Transient Ischemic Attack Score Research Articles

Validation of the Canadian TIA Score to Predict Subsequent Stroke Risk in Chinese TIA Patients

Background and Objectives: The Canadian TIA Score has been verified as a good predictive tool for subsequent stroke risk in Caucasian patients; however, it had insufficient external verification of other races. We aimed to validate the Canadian TIA Score in Chinese patients and compared it with ABCD² for subsequent stroke risk after transient ischemic attack (TIA). Methods: The Third China National Stroke Registry (CNSR-III) was a nationwide, multicenter prospective registry recruiting consecutive patients with acute ischemic stroke or TIA within 7 days of the onset from August 2015 to March 2018. The Canadian TIA Score was verified in patients diagnosed with TIA from the CNSR-III (N = 1,184). The outcomes were subsequent stroke at 7 days, 14 days/discharge, 3 months, and 1 year. Outcomes were recorded by face-to-face assessment or telephone interview. The prognostic performance of the scoring system was assessed by the area under the receiver operator characteristic curve (AUC). Results: Of 1,184 TIA patients (mean [IQR] age, 61.00 [53.00–69.00] years; 413 women [34.88%]), there were 40 patients (3.38%) having subsequent stroke within 7 days, 45 (3·80%) within 14 days/hospitalization, 66 (5·57%) within 3 months, and 100 (8·45%) within 1 year. The Canadian TIA Score (AUC 0 63–0·68) seemed to be a better prognostic score of stroke risk than the ABCD² score (AUC 0·61–0·62), although no significant differences were noted. In the subgroup of atypical TIA, the Canadian TIA Score showed significantly stronger predictivity than the ABCD² score within 7 days (0.80 [0.62–0.98] vs. 0.52 [0.30–0.73]; difference in AUC, 0.28 [0.03–0.53]; p, 0.026), and marginal significantly stronger predictivity within 1 year (0.71 [0.61–0.80] vs. 0.58 [0.48–0.68]; difference in AUC, 0.12 [−0.01 to 0.25]; p, 0.06). Conclusion: The Canadian TIA Score might be a better prognostic score than the ABCD² score for post-TIA stroke risk, especially in patients with atypical TIA.

The Canadian TIA Score Is Now Prospectively Validated

The elevated risk for stroke after a transient ischemic attack (TIA) presents an important opportunity for interventions to prevent an impending

Dysphasia is associated with diffusion-weighted MRI abnormalities in patients with transient neurological symptoms

BackgroundThe clinical characteristics of diffusion-weighted imaging (DWI) abnormalities after transient neurological symptoms are of great significance for the early diagnosis and urgent intervention of transient ischemic attack (TIA). This study was aimed to investigate the clinical characteristics associated with acute DWI lesions in transient neurological symptoms.MethodsWe retrospectively recruited 302 patients with transient neurological symptoms. According to DWI findings, they were divided into DWI positive and DWI negative group. The clinical characteristics and the TIA-related scores such as ABCD2, ABCD3, ABCD3I, Dawson score, and the Diagnosis of TIA (DOT) score were compared between the two groups. Logistic regression analysis and receiver operating characteristic curves were used to identify the independent factors and compare the predictive value of different TIA scores for acute DWI lesions.ResultsA total of 302 patients were enrolled in this study. The mean age was 61.8 years, and 67.2% were male. We found 89 (29.5%) patients with DWI positivity. Logistic regression analysis showed the characteristic associated with DWI lesions was dysphasia (OR 2.226, 95% CI 1.220–4.062). The area under the curve for Dawson score and the DOT score was 0.610 (95% CI 0.543–0.678) and 0.625 (95% CI 0.559–0.691), respectively.ConclusionWe found that DWI lesions were detected in 29.5% of patients with transient neurological symptoms and were associated with dysphasia. Dawson score and DOT score could have a higher predictability of DWI lesions in patients with transient neurological symptoms.

External Validation of the Diagnosis of TIA (DOT) Score for Identification of TIA in a Chinese Population.

Background: Recently, the [diagnosis of transient ischemic attack (TIA), DOT] score has been recognized to be a new tool for non-specialists to diagnose TIA more accurately with the sensitivity and specificity being 89 and 76%, respectively. However, the DOT score has not yet been validated externally in patients with TIA in China.Methods: We retrospectively enrolled 500 consecutive patients with transient neurological symptoms, who were admitted to the Department of Neurology, Beijing Chaoyang Hospital and underwent magnetic resonance imaging (MRI) between Jan 2016 and Dec 2018. Patients with transient neurological symptoms were divided into two subgroups: TIA mimic group (N = 140, 28%) and definite cerebrovascular events group including tissue-based TIA (DWI negative, N = 252, 50.4%) and minor stroke (DWI positive, N = 108, 21.6%). The demographic data, clinical characteristics, laboratory findings, and scores of Dawson and DOT were compared between the two groups.Results: A total of 500 patients with transient neurological symptoms (mean age, 61.1 ± 12.8) were enrolled and 70% (N = 350) were male. Comparing with TIA mimic groups, patients with cerebrovascular events group were more likely to have higher diastolic blood pressure, uric acid and homocysteine, more motor weakness and speech abnormalities, and also scored higher using the Dawson and DOT. The area under the curve (AUC) was 0.728 for DOT, with a sensitivity of 70.3% and specificity of 62.9%, respectively.Conclusion: In patients with transient neurological symptoms, our findings showed that the DOT score had relatively good calibration and discrimination to identify of TIA in a Chinese Population. As a novel tool of TIA identification, further validations are needed in multiple centers with larger samples in China.

PL01: Prospective multicenter validation of the Canadian TIA Score for predicting subsequent stroke within seven days

Introduction: Individualizing risk for stroke following a transient ischemic attack (TIA) is a topic of intense research, as existing scores are context-dependent or have not been well validated. The Canadian TIA Score stratifies risk of subsequent stroke into low, moderate and high risk. Our objective was to prospectively validate the Canadian TIA Score in a new cohort of emergency department (ED) patients. Methods: We conducted a prospective cohort study in 14 Canadian EDs over 4 years. We enrolled consecutive adult patients with an ED visit for TIA or nondisabling stroke. Treating physicians recorded standardized clinical variables onto data collection forms. Given the ability of prompt emergency carotid endarterectomy (CEA) to prevent stroke (NNT = 3) in high risk patients, our primary outcome was the composite of subsequent stroke or CEA ≤7 days. We conducted telephone follow-up using the validated Questionnaire for Verifying Stroke Free Status at 7 and 90 days. Outcomes were adjudicated by panels of 3 local stroke experts, blinded to the index ED data collection form. Based on prior work, we estimated a sample size of 5,004 patients including 93 subsequent strokes, would yield 95% confidence bands of +/− 10% for sensitivity and likelihood ratio (LR). Our analyses assessed interval LRs (iLR) with 95% CIs. Results: We prospectively enrolled 7,569 patients with mean 68.4 +/−14.7 years and 52.4% female, of whom 107 (1.4%) had a subsequent stroke and 74 (1.0%) CEA ≤7 days (total outcomes = 181). We enrolled 81.2% of eligible patients; missed patients were similar to enrolled. The Canadian TIA Score stratified the stroke/CEA ≤7days risk as: Low (probability <0.2%, iLR 0.20 [95%CI 0.091-0.44]; Moderate (probability 1.3%, iLR 0.79 [0.68-0.92]; High (probability 2.6%, iLR 2.2 [1.9-2.6]. Sensitivity analysis for just stroke ≤7 days yielded similar results: Low iLR 0.17 [95%CI 0.056-0.52], Medium iLR 0.89 [0.75-1.1], High iLR 2.0 [1.6-2.4]. Conclusion: The Canadian TIA Score accurately identifies TIA patients risk for stroke/CEA ≤7 days. Patients classified as low risk can be safely discharged following a careful ED assessment with elective follow-up. Patients at moderate risk can undergo additional testing in the ED, have antithrombotic therapy optimized, and be offered early stroke specialist follow-up. Patients at high risk should in most cases be fully investigated and managed ideally in consultation with a stroke specialist during their index ED visit.

Acute Ischemic Events in Patient Receiving Direct Oral Anticoagulants for Atrial Fibrilation: Incidence, Outcome and Clinical Profile

▪IntroductionThe use of direct oral anticoagulants (DOACs) is increasing for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). Despite the good efficacy/safety balance, clinicians will be confronted with patients under treatment with DOAC presenting with ischemic events. Currently, there is a paucity of data from investigational studies regarding the clinical profile, risk factors and most suitable therapeutic intervention after therapeutic failure with these anticoagulants.AimsTo describe the clinical profile and assess the rate of subsequent ischemic events appearing during the course of anticoagulant therapy and tried to identify risk factors for these events in "real life" population treated with DOACs.MethodsIn this multicenter and retrospective study we included patients with NVAF who had recived DOACs. Ischemic Events during february 2013 to february 2016 was analyzed.ResultsWe enrolled, 3353 patients with NVAF who had recived DOACs. During the course of anticoagulation (mean, 9.4 months), 39 patients (1.16%) developed ischemic events (stroke, 22; transient ischemic attack (TIA), 7; peripheral embolism, 10). Rate of ischemic events was 0.9/100 patient-years. Median age was 76 years (range: 51-92) and 25 (64.1%) were female. Among them, 19 patients received dabigatran, 14 rivaroxaban and 6 apixaban. As per the thrombotic risk score, 66.7% of the patients were classified as "high risk" (CHA2DS2-VASc score > 5). Thirty-eight patients (97.4%) received vitamin K antagonists (VKA) prior to use of DOAC. Ischemic events patients had a higher incidence of hypertention (94.9% ), diabetes (64.1%), history of previous ischemic stroke (74.4%) and therapeutic failure with VKA (79.5%). Nonadherence to treatment was identified only in 6 patients (15.4%). On multivariable analysis, previous ischemic stroke/ TIA (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.21-2.61), female sex (HR, 1.54; 95% CI, 1.05-2.26), and CHA2DS2-VASc score>5 (HR, 1.72; 95% CI, 1.25-2.36) were independently associated with the risk for ischemic events.For the management of acute ischemic event, 20 patients received endovascular treatment, 12 patients switched from DOAC to unfractionated heparin or low molecular weight heparin and intravenous fibrinolysis was performed in 7 patients; intracranial hemorrhage being observed in two patients after treatment with thrombolytic therapy. Regarding the subsequent anticoagulation continuation at discharge, 19 patients switched to concomitant therapy with DOAC and antiplatelets, 12 patients to other DOAC and only 8 to VKA. There was a 5.1% 30 day mortality after ischemic event and 15.4% of patients had neurologic complications after ischemic event.ConclusionsWe described a low rate of stroke in patients treated with DOACs, but further studies are necessary in order to identify very high-risk patients with special emphasis in those with high CHA2DS2-VASC score, previous stroke and a correct anticoagulation. DisclosuresNo relevant conflicts of interest to declare.

National Survey of Neurologists for Transient Ischemic Attack Risk Stratification Consensus and Appropriate Treatment for a Given Level of Risks

Patients with a new transient ischemic attack (TIA) have a 5% subsequent stroke risk within 7 days. The Canadian TIA Score accurately determines the risk of subsequent stroke risk; however, it is unclear if physicians will use this new scale or how it will be used. Our objectives were to assess: (1) anticipated use; (2) component face validity; (3) risk strata for stroke within 7 days; and (4) actions required, for a given risk for subsequent stroke based on the proposed Canadian TIA Score. After a rigorous development process (sample selection, key informant interviews, development of questionnaire following Dillman Tailored Design technique, cognitive interviews, and pilot-testing), a survey questionnaire was administered to a random sample of 300 neurologists selected from all neurologists listed in a national medical directory. The surveys were distributed using a modified Dillman technique. From a total of 265 eligible surveys, we received 140 (52.8%) completed surveys; 7 of 13 components comprising the Canadian TIA Score were rated as "very important" or "important" by survey respondents. Risk categories for subsequent stroke were defined as: minimal risk: less than 1%; low risk: 2%-4.9%; high risk: 5%-10%; critical risk: more than 10% risk of subsequent stroke within 7 days. Most (87.1%) of the neurologists would use a validated Canadian TIA Score. Neurologists appear ready to use a validated Canadian TIA Score in their clinical practice. Risk strata are definable, which may allow physicians to determine immediate actions, based on subsequent stroke risk.

National survey of emergency physicians for transient ischemic attack (TIA) risk stratification consensus and appropriate treatment for a given level of risk.

Five percent of transient ischemic attack (TIA) patients have a subsequent stroke within 7 days. The Canadian TIA Score uses clinical findings to calculate the subsequent stroke risk within 7 days. Our objectives were to assess 1) anticipated use; 2) component face validity; 3) risk strata for stroke within 7 days; and 4) actions required, for a given risk for subsequent stroke. After a rigorous development process, a survey questionnaire was administered to a random sample of 300 emergency physicians selected from those registered in a national medical directory. The surveys were distributed using a modified Dillman technique. From a total of 271 eligible surveys, we received 131 (48.3%) completed surveys; 96.2% of emergency physicians would use a validated Canadian TIA Score; 8 of 13 components comprising the Canadian TIA Score were rated as Very Important or Important by survey respondents. Risk categories for subsequent stroke were defined as minimal-risk: 10% risk of subsequent stroke within 7 days. A validated Canadian TIA Score will likely be used by emergency physicians. Most components of the TIA Score have high face validity. Risk strata are definable, which may allow physicians to determine immediate actions, based on subsequent stroke risk, in the emergency department.

SS12. Urgent Carotid Intervention Is Safe After Thrombolysis for Acute Stroke

Carotid intervention (carotid endarterectomy [CEA], carotid artery stenting [CAS]) shortly after an acute neurologic ischemic event is being performed more frequently in stroke centers to reduce the risk of recurrent stroke and is most effective when performed within 7 to 14 days. Thrombolysis is offered to select patients with ischemic stroke symptoms who present within 4.5 hours. However, there is a paucity of data whether thrombolysis followed by “urgent” CEA/CAS (uCEA/uCAS) has an increased risk of complications, particularly intracerebral hemorrhage (ICH). We sought to determine the periprocedural complications of uCEA/uCAS following thrombolysis. From January 2009 to January 2015, 762 patients underwent carotid interventions (CEA, n = 440; CAS, n = 323) at our tertiary referral center. Of these, 165 patients (21.6%) underwent uCEA/uCAS during the index hospitalization for an acute transient ischemic attack (TIA)/stroke. A vascular neurologist assessed all patients on admission. We compared the effect of thrombolysis (tissue plasminogen activator (tPA): 0.9 mg/kg; 10% bolus, followed by 90% infusion over 1 hour) on 30-day complications, including ICH, any bleeding, stroke, death, and myocardial infarction (MI). The Fisher exact test was used to determine significance between groups. During the 6-year period, 165 patients underwent an urgent carotid intervention (uCEA, n = 135; uCAS, n = 30) for acute neurologic symptoms. The mean National Institutes of Health Stroke Scale (NIHSS) was 5.6 (range, 0-26), and the mean ABCD2 TIA score was 4.4 (range, 2-7). Of these, 19% (31 patients [CEA, n = 25; CAS, n = 6]) had tPA for an acute stroke, and the rest (134 patients [CEA, n = 110; CAS, n=24]) were outside of the tPA time window. The mean time to intervention (uCEA/uCAS) was 2.4 days (range, 0-15); for the tPA group, it was 1.9 days (range, 0-7 days) compared with 2.9 days (range, 0-15 days) for the no tPA group (Fig). The 30-day overall complication rate was not statistically different between the tPA group (4 of 31) compared with the non-tPA cohort (9 of 134; P = .35). In the tPA group, there were 1 ICH, 1 neck hematoma, and 2 deaths; in the non-tPA group there were 2 ICHs, 2 neck hematomas, 2 deaths, 1 stroke, and 2 MIs. No significant increased rates of bleeding were noted within the tPA (2 of 31) vs no tPA group (4 of 134; P = .32). Moreover, in the tPA cohort, more than half of the patients (17 of 31) underwent revascularization (CEA = 13, CAS=4) within 48 hours, and no worse outcomes were noted in these patients compared with those who underwent revascularization after 48 hours (P = .30). Thrombolysis, followed by uCEA/uCAS, is not associated with an increased risk of complications in select patients who present with acute neurologic symptoms. Patient selection is important, because most patients had a small-to-moderate ischemic stroke (NIHSS <10). Furthermore, there was no increased bleeding risk, particularly ICH, in patients whose carotid intervention was performed <2 days after receiving thrombolysis.

A Prospective Cohort Study of Patients With Transient Ischemic Attack to Identify High-Risk Clinical Characteristics

The occurrence of a transient ischemic attack (TIA) increases an individual's risk for subsequent stroke. The objectives of this study were to determine clinical features of patients with TIA associated with impending (≤7 days) stroke and to develop a clinical prediction score for impending stroke. We conducted a prospective cohort study at 8 Canadian emergency departments for 5 years. We enrolled patients with a new TIA. Our outcome was subsequent stroke within 7 days of TIA diagnosis. We prospectively enrolled 3906 patients, of which 86 (2.2%) experienced a stroke within 7 days. Clinical features strongly correlated with having an impending stroke included first-ever TIA, language disturbance, longer duration, weakness, gait disturbance, elevated blood pressure, atrial fibrillation on ECG, infarction on computed tomography, and elevated blood glucose. Variables less associated with having an impending stroke included vertigo, lightheadedness, and visual loss. From this cohort, we derived the Canadian TIA Score which identifies the risk of subsequent stroke≤7 days and consists of 13 variables. This model has good discrimination with a c-statistic of 0.77 (95% confidence interval, 0.73-0.82). Patients with TIA with their first TIA, language disturbance, duration of symptoms≥10 minutes, gait disturbance, atrial fibrillation, infarction on computed tomography, elevated platelets or glucose, unilateral weakness, history of carotid stenosis, and elevated diastolic blood pressure are at higher risk for an impending stroke. Patients with vertigo and no high-risk features are at low risk. The Canadian TIA Score quantifies the impending stroke risk following TIA.