Fast track — ArticlesAddition of brain and carotid imaging to the ABCD2 score to identify patients at early risk of stroke after transient ischaemic attack: a multicentre observational study
Introduction
Transient ischaemic attack (TIA) is associated with high risk of early recurrent stroke, with stroke rates as high as 35% in some subgroups by 7 days.1 Clinical prediction scores such as the ABCD2 score (age ≥60 years [1 point]; blood pressure ≥140/90 mm Hg [1 point]; clinical features of weakness [2 points] or speech impairment [1 point]; duration of symptoms ≥60 min [2 points] or 10–59 min [1 point]; diabetes mellitus [1 point]) have been developed to improve early stroke risk stratification after TIA1, 2, 3 and have been recommended for use in international guidelines.4, 5, 6 Although not intended to replace clinical judgment in the assessment of individual patients, the ABCD2 score provided clinically useful risk stratification in independent cohorts from Oxfordshire, UK, and California, USA, and in a recent meta-analysis of several other validation studies.2, 7
The ABCD2 score was originally intended for use at the initial assessment of patients with suspected TIA by primary care and emergency department physicians to help with triage decisions for hospital admission and urgent referral to specialist stroke services.1, 2, 3 The score deliberately does not include information that is often obtained from initial investigations done in secondary care, including carotid and brain imaging and electrocardiography (ECG), which might provide additional predictive information.6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 The need to develop a version of the ABCD2 score for use in secondary care was recognised in the report of the initial derivation and validation of the score;1 this extended version of the score would allow inclusion of information from initial diagnostic investigations that might be useful for prognosis.9, 11, 12, 13, 14, 15, 16, 17, 18, 19
In addition to the ABCD2 items, several other variables might be useful markers of unstable vascular disease that is associated with high risk of early stroke after TIA. Recent earlier TIA has been associated with high risk of early stroke, possibly because of repeated emboli, poor collateral circulation, or impaired cerebral autoregulation.4, 20, 21 Carotid stenosis has been associated with increased stroke risk after TIA, probably because of recurrent embolisation from unstable carotid plaques.9, 12, 22 Acute diffusion-weighted imaging (DWI) hyperintensity after TIA has been associated with predictors of stroke risk and early stroke in several studies, but statistical power has been inadequate to allow reliable integration of DWI with other predictors.14, 15, 16, 17, 23 Inclusion of these variables might improve the ability of the ABCD2 score to identify patients who can be safely treated without hospital admission and those who require intensive measures to prevent and treat early stroke recurrence.14, 15, 16
We aimed to assess whether the ABCD2 score could be developed to improve prediction of stroke on the basis of preclinical information (ABCD3) and after completion of initial investigations in secondary care settings (ABCD3-I).
Section snippets
Participants
We did a pooled international multicentre analysis of patients with TIA. For the derivation sample, centres with large numbers of patients with TIA who had early DWI and were followed up were identified from studies of specialist-treated patients in hospital-based settings, and lead investigators were invited to include data from individual patients for analysis. Follow-up was done in person, by telephone interview, or by medical chart review; follow-up periods varied across studies. Inclusion
Results
3886 patients were included in the study: 2654 in the derivation sample and 1232 in the validation sample. Table 1 and the webappendix (pp 2–3) describe the clinical characteristics of the patients. Eight centres from Europe and North America contributed data to the derivation sample; seven centres contributed data from patients admitted to hospital and one from patients who visited a 7-day TIA clinic that was run by a stroke specialist.8, 12, 15, 17, 19, 30, 31, 32 In the derivation sample,
Discussion
Our data show the value of recent TIA, carotid stenosis, and acute DWI hyperintensity as markers for the identification of patients with TIA who are at high risk of stroke as early as 2 days after assessment (panel). We found that patients with symptomatic carotid stenosis, recent earlier TIA, and DWI abnormality were at 3–7 times higher risk of stroke, after adjusting for other known risk factors for early recurrence (table 3 and table 6). The high risk of stroke within 7 days of symptom onset
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