Prediction of Recurrent Stroke and Vascular Death in Patients With Transient Ischemic Attack or Nondisabling Stroke

Weimar, Christian; Benemann, Jens; Michalski, Michał; Müller, Martin; Luckner, Konrad; Katsarava, Zaza; Weber, Ralph; Diener, Hans‐Christoph

doi:10.1161/strokeaha.109.562157

Cited by 77 publications

(83 citation statements)

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“…187 Another prospective assessment of prognostic scores in patients with TIA or non-disabling stroke [including Essen Stroke Risk Score (ESRS), Stroke Prognosis Instrument II (SPI-II), Life Long After Cerebral ischaemia (LiLAC) score and Hankey score, discussed in Chapter 5] showed that the discrimination for annual risk of stroke was similar across each score, with a marginal superiority of SPI-II score (AUC 0.65; 95% CI 0.6 to 0.7). 154 Current clinical guidelines 67 recommend urgent treatment only for patients with high ABCD2 scores, whereas patients with low scores should be triaged for further clinical assessment within 1 week. 67,97 This would risk missing patients with carotid stenosis requiring endarterectomy.…”

Section: Discussionmentioning

confidence: 99%

“…telephone interviews, medical records, letters) in 11 studies, 65,131,[146][147][148]153,154,158,160,162,163 and was not reported in two studies.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

“…152,167,177,186,209 For the purpose of the present HTA project, we systematically reviewed studies that assessed ABCD score of ≥ 4 or < 4 in TIA patients (see Chapter 4). Among 26 cohorts, 15 cohorts reported the risk of recurrent stroke at 7 days; 18 cohorts at 90 days, and three cohorts at > 90 days, and nine studies 63,139,141,[151][152][153][154]160,165 provided stroke risk data at both 7 and 90 days. Among these nine studies 63,139,141,[151][152][153][154]160,165 the pooled estimates for stroke risk at 7 days were 4.76% (95% CI 2.40% to 8.70%) in patients with an ABCD2 score of ≥ 4 and 1.6% (95% CI 1.0% to 3.4%) in patients with score of < 4; at 90 days the risk was 8.2% (95% CI 4.7% to 14.0%) and 2.7% (95% CI 1.5% to 4.7%), respectively.…”

Section: Prognosis Among Patients With Suspected Transient Ischaemic mentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

“…telephone interviews, medical records, letters) in 11 studies, 65,131,[146][147][148]153,154,158,160,162,163 and was not reported in two studies.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

Section: Prognosis Among Patients With Suspected Transient Ischaemic mentioning

confidence: 99%

See 1 more Smart Citation

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

View full text Add to dashboard Cite

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“…Demographic characteristics and presence of vascular risk factors were assessed.ESRS was calculated for each patient with 1 point given for hypertension, diabetes, previous myocardial infarction (MI), other cardiovascular disease (except MI and atrial fibrillation), peripheral arterial disease, previous transient ischemic attack (TIA) or ischemic stroke, age 65-75 or smoking, and 2 points for age >75 [1].…”

Section: Demographic Data and Risk Factorsmentioning

confidence: 99%

“…Essen stroke risk score (ESRS) has been proposed for stratifying recurrent risk of stroke caused by extra-and intra-cranial atherosclerotic disease [1]. Meanwhile, risk factors of atherosclerotic diseaseare largely shared by cerebral small vessel disease (CSVD) as well [2,3].…”

Section: Introductionmentioning

confidence: 99%

Essen stroke risk score, cerebral cholinergic pathways and cognitive performances in patients with cerebral small vessel disease

Zhu¹,

Han²,

Fang³

et al. 2016

J Integr Syst Neurosci

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Background: Essen stroke risk score (ESRS) has been proposed for predicting recurrent risk of stroke caused by extra-and intra-cranial atherosclerotic disease. Nevertheless, the role of ESRS in cognition associated with cerebral small vessel disease (CSVD) has not been reported to our knowledge. We investigated the relationship between higher ESRS and impaired cognitive performances in patients with CSVD, with the hypothesis that cerebral cholinergic deafferentation may be one of the mechanisms.

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Targeting Pioglitazone Hydrochloride Therapy After Stroke or Transient Ischemic Attack According to Pretreatment Risk for Stroke or Myocardial Infarction

et al. 2017

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IMPORTANCE There is growing recognition that patients may respond differently to therapy and that the average treatment effect from a clinical trial may not apply equally to all candidates for a therapy.OBJECTIVE To determine whether, among patients with an ischemic stroke or transient ischemic attack and insulin resistance, those at higher risk for future stroke or myocardial infarction (MI) derive more benefit from the insulin-sensitizing drug pioglitazone hydrochloride compared with patients at lower risk. DESIGN, SETTING, AND PARTICIPANTSA secondary analysis was conducted of the Insulin Resistance Intervention After Stroke trial, a double-blind, placebo-controlled trial of pioglitazone for secondary prevention. Patients were enrolled from 179 research sites in 7 countries from February 7, 2005, to January 15, 2013, and were followed up for a mean of 4.1 years through the study's end on July 28, 2015. Eligible participants had a qualifying ischemic stroke or transient ischemic attack within 180 days of entry and insulin resistance without type 1 or type 2 diabetes.INTERVENTIONS Pioglitazone or matching placebo. MAIN OUTCOMES AND MEASURESA Cox proportional hazards regression model was created using baseline features to stratify patients above or below the median risk for stroke or MI within 5 years. Within each stratum, the efficacy of pioglitazone for preventing stroke or MI was calculated. Safety outcomes were death, heart failure, weight gain, and bone fracture. RESULTS Among 3876 participants (1338 women and 2538 men; mean [SD] age, 63 [11] years), the 5-year risk for stroke or MI was 6.0% in the pioglitazone group among patients at lower baseline risk compared with 7.9% in the placebo group (absolute risk difference, -1.9% [95% CI, -4.4% to 0.6%]). Among patients at higher risk, the risk was 14.7% in the pioglitazone group vs 19.6% for placebo (absolute risk difference, -4.9% [95% CI, -8.6% to 1.2%]). Hazard ratios were similar for patients below or above the median risk (0.77 vs 0.75; P = .92). Pioglitazone increased weight less among patients at higher risk but increased the risk for fracture more. CONCLUSIONS AND RELEVANCEAfter an ischemic stroke or transient ischemic attack, patients at higher risk for stroke or MI derive a greater absolute benefit from pioglitazone compared with patients at lower risk. However, the risk for fracture is also higher. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00091949

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Prediction of Recurrent Stroke and Vascular Death in Patients With Transient Ischemic Attack or Nondisabling Stroke

Cited by 77 publications

References 14 publications

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

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

Essen stroke risk score, cerebral cholinergic pathways and cognitive performances in patients with cerebral small vessel disease

Targeting Pioglitazone Hydrochloride Therapy After Stroke or Transient Ischemic Attack According to Pretreatment Risk for Stroke or Myocardial Infarction

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