent TIA (40%), not progressing to stroke. However, the syndrome of recurrent pure sensory episodes has been documented.[2,3] C. Miller Fisher pioneered its description (the authors cite Fisher's papers on late life migraine accompaniments, but not on this entity). In a series of 135 cases, Fisher found that isolated, unilateral sensory disturbance presented in two distinct, and equally frequent manners: 1) sudden onset of pure sensory stroke preceded by no or few TIAs; and 2) frequent transient, unilateral hypoesthesia or paresthesias not progressing to permanent deficit.[2]
The syndrome of recurrent pure sensory episodes has been associated with ventroposterolateral infarcts on imaging and autopsy.[2,3] Its pathogenesis is speculative, but likely a substantial proportion of cases are due to waxing/waning poststroke paresthesias as a variant manifestion of poststroke pain, and others due to recurrent ischemia beyond a fixed stenosis in a penetrating vessel, migrainous phenomena, hyperventilation paresthesias, and simple partial seizures. Approximately three to five patients a year are referred to our stroke center for sensory spells that recur despite multiple combinations of antithrombotics and anticonvulsants. Making the diagnosis spares patients from repeated invasive imaging, treatment with aggressive combination antithrombotic regimens likely to produce bleeding complications, and undue worry when episodes recur.
References
1. Johnston SC, Sidney S, Bernstein AL, Gress DR. A comparison of risk factors for recurrent TIA and stroke in patients diagnosed with TIA. Neurology 2003;60:280-285.
2. Fisher CM. Pure sensory stroke and allied conditions. Stroke 1982;13:434-447.
3. Fernandez-Beer E, Patrick T, Biller J, Saver JL. Recurrent pure sensory transient ischemic attacks: in vivo demonstration of associated thalamic infarction. J Stroke Cerebrovasc Dis 1994;4:174-178.
We are grateful for the comments of Dr. Saver. As he points out, our results extend those of Dr. Fisher by demonstrating that patients initially presenting with pure sensory transient ischemic attacks (TIA) generally have a benign prognosis, with high risk of recurrent transient symptoms but low risk of subsequent stroke. Fisher notes that only 10 of 100 cases of sensory TIA or stroke had both a TIA and a stroke but he provides no information on the timing of events and risks cannot be calculated [1]. We fully agree that escalation to more aggressive and dangerous antithrombotic therapies may not be indicated in patients with recurrent pure sensory TIA. There may be a role for calcium-channel blockers [2] as we have found in two of our patients with such spells, but this requires further study.
1. Fisher CM. Pure sensory stroke and allied conditions. Stroke 1982;13(4):434-447.
2. Winterkorn JM, Kupersmith MJ, Wirtschafter JD, Forman S. Brief report: treatment of vasospastic amaurosis fugax with calcium-channel blockers. N Engl J Med 1993;329(6):396-398.