Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA
A multicenter study
Abstract
Objectives:
Stroke risk immediately after TIA defined by time-based criteria is high, and prognostic scores (ABCD2 and ABCD3-I) have been developed to assist management. The American Stroke Association has proposed changing the criteria for the distinction between TIA and stroke from time-based to tissue-based. Research using these definitions is lacking. In a multicenter observational cohort study, we have investigated prognosis and performance of the ABCD2 score in TIA, subcategorized as tissue-positive or tissue-negative on diffusion-weighted imaging (DWI) or CT imaging according to the newly proposed criteria.
Methods:
Twelve centers provided data on ABCD2 scores, DWI or CT brain imaging, and follow-up in cohorts of patients with TIA diagnosed by time-based criteria. Stroke rates at 7 and 90 days were studied in relation to tissue-positive or tissue-negative subcategorization, according to the presence or absence of brain infarction. The predictive power of the ABCD2 score was determined using area under receiver operator characteristic curve (AUC) analyses.
Results:
A total of 4,574 patients were included. Among DWI patients (n = 3,206), recurrent stroke rates at 7 days were 7.1%(95% confidence interval 5.5–9.1) after tissue-positive and 0.4% (0.2–0.7) after tissue-negative events (p diff < 0.0001). Corresponding rates in CT-imaged patients were 12.8% (9.3–17.4) and 3.0% (2.0–4.2), respectively (p diff < 0.0001). The ABCD2 score had predictive value in tissue-positive and tissue-negative events (AUC = 0.68 [95% confidence interval 0.63–0.73] and 0.73 [0.67–0.80], respectively; p sig < 0.0001 for both results, p diff = 0.17). Tissue-positive events with low ABCD2 scores and tissue-negative events with high ABCD2 scores had similar stroke risks, especially after a 90-day follow-up.
Conclusions:
Our findings support the concept of a tissue-based definition of TIA and stroke, at least on prognostic grounds.
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Information & Authors
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Copyright © 2011 by AAN Enterprises, Inc.
Publication History
Received: November 4, 2010
Accepted: April 7, 2011
Published online: August 24, 2011
Published in print: September 27, 2011
Disclosure
Dr. Giles has received funding for travel and speaker honoraria from Boehringer Ingelheim and has received research support from National Institute of Health Research. Dr. Albers serves on a scientific advisory board for Lundbeck Inc.; has received funding for travel or speaker honoraria from Genentech, Inc.; serves on the editorial board of Stroke; serves as a consultant for Bristol-Myers Squibb, Merck Serono, Arbor Vita Corporation, AstraZeneca, and Mitsubishi Tanabe Pharma Corporation; receives research support from the NIH; and has served as an expert witness in medico-legal cases. Dr. Amarenco serves on scientific advisory boards for and has received funding for travel and speaker honoraria from Bristol-Myers Squibb, Pfizer Inc, Merck Serono, AstraZeneca, sanofi-aventis, and Boehringer Ingelheim; serves as Associate Editor, Europe for Stroke; and receives research support from sanofi-aventis, Bristol-Myers Squibb, Merck Serono, AstraZeneca, and PHRC. Dr. Arsava reports no disclosures. Dr. Asimos receives research support from Boehringer Ingelheim. Dr. Ay serves on the editorial boards of Stroke and Cerebrovascular Diseases and receives research support from the NIH. Dr. Calvet reports no disclosures. Dr. Coutts receives research support from Pfizer Inc, CIHR, Alberta-Innovates-Health Solutions, and a Heart and Stroke Foundation of Canada's Distinguished Clinician Scientist award, supported in partnership with the CIHR, Institute of Circulatory and Respiratory Health, and AstraZeneca. Dr. Cucchiara serves on a data safety monitoring board for Wyeth; has received speaker honoraria from Boehringer Ingelheim and diaDexus, Inc.; has received publishing royalties from UpToDate, Inc.; serves as a consultant for Ferrer, diaDexus, Inc., and iNova Pharmaceuticals; and receives research support from the NIH, the American Heart Association, and the American Stroke Association. Dr. Demchuk served on scientific advisory boards for Boehringer Ingelheim and Bayer Schering Pharma; has received funding for travel from sanofi-aventis; serves on the editorial boards of Journal of Neuroimaging, Stroke, and the International Journal of Stroke; has received speaker honoraria from Boehringer Ingelheim; receives research support from Novo Nordisk, the NIH/NINDS, and the CIHR; and owns stock in Calgary Scientific, Inc. Dr. Johnston is co-holder of patent re: the RNA panel to identify TIA and risk stratify and receives research support from sanofi-aventis, Strkyer Neurovascular, Boston Scientific, the NIH (NCRR, NINDS), Kaiser-Permanente, and AHA/ASA Bugher Award. Dr. Kelly has received research support to his institution from Pfizer Inc, Servier, and Bristol-Myers Squibb and has received research support from the Health Research Board of Ireland and the Irish Heart Foundation. Dr. Kim receives research support from the NIH (NCRR, NINDS), the American Heart Association, and the National Stroke Association. J. Labreuche and Dr. Lavallee report no disclosures. Dr. Mas serves on scientific advisory boards for AstraZeneca, Bayer Schering Pharma, Boehringer Ingelheim, sanofi-aventis/Bristol-Myers Squibb, Servier, and Takeda Pharmaceutical Company Limited; has received research support from Boehringer Ingelheim, sanofi-aventis, and Servier; and receives research support from sanofi-aventis, the French Ministry of Health, and INSERM Institut National Scientifique et de la Recherche Medicale. Dr. Merwick has received research support from Pfizer Inc, Lundbeck Inc., and Boehringer Ingelheim and receives salary support from the Health Research Board of Ireland. Dr. Olivot reports no disclosures. Dr. Purroy received research support from the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III. Dr. Rosamond receives research support from the CDC and the NIH. Dr. Sciolla reports no disclosures. Prof. Rothwell serves on scientific advisory boards for Bayer Schering Pharma, Servier, Pfizer Inc, and Biotronic; has received funding for travel from sanofi-aventis, Servier, AstraZeneca, and Bayer Schering Pharma; and serves on the editorial boards of Lancet Neurology, Stroke, and Cerebrovascular Diseases and as Assistant Editor for the International Journal of Stroke.
Authors
Author Contributions
All authors ascertained patients and contributed data. M.F.G. and P.M.R. devised the study. M.F.G. and P.M.R. wrote the manuscript. All authors reviewed and approved the manuscript.
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Giles and colleagues showed the prognostic value of the ABCD2-score in TIA-patients stratified by the presence of a DWI-lesion. [1] However, we feel that differences in delay from TIA to imaging could have influenced the observed prognostic profiles of patients with and without DWI-lesions.
The authors used data from 9 individual studies that included TIA- patients who underwent DWI. [1] Although not all data could be derived from the source papers, apparently the delay from TIA to DWI extended up to two weeks in one of the studies. [2] Differences in this delay between patients with and without DWI-lesions are not provided.
A longer latency between TIA and DWI could affect the incidence of DWI-lesions with a lower likelihood of finding DWI-lesions when imaging was performed >24 hours after TIA. Others have described this before [3], as well as a lower DWI-lesion rate in patients scanned in the subacute phase. [4] Furthermore, occurrence of stroke before DWI excluded patients from the analysis, something expected especially in DWI-positive patients, given their worse prognosis. [1] This may also alter the prognostic value of DWI in this population.
We think that providing data additionally stratified by delay from TIA to DWI would be both informative and clarifying, given that still a large proportion of TIA-patients receives their imaging >24 hours after symptom onset.
References
1. Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: A multicenter study. Neurology 2011;77:1222-1228.
2. Lavallee PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007;6:953-960.
3. Shah SH, Saver JL, Kidwell CS, et al. Abstracts from the 2007 International Stroke Conference. Stroke 2007;38:463.
4. Schulz UG, Briley D, Meagher T, et al. Diffusion-weighted MRI in 300 patients presenting late with subacute transient ischemic attack or minor stroke. Stroke 2004;35:2459-2465.
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