Incidence, Risk Factors and Prognosis of Stroke and TIA: The Need for High-Quality, Large-Scale Epidemiological Studies and Meta-Analyses

Rothwell, Peter M.

doi:10.1159/000070271

Cited by 51 publications

(27 citation statements)

References 71 publications

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“…described previously, 17 and direct assessment has shown that caseascertainment is near complete. 18 All cases were reviewed by a neurologist to confirm the diagnoses, which were based on standard criteria.…”

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confidence: 51%

A Population-Based Study of the Prevalence of Fatigue After Transient Ischemic Attack and Minor Stroke

Winward

Sackley

Metha

et al. 2009

Stroke

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144

108

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Background and Purpose-Fatigue is common after stroke and can be attributable to the increased physical effort associated with severe neurological deficits; however, its presence in those with little motor deficit raises the possibility of confounding by other factors, such as comorbidity, anxiety, and medication. To control for such factors and determine the extent of stroke-specific fatigue, we compared patients with minor stroke who had little or no residual neurological deficit with patients with TIA; both groups had undergone similar investigations and treatment. Methods-The prevalence of fatigue 6 months after TIA or minor stroke was assessed in consecutive patients using the Chalder fatigue scale in a population-based incidence study (Oxford Vascular Study). Patients were included if they were independent in self-care Barthel Index (Ն18/20) and without major cognitive impairment (Mini-Mental State Examination Ն24/30). Stroke severity at baseline was assessed with the National Institute of Health Stroke Scale (NIHSS). Other potential causes of fatigue were assessed including anxiety, depression, recent life events, medication, and abnormalities in biochemistry or hematologic tests. Results-Seventy-six participants had minor stroke (mean age, 74.1 years; 42 men) and 73 had TIA (mean age, 72.5 years; 40 men). At 6-month follow-up, median Barthel Index score was 20 (interquartile range, 20 -20) in both groups. However, fatigue was more common after stroke than TIA (56% vs 29%; OR, 3.14; 95% CI, 1.51-6.57; Pϭ0.0008).This difference was present both in patients with modified Rankin score of 0 at 6 months (23.8% vs 10.3%) and patients with modified Rankin score Ն1 (69.2% vs 48.6%), and remained more frequent in stroke patients after adjustment for potential confounders. Within the group of patients with stroke, the prevalence of fatigue increased with initial stroke severity (87% NIHSS Ն4 vs 48% NIHSS Յ3; Pϭ0.0087); however, stroke patients with initial NIHSS of 0 were still more fatigued than patients with TIA (57% vs 29%; Pϭ0.015). Conclusions-The prevalence of fatigue after minor stroke is higher than after TIA, suggesting that it is not simply a consequence of the stress of a recent acute cerebral event, comorbidity, medication, or other potential confounders. The high levels of fatigue in stroke patients without neurological impairment suggest it has a central origin rather than being the result of increased physical effort required after stroke.

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confidence: 51%

A Population-Based Study of the Prevalence of Fatigue After Transient Ischemic Attack and Minor Stroke

Winward

Sackley

Metha

et al. 2009

Stroke

Self Cite

144

108

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“…Approximately 15-20% of ischaemic strokes are preceded by a TIA 117 and the appropriate detection and urgent diagnostic work-up for patients with TIA can avoid a further disabling stroke if the correct treatment is indicated. A retrospective study of consecutive patients attending emergency departments (EDs) within 24 hours after TIA demonstrated that the stroke risk after the index event was higher than previously thought; the stroke rate was 10.5% at 90 days, with half of the events (5.3%) occurring within 2 days of symptoms onset.…”

Section: Introductionmentioning

confidence: 99%

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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BackgroundPatients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.ObjectivesIs MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as ‘one-stop’ brain-carotid imaging? What is the current UK availability of services for stroke prevention?Data sourcesPublished literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.Review methodsSystematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.ResultsThe pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35–41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40–45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51–54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with ‘CT scan all patients’ MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. ‘One-stop’ CT/MR angiographic-plus-brain imaging was not cost-effective.LimitationsData on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.ConclusionsMagnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…Furthermore, such variations in results, which might be perceived as a lack of reliable evidence, might hamper the effective provision of services and treatment. 40 To ascertain the validity of costing studies of cerebrovascular diseases and to make results more comparable across studies, this review set out a number of criteria that studies should ideally fulfill.…”

Section: Luengo-fernandez Et Al Cerebrovascular Disease Costs E21mentioning

confidence: 99%

Costs of Stroke Using Patient-Level Data

Luengo-Fernández

Gray

Rothwell

2009

Stroke

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122

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Background and Purpose-With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria. Methods-A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups. Results-A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs. Conclusions-This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results. (Stroke. 2009;40:e18-e23.)

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Incidence, Risk Factors and Prognosis of Stroke and TIA: The Need for High-Quality, Large-Scale Epidemiological Studies and Meta-Analyses

Cited by 51 publications

References 71 publications

A Population-Based Study of the Prevalence of Fatigue After Transient Ischemic Attack and Minor Stroke

A Population-Based Study of the Prevalence of Fatigue After Transient Ischemic Attack and Minor Stroke

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Costs of Stroke Using Patient-Level Data

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