ABCD3-I Score Research Articles

Diagnostic value of ABCD2 and ABCD3-I risk scoring systems in determining one-month risk of stroke in patients with transient ischemic attack: An observational study

Objective: To compare the diagnostic value of the ABCD2 and ABCD3-I scoring systems in predicting the development of a 30-day neurological event in adult patients with transient ischemic attack (TIA) presenting to the emergency department. Methods: The study was observational and prospective and was conducted in a single center. The diagnostic values of the ABCD2 and ABCD3-I scores in predicting a neurological event within one month were compared in patients diagnosed with TIA in the emergency department. Results: A statistically significant difference was observed between groups with or without stroke within one month in terms of both the ABCD2 and ABCD3-I scores (P=0.044 and P=0.029, respectively). There was no statistically significant difference between the patients with and without a recurrent TIA within one month in relation to the ABCD2 score (P=0.934), but a statistically significant difference was found in the ABCD3-I scores of these groups (P<0.001). Conclusions: Both the ABCD2 and ABCD3-I scoring systems could predict ischemic stroke within 30 days of TIA, the ABCD3-I score is more effective than the ABCD2 score in the prediction of TIA recurrence.

Predictive role of ABCD2, ABCD3I, C-reactive protein, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and systemic immune-inflammation index in 90-day and long-term stroke after transient ischemic attack

Objectives: Transient ischemic attack (TIA) is a neurological emergency and a precursor of ischemic stroke. ABCD2 and ABCD3I scores predict stroke after TIA, and clinicians use preclinical, clinical, and radiological parameters for calculating these scores. Our study aimed to investigate the efficacy of peripheral blood markers in predicting 90-day and long-term stroke risk after TIA. Methods: This retrospective study was conducted in Kastamonu Training and Research Hospital between January 2015 and November 2022. The demographic data of 99 patients who applied with the diagnosis of TIA and peripheral blood markers at the time of first admission to the hospital were used in the study. These parameters was evaluated in 90-day and long-term (>12 months) stroke after TIAs. Results: Of the 99 patients in our study, 59% (n = 58) were male. The mean age of the patients was 70 ± 13 years. ABCD2 (age, blood pressure, clinical features, duration of symptoms, and presence of diabetes mellitus) and ABCD3I (age, blood pressure, clinical features, duration of symptoms, presence of diabetes mellitus, dual TIA, and ipsilatheral carotis stenosis) scores and C-reactive protein (CRP) were statistically significant in predicting 90-day stroke. ABCD2 and ABCD3I were not effective in predicting long-term stroke. In addition, CRP, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) parameters were statistically significant in long-term stroke. CRP (AUC=793, sensitivity=82%, and specificity=81%) values were higher than ABCD2 (AUC=779, sensitivity=73%, and specificity=76%) and ABCD3I (AUC=755, sensitivity=82%, and specificity=70%) scores in predicting 90-day stroke. Conclusions: Our study showed that ABCD2, ABCD3I, and CRP effectively predict 90-day stroke after TIA. Furthermore, CRP was more effective than ABCD2 and ABCD3I scores in predicting 90-day stroke after TIA. CRP, NLR, PLR, and SII also effectively predicted long-term stroke after TIA.

Patient with non-cardioembolic ischemic stroke or high-risk transient ischemic attack. Part 1. Diagnosis

Non-cardioembolic stroke and transient ischemic attack (TIA) are heterogeneous conditions, some variants of which are associated with a high short-term and long-term risk of cardiovascular events. The article presents clinical portraits of patients in high and very high risk groups: 1) patients with extracranial atherosclerosis and severe stenosis/subocclusion/occlusion or CT signs of atherosclerotic plaque instability; 2) all patients with intracranial atherosclerosis, especially those with symptoms of hemodynamic compromise or multiple infarcts; 3) all patients with mobile/ulcerative atheroma of the aortic arch. For the timely identification of these subtypes, it is necessary to use clinical and radiological clues with necessary diagnostic search. In addition, the following patients with TIA may be at high or very high risk: those with an ABCD2 score of ≥4 points or an ABCD3-I score of ≥8 points; with TIA in the vertebrobasilar basin, "crescendo" or "limb shaking" type, orthostatic TIA, as well as patients with warning capsular and bridge syndromes. Assigning a patient to one of the considered categories requires the immediate administration of enhanced secondary prevention, which will be discussed in the second part of this article.

O073 Triple neuroprotection during emergency carotid endarterectomy for acute stroke after failed TPA or beyond the 24-hour window of opportunity

Abstract Introduction Clinical dilemma during tissue plasminogen activator (tPA) failure in ischemic stroke management is a daunting challenge. We propose an innovative approach called triple neuro-protection (TNP), which encompasses three technical domains - targeted hypothermia, systemic induced hypertension, and barbiturates infusion. Methods From 2002–2019, we performed 832 carotid interventions amongst more than 12,000 patients referred to our tertiary vascular services with carotid artery disease. Amongst them, 25 patients presented between March 2015 and 2019 with acute dense stroke with either failed tPA or passed the recommended timing for acute stroke intervention. Fifteen (60%) had hemineglect with acute infarct on MRI brain and a Rankin score of 4 or 5, and 96% had 80–99% stenosis on the symptomatic side (mean ABCD3-I score 11.35). All patients underwent emergency carotid endarterectomy (CEA) with therapeutically induced hypothermia (32–34°C), targeted hypertension (systolic blood pressure 180–200 mm of Hg), and brain suppression with a barbiturate. Results There were no perioperative complications and mortality. There were no myocardial infarction cases, death, cranial nerve injury, wound hematoma, or procedural bleeding. Mean hospital stay was 8.4±5.5 days. All patients had resolution of neurological symptoms, except three (failed thrombolysis previously). Eighty percent had a postoperative Rankin score of 0 on discharge, and 88% of patients were discharged home with three requiring rehabilitation. Conclusion We observed positive neurological outcomes without serious adverse events with TNP during emergency CEA in acute brain injury patients. Based on our experience, we recommend a large scale study on TNP. Take-home message Triple neuroprotection showed positive neurological outcomes without serious adverse events during emergency carotid endarterectomy in acute brain injury patients.

Validation of CSR model to predict stroke risk after transient ischemic attack

It is essential to identify high risk transient ischemic attack (TIA) patients. The previous study reported that the CSR (comprehensive stroke recurrence) model, a neuroimaging model, had a high predictive ability of recurrent stroke. The aims of this study were to validate the predictive value of CSR model in TIA patients and compare the predictive ability with ABCD3-I score. Data were analyzed from the prospective hospital-based database of patients with TIA which defined by the World Health Organization time-based criteria. The predictive outcome was stroke occurrence at 90 days. The receiver-operating characteristic (ROC) curves were plotted and the C statistics were calculated as a measure of predictive ability. Among 1186 eligible patients, the mean age was 57.28 ± 12.17 years, and 474 (40.0%) patients had positive diffusion-weighted imaging (DWI). There were 118 (9.9%) patients who had stroke within 90 days. In 1186 TIA patients, The C statistic of CSR model (0.754; 95% confidence interval [CI] 0.729–0.778) was similar with that of ABCD3-I score (0.717; 95% CI 0.691–0.743; Z = 1.400; P = 0.1616). In 474 TIA patients with positive DWI, C statistic of CSR model (0.725; 95% CI 0.683–0.765) was statistically higher than that of ABCD3-I score (0.626; 95% CI 0.581–0.670; Z = 2.294; P = 0.0245). The CSR model had good predictive value for assessing stroke risk after TIA, and it had a higher predictive value than ABCD3-I score for assessing stroke risk for TIA patients with positive DWI.

Predictive Value of the ABCD3-I for Short- and Long-Term Stroke after TIA with or without sICAS.

Aims: We aimed to validate the predictive value of the ABCD3-I score for short-term and long-term stroke risk after transient ischemic attack (TIA) and to evaluate the influence of symptomatic intracranial artery stenosis (sICAS) on the performance of ABCD3-I. Methods: We recruited TIA patients from the Third China National Stroke Registry study. Outcome parameters were stroke events during the 14-day, 3-month, 6-month, and 12-month points. The area under the curve (AUC) was calculated as a measure of predictive ability. A multivariable-adjusted Cox proportional hazards model was used to assess the hazard ratio of risk factors for stroke. Results: Among 986 patients, 3.9%, 5.1%, 6.5 %, and 8.2% of participants experienced a stroke event during the 14-day, 3-month, 6-month, and 12-month points post TIA, respectively. The AUCs of ABCD3-I score for the prediction of stroke were 0.786, 0.732, 0.715, and 0.699 at the 14-day, 3-month, 6-month, and 12-month points, respectively. The AUCs were 0.774, 0.690, 0.617, and 0.611 in patients with sICAS, 0.789, 0.748, and 0.758 and 0.734 in those without sICAS. P values of the interaction between ABCD3-I categories and sICAS were 0.0618 for 14-day, 0.0098 for 3-month, 0.0318 for 6-month, and 0.0294 for 12-month. Conclusions: ABCD3-I score performed well in predicting short-term risk of a stroke after an index TIA in patients with or without sICAS. However, the predictive power decayed with the prolonged period, and the decayed extent was more pronounced among those with sICAS. The assessment of sICAS is a non-ignorable item when using the ABCD3-I score for long-term stroke risk prediction in patients with TIA.

ABCD3-I and ABCD2 Scores in a TIA Population with Low Stroke Risk.

Objectives We aimed to evaluate the ABCD3-I score and compare it with the ABCD2 score in short- (1 week) and long-term (3 months; 1 year) stroke risk prediction in our post-TIA stroke risk study, MIDNOR TIA. Materials and Methods We performed a prospective, multicenter study in Central Norway from 2012 to 2015, enrolling 577 patients with TIA. In a subset of patients with complete data for both scores (n = 305), we calculated the AUC statistics of the ABCD3-I score and compared this with the ABCD2 score. A telephone follow-up and registry data were used for assessing stroke occurrence. Results Within 1 week, 3 months, and 1 year, 1.0% (n = 3), 3.3% (n = 10), and 5.2% (n = 16) experienced a stroke, respectively. The AUCs for the ABCD3-I score were 0.72 (95% CI, 0.54 to 0.89) at 1 week, 0.66 (95% CI, 0.53 to 0.80) at 3 months, and 0.68 (0.95% CI, 0.56 to 0.79) at 1 year. The corresponding AUCs for the ABCD2 score were 0.55 (95% CI, 0.24 to 0.86), 0.55 (95% CI, 0.42 to 0.68), and 0.63 (95% CI, 0.50 to 0.76). Conclusions The ABCD3-I score had limited value in a short-term prediction of subsequent stroke after TIA and did not reliably discriminate between low- and high-risk patients in a long-term follow-up. The ABCD2 score did not predict subsequent stroke accurately at any time point. Since there is a generally lower stroke risk after TIA during the last years, the benefit of these clinical risk scores and their role in TIA management seems limited. Clinical Trial Registration. This trial is registered with NCT02038725 (retrospectively registered, January 16, 2014).

Safety of Triple Neuroprotection with Targeted Hypothermia, Controlled Induced Hypertension, and Barbiturate Infusion during Emergency Carotid Endarterectomy for Acute Stroke after Missing the 24 Hours Window Opportunity

The aim of this study is to establish the initial safety of triple neuroprotection (TNP) in an acute stroke setting in patients presenting outside the window for systemic tissue plasminogen activator (tPA). Over 12,000 patients were referred to our vascular services with carotid artery disease, of whom 832 had carotid intervention with a stroke rate of 0.72%. Of these, 25 patients presented (3%), between March 2015 and 2019, with acute dense stroke. These patients had either failed tPA or passed the recommended timing for acute stroke intervention. Fifteen (60%) had hemi-neglect with evidence of acute infarct on magnetic resonance imaging of the brain and a Rankin score of 4 or 5. Ninety-six percent had an 80-99% stenosis on the symptomatic side. Mean ABCD3-I score was 11.35. All patients underwent emergency carotid endarterectomy (CEA) with therapeutically induced hypothermia (32-34°C), targeted hypertension (systolic blood pressure 180-200mm Hg), and brain suppression with barbiturate. There were no cases of myocardial infarction, death, cranial nerve injury, wound hematoma, or procedural bleeding. Mean hospital stay was 8.4 (±9.5) days. All cases had resolution of neurological symptoms, except 3 who had failed previous thrombolysis. Eighty percent had a postoperative Rankin score of 0 on discharge and 88% of patients were discharged home with 3 requiring rehabilitation. Positive neurological outcomes and no serious adverse events were observed using TNP during emergency CEA in patients with acute brain injury. We recommend TNP for patients who are at an increased risk of stroke perioperatively, or who have already suffered from an acute stroke beyond the recommended window of 24hr. Certainly, the positive outcomes are not likely reproducible outside of high-volume units and patients requiring this surgery should be transferred to experienced surgeons in appropriate tertiary referral centers.

Abstract TP414: ABCD3-I Score Performance With Tissue- vs Time-Based Dual Transient Ischemic Attack

Background: Evidence demonstrated diffusion-weighted imaging (DWI) lesions of different age predicted future stroke in transient ischemic attack (TIA) patients. The aim of this study is to develop a novel score (mABCD3-I) by replacing dual TIA with DWI lesions of different age and externally validate it in a multicenter TIA cohort. Methods: We conducted a prospective cohort study. The predictive outcome was stroke/all-cause death. Cox proportional hazards model was used to evaluate the predictive value of risk factors. The area under the curves (AUC) and net reclassification improvement (NRI) were used to present the discriminative and risk stratification abilities. Results: 2283 patients were included: 1077 in the derivation cohort and 1206 in the validation cohort. We derived mABCD3-I score by replacing dual TIA with DWI lesions of different age based on results of the multivariate analysis (Table 1). In the derivation cohort (Table 2), the AUCs for the mABCD3-I score were 0.78 at 90-day (95% confidence interval [CI]: 0.75-0.80; compared with ABCD3-I score, p=0.002), 0.78 at 6-month (95%CI: 0.75-0.81; p=0.008) and 0.78 at 1-year (95%CI: 0.75-0.81; p=0.018). The mABCD3-I score improved the reclassification at 90-day (p=0.006) and 6-month (p=0.033). In the validation cohort, the mABCD3-I had equal discriminative abilities compared with ABCD3-I score at 90-day (p=0.056) and 6-month (p=0.054), and higher ability at 1-year (p=0.044). Conclusions: Replacing dual TIA with DWI lesions of different age in ABCD3-I score improved risk prediction for stroke/death risk after TIA.

Incidence and Predictors of Acute Ischemic Lesions on Brain Magnetic Resonance Imaging in Patients With a Clinical Diagnosis of Transient Ischemic Attack in China.

Background: The associations between the clinical characteristics and diffusion-weighted imaging (DWI) positivity in patients with a clinical diagnosis of transient ischemic attack (TIA) are still poorly understood. The purpose of our study was to determine the incidence of TIA related acute infarction by DWI, and to determine the underlying predictors of DWI positivity in TIA patients.Methods: Between Jan 2017 and Dec 2018, we retrospectively enrolled 430 patients with a clinical diagnosis of TIA who underwent DWI. Patients were divided into those with acute ischemic lesions (DWI positive group) and those without (DWI negative group). The clinical characteristics, laboratory data, and imaging parameters were compared between the two groups.Results: A total of 430 time-based TIA patients (mean age, 61.4 ± 13.0) were enrolled in this study. About 126 (29.3%) of TIA patients had a DWI positive lesion in our series. Comparing TIA patients with positive DWI to those with negative DWI, acute lesions were more likely to be more male, have higher hyperlipidemia and a smoking history, more speech abnormalities and increased motor weakness; and higher systolic and diastolic blood pressure, homocysteine, fasting blood glucose, and the scores of ABCD2, ABCD3, ABCD3-I, and Dawson. Several independent predictors of DWI positivity were identified with logistic regression analysis: motor weakness (odds ratio 4.861, P = 0.021), speech abnormalities (odds ratio 4.029, P = 0.024), and ABCD3-I (odds ratio 13.141, P = 0.001). ABCD3-I showed the greatest area under the ROC curve, with a sensitivity of 85.7% and specificity of 72.4%.Conclusion: In patients with a clinical diagnosis of TIA, 29.3% demonstrated acute DWI lesions on brain magnetic resonance imaging (MRI). They were associated with motor weakness, speech abnormalities and higher ABCD3-I score at admission.

Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department

BackgroundThe use of ABCD3-I score for Transient ischemic attack (TIA) evaluation has not been widely investigated in the ED. We aim to determine the performance and cost-effectiveness of an ABCD3-I based pathway for expedited evaluation of TIA patients in the ED. MethodsWe conducted a single-center, pre- and post-intervention study among ED patients with possible TIA. Accrual occurred for seven months before (Oct. 2016–April 2017) and after (Oct. 2017–April 2018) implementing the ABCD3-I algorithm with a five-month wash-in period (May–Sept. 2017). Total ED length of stay (LOS), admissions to the hospital, healthcare cost, and 90-day ED returns with subsequent stroke were analyzed and compared. ResultsPre-implementation and post-implementation cohorts included 143 and 118 patients respectively. A total of 132 (92%) patients were admitted to the hospital in the pre-implementation cohort in comparison to 28 (24%) patients admitted in the post-implementation cohort (p < 0.001) with similar 90-day post-discharge stroke occurrence (2 in pre-implementation versus 1 in post-implementation groups, p > 0.05). The mean ABCD2 scores were 4.5 (1.4) in pre- and 4.1 (1.3) in post-implementation cohorts (p = 0.01). The mean ABCD3-I scores were 4.5 (1.8) in post-implementation cohorts. Total ED LOS was 310 min (201, 420) in pre- and 275 min (222, 342) in post-implementation cohorts (p > 0.05). Utilization of the ABCD3-I algorithm saved an average of over 40% of total healthcare cost per patient in the post-implementation cohort. ConclusionsThe initiation of an ABCD3-I based pathway for TIA evaluation in the ED significantly decreased hospital admissions and cost with similar 90-day neurological outcomes.

Abstract TP405: Dual Antiplatelet Therapy Reduced Stroke Risk in High-risk Transient Ischemic Attack Patients Assessed by ABCD3-I Score

Introduction: Studies showed dual antiplatelet therapy (DAPT) benefited TIA patients with an ABCD2 score ≥4. The present study aims to investigate whether the ABCD3-I score could be a more appropriate tool for TIA patients’ selection to use DAPT in the real-world experience. Methods: We derived data from the TIA database of the First Affiliated Hospital of Zhengzhou University. The predictive outcome was ischemic stroke at 90-day. Cox proportional hazards regression was used to examine the interaction effect between risk score and antiplatelet treatment. The Kaplan-Meier curves were plotted to present cumulative stroke rates in different risk patients with monotherapy and DAPT. Results: Among 785 patients, the mean (SD) age was 56.95 (12.73) years and 38.3% were female (n =301). A percentage of 36.9% patients used DAPT during hospitalization, and 77 patients (9.8%) had an ischemic stroke at 90-day. The Kaplan-Meier curves showed a significant difference between patients with monotherapy and DAPT in high-risk TIA patients (p= 0.021, Figure 1). After adjustment for confounding factors, DAPT only reduced 90-day stroke risk in high-risk TIA patients assessed by ABCD3-I score (HR= 0.402, 95%CI 0.189-0.859, p= 0.019, Table 1 and 2). Conclusions: High-risk TIA patients assessed by ABCD3-I score received the most pronounced clinical benefit from DAPT in the real-clinical experience.

Abstract TMP97: Impact of Intima Media Thickness on Stroke Recurrence in Patients With Transient Ischemic Attack

Introduction: Carotid stenosis lesions are a risk factor for stroke recurrence after transient ischemic attack (TIA) and are taken into consideration when determining the ABCD 3 -I score. However, few reports have examined the impact of the degree of maximum intima media thickness (max IMT) by sonographic examination on stroke recurrence. Hypothesis: We hypothesized that a larger max IMT would be associated with a greater risk of stroke recurrence. Methods: We enrolled 3,100 consecutive acute stroke patients who were hospitalized in our stroke center from June 2007 to February 2016. The clinical characteristics of patients were assessed on admission, and the clinical course of all patients was subsequently followed. Patients were divided into four groups based on the level of max IMT: I (max IMT &lt; 1.1 mm), II (max IMT ≥ 1.1 but &lt; 2.1 mm), III (max IMT ≥ 2.1 but &lt; 3.1 mm), and IV (max IMT ≥ 3.1 mm). We performed multivariate cox proportional hazards analyses to determine the influence of max IMT grade in these groups on stroke recurrence. Results: Of all patients, 468 (295 men, 68 ± 13 years) cases with TIA were investigated in the present study. Thirty-seven patients (9.2%) suffered recurrence of ischemic stroke during the follow-up period of three months. The three-months gross recurrence rate was 7.7% in group I, 8.7% in group II, 11.4% in group III, and 28.6% in group IV. The Kaplan-Meier method revealed significantly different cumulative recurrence rates of ischemic stroke in the four groups of patients, as shown in Figure 1 (I vs. IV, p &lt; 0.01, log-rank test). On Cox proportional analysis with adjustments for multiple confounding factors, group IV (hazard ratio: 6.17, 95% confidence interval: 1.86-8.52, p &lt; 0.05) had a greater risk of stroke recurrence compared with group I (reference). Conclusions: There is a significant relationship between the level of max IMT and recurrence of ischemic stroke. TIA patients with a larger max IMT have a greater risk of stroke recurrence.

Combining Diffusion-Weighted Imaging Patterns with ABCD2 Score Predicts Stroke Risk after Transient Ischemic Attack.

Recent studies indicated that multiple acute infarctions on Diffusion- Weighted Imaging (DWI) were associated with a higher risk of stroke. The study aims to estimate the association of different infarction patterns and ABCD2 score with the prognosis of Transient Ischemic Attack (TIA). We prospectively analyzed the data from TIA database of the First Affiliated Hospital of Zhengzhou University. The predictive outcome was a 90-day ischemic stroke. Cox proportional hazards model was used to evaluate the predictive value of risk factors associated with stroke. The receiver-operating characteristics curves were plotted, and the predictive value was assessed by computing the Area Under the Curve (AUC). A total of 1376 eligible patients were enrolled. DWI patterns were significant predictors for stroke (single acute infarction: hazard ratio [HR] =2.942, p <0.001; multiple acute infarctions: HR =5.552, p <0.001, in comparison with no acute infarction). Patients with both multiple infarctions and ABCD2 ≥4 were associated with approximately 15.5-fold risk of stroke at 90 days (28.8% vs. 2.1%, HR =15.455, 95% confidence interval [CI], 7.946-30.057, p <0.001), compared with those with no infarction or ABCD2 <4. The ABCD2+ DWI patterns showed a better discrimination with an AUC of 0.765 (95% CI, 0.741-0.787) than the ABCD2 score (AUC =0.651; 95% CI, 0.625-0.676; Z =4.777; p <0.0001) and ABCD3-I score (AUC =0.724; 95% CI, 0.700- 0.748; Z =2.697; p =0.007). Combining infarction patterns with ABCD2 score could enhance the predictive value for early stroke risk in TIA.

Dual antiplatelet therapy reduced stroke risk in high-risk patients with transient ischaemic attack assessed by ABCD3-I score.

Several clinical trials have demonstrated that dual antiplatelet therapy (DAPT) benefited patients with transient ischaemic attack (TIA) with an ABCD2 score ≥4. The present study aimed to investigate whether the ABCD3-I score could be a more appropriate tool for selection of patients with TIA to receive DAPT in real-world settings. We derived data from the TIA database of The First Affiliated Hospital of Zhengzhou University. The predictive outcome was ischaemic stroke at 90days. The additive interaction effect was presented by the attributable proportion due to interaction. Kaplan-Meier curves were plotted to present cumulative stroke rates in different risk categories with monotherapy and DAPT. Cox proportional hazards regression was used to determine risk factors associated with stroke. Among 785 patients, the mean (SD) age was 56.95 (12.73) years and 77 patients (9.8%) had an ischaemic stroke at 90days. A total of 55.8% of patients (attributable proportion due to interaction; 95% confidence interval, 20.8%-90.9%) were attributed to additive interaction of ABCD3-I score and antiplatelet therapy. Kaplan-Meier curves showed a significant difference between patients receiving monotherapy and DAPT in high-risk patients with TIA (P=0.021). DAPT reduced 90-day stroke risk in high-risk patients with TIA as assessed independently by ABCD3-I score (adjusted hazard ratio, 0.43; 95% confidence interval, 0.20-0.92, P=0.031). The benefit did not exist in low- and medium-risk patients by ABCD3-I score (patients with ABCD2 score≥4 or <4). High-risk patients with TIA assessed by ABCD3-I score received the most pronounced clinical benefit from early use of DAPT in real-world clinical experience.

The inreased level of serum small dense low-density lipoprotein cholesterol in patients with transient ischemic attacks and its correlation with recurrent stroke

Objective To investigate serum levels of small dense low-density lipoprotein cholesterol (sdLDL-C) in transient ischemic attacks (TIA) patients and assess their predictive values for subsequent stroke risk after TIA. Methods Clinical case-control study. Serum sdLDL-C levels were determined in 96 TIA patients who were admitted to Jinling Hospital from January 2016 to December 2016 and 44 healthy controls who had contemporaneously visited Jinling Hospital For a routine or the routine. ABCD3-I scores in TIA patients were calculated. All TIA patients were classified into three subgroups: high-risk (8≤ABCD3-I≤ 13, n=23), moderate-risk (4≤ABCD3-I≤ 7, n=36) and low-risk (0≤ABCD3-I≤ 3, n=37). Total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and other lipid/lipoprotein parameters in TIA patients and controls were also analyzed. Spearman correlation analyses and multivariate linear regression analyses were performed to investigate the association of serum sdLDL-C levels with ABCD3-I scores. Logistic regression analyses were performed to investigate the predictive values of serum sdLDL-C for TIA patients. Results Serum sdLDL-C levels were significantly increased in TIA patients compared with controls (t=-5.202, P<0.001). Furthermore, sdLDL-C levels in high-risk patients were significantly higher than that in moderate-risk (t=3.534, P=0.001) and low-risk (t=4.154, P<0.001) patients. Serum sdLDL-C levels were positively correlated with ABCD3-I scores (r=0.317, P=0.002) in TIA patients. The stepwise multiple regression analysis showed that only sdLDL-C was a significant independent predictor of ABCD3-I scores (β=0.481, P=0.032, adjusted R2=0.189), after adjusting for age, gender, blood pressure and other lipid/lipoprotein parameters. Binary Logistic analyses indicated that serum sdLDL-C levels were closely associated with TIA presence (OR=2.84, 95% CI=1.42-5.70, P=0.003), after adjustment with age, gender, blood pressure and other lipid/lipoprotein parameters. Conclusions Serum sdLDL-C levels were increased in TIA patients. The significantly independent associations of sdLDL-C levels with ABCD3-I scores were observed. Serum sdLDL-C levels may contribute to assessing subsequent stroke risk after TIA.(Chin J Lab Med, 2018, 41: 316-320) Key words: Ischemic attack, transient; Cholesterol, LDL; Stroke; Risk factors; Biomarkers

ABCD3-I score and the risk of early or 3-month stroke recurrence in tissue- and time-based definitions of TIA and minor stroke

Changing definition of TIA from time to a tissue basis questions the validity of the well-established ABCD3-I risk score for recurrent ischemic cerebrovascular events. We analyzed patients with ischemic stroke with mild neurological symptoms arriving < 24 h after symptom onset in a phase where it is unclear, if the event turns out to be a TIA or minor stroke, in the prospective multi-center Austrian Stroke Unit Registry. Patients were retrospectively categorized according to a time-based (symptom duration below/above 24 h) and tissue-based (without/with corresponding brain lesion on CT or MRI) definition of TIA or minor stroke. Outcome parameters were early stroke during stroke unit stay and 3-month ischemic stroke. Of the 5237 TIA and minor stroke patients with prospectively documented ABCD3-I score, 2755 (52.6%) had a TIA by the time-based and 2183 (41.7%) by the tissue-based definition. Of the 2457 (46.9%) patients with complete 3-month followup, corresponding numbers were 1195 (48.3%) for the time- and 971 (39.5%) for the tissue-based definition of TIA. Early and 3-month ischemic stroke occurred in 1.1 and 2.5% of time-based TIA, 3.8 and 5.9% of time-based minor stroke, 1.2 and 2.3% of tissue-based TIA as well as in 3.1 and 5.5% of tissue-based minor stroke patients. Irrespective of the definition of TIA and minor stroke, the risk of early and 3-month ischemic stroke steadily increased with increasing ABCD3-I score points. The ABCD3-I score performs equally in TIA patients in tissue- as well as time-based definition and the same is true for minor stroke patients.

Comparison of Stroke Prediction Accuracy of ABCD2 and ABCD3-I in Patients with Transient Ischemic Attack: A Meta-Analysis

A direct comparison of the stroke prediction utility of the ABCD2 and ABCD3-I scores has not been performed. Thus, we conducted a diagnostic meta-analysis and applied the results to a hypothetical cohort of 1000 patients with transient ischemic attack (TIA) to assess the power of stroke prediction by ABCD2 and ABCD3-I scores. Medline, PubMed, Embase, and manuscript references were searched to identify studies that directly compared the stroke predictive powers of ABCD2 and ABCD3-I scores. We conducted a diagnostic meta-analysis using bivariate random effects models, and the predictive powers of ABCD2 and ABCD3-I scores were assessed by their summary sensitivity and specificity. Then, we applied the results to a hypothetical cohort of 1000 patients with TIA to calculate the effect per 1000 patients triaged for stroke prevention in a virtual setting. Of the 35 identified studies on ABCD2 and ABCD3-I, 6 studies (7364 participants) directly compared the diagnostic accuracies of ABCD2 and ABCD3-I scores for occurrence of a future stroke. The pooled sensitivities of ABCD2 versus ABCD3-I were 79.9% (62.2%-90.6%) versus 96.1% (90.2%-98.5%) at 7 days (P = .022), and 76.6% (63.8%-85.8%) versus 94.6% (88.9%-97.5%) at 90 days (P = .001). The pooled specificities of ABCD2 versus ABCD3-I were 29.2% (18.2%-43.3%) versus 17.7% (8.5%-33.3%) at 7 days (P = .214), and 40.3% (25.0%-57.7%) versus 20.2% (12.6%-30.6%) at 90 days (P = .032). ABCD3-I scores had a better sensitivity but poorer specificity than ABCD2 scores. However, in community-based referring settings, it is more suitable to use ABCD2 at initial triage and deciding on urgency of specialist assessment. The prognostic utility of each of the components of the scores should be carefully considered rather than dichotomized scores during clinical triage.

Validation and comparison of imaging-based scores for prediction of early stroke risk after transient ischaemic attack: a pooled analysis of individual-patient data from cohort studies

Identification of patients at highest risk of early stroke after transient ischaemic attack has been improved with imaging based scores. We aimed to compare the validity and prognostic utility of imaging-based stroke risk scores in patients after transient ischaemic attack. We did a pooled analysis of published and unpublished individual-patient data from 16 cohort studies of transient ischaemic attack done in Asia, Europe, and the USA, with early brain and vascular imaging and follow up. All patients were assessed by stroke specialists in hospital settings as inpatients, in emergency departments, or in transient ischaemic attack clinics. Inclusion criteria were stroke-specialist confirmed transient ischaemic attack, age of 18 years or older, and MRI done within 7 days of index transient ischaemic attack and before stroke recurrence. Multivariable logistic regression was done to analyse the predictive utility of abnormal diffusion-weighted MRI, carotid stenosis, and transient ischaemic attack within 1 week of index transient ischaemic attack (dual transient ischaemic attack) after adjusting for ABCD2 score. We compared the prognostic utility of the ABCD2, ABCD2-I, and ABCD3-I scores using discrimination, calibration, and risk reclassification. In 2176 patients from 16 cohort studies done between 2005 and 2015, after adjusting for ABCD2 score, positive diffusion-weighted imaging (odds ratio [OR] 3·8, 95% CI 2·1-7·0), dual transient ischaemic attack (OR 3·3, 95% CI 1·8-5·8), and ipsilateral carotid stenosis (OR 4·7, 95% CI 2·6-8·6) were associated with 7 day stroke after index transient ischaemic attack (p<0·001 for all). 7 day stroke risk increased with increasing ABCD2-I and ABCD3-I scores (both p<0·001). Discrimination to identify early stroke risk was improved for ABCD2-I versus ABCD2 (2 day c statistic 0·74 vs 0·64; p=0·006). However, discrimination was further improved by ABCD3-I compared with ABCD2 (2 day c statistic 0·84 vs 0·64; p<0·001) and ABCD2-I (c statistic 0·84 vs 0·74; p<0·001). Early stroke risk reclassification was improved by ABCD3-I compared with ABCD2-I score (clinical net reclassification improvement 33% at 2 days). Although ABCD2-I and ABCD3-I showed validity, the ABCD3-I score reliably identified highest-risk patients at highest risk of a stroke after transient ischaemic attack with improved risk prediction compared with ABCD2-I. Transient ischaemic attack management guided by ABCD3-I with immediate stroke-specialist assessment, urgent MRI, and vascular imaging should now be considered, with monitoring of safety and cost-effectiveness. Health Research Board of Ireland, Irish Heart Foundation, Irish Health Service Executive, Irish National Lottery, National Medical Research Council of Singapore, Swiss National Science Foundation, Bangerter-Rhyner Foundation, Swiss National Science Foundation, Swisslife Jubiläumsstiftung for Medical Research, Swiss Neurological Society, Fondazione Dr Ettore Balli (Switzerland), Clinical Trial Unit of University of Bern, South Korea's Ministry for Health, Welfare, and Family Affairs, UK Wellcome Trust, Wolfson Foundation, UK Stroke Association, British Heart Foundation, Dunhill Medical Trust, National Institute of Health Research (NIHR), Medical Research Council, and the NIHR Oxford Biomedical Research Centre.

Spotlight on the August 30 Issue

#### Notable in Neurology This issue features an article determining whether diabetes mellitus is a risk factor for spontaneous intracerebral hemorrhage and another investigating the effects of hormone therapy on brain structure in recently postmenopausal women. A featured article analyzes the clinical presentation and outcomes of surgically treated focal cortical dysplasia in children. ### Predictive value of ABCD2 and ABCD3-I scores in TIA and minor stroke in the stroke unit setting![Graphic][1]</img> Established scores predicted risk of recurrent stroke after TIA and minor stroke for patients treated on stroke units. Initial clinical presentation with hemiparesis, results of imaging studies, and symptom duration over 24 hours were the most … [1]: /embed/inline-graphic-1.gif