Transient ischemic attack: Difference between revisions

From Citizendium
Jump to navigation Jump to search
imported>Nancy Sculerati
No edit summary
mNo edit summary
 
(34 intermediate revisions by 6 users not shown)
Line 1: Line 1:
===Overview (summary)===
{{subpages}}
A '''Transient Ischemic Attack''' (TIA) is a ''brief'' loss of neurologic function. In a TIA, the affected brain cells were not killed, but only transiently deprived of blood supply and the signs of what seems to be a stroke, (or black-out), pass quickly and ''completely''. A TIA is often a warning sign of an impending stroke, however, and like a true stroke, is a neurologic emergency. None the less, a TIA is ''not'' a true stroke.
{{TOC|right}}
A '''transient ischemic attack''' ('''TIA''') is a type of [[transient neurological attack]]. In a TIA, the focal area of [[brain]] cells were not killed, but only transiently deprived of blood supply and the signs of what seems to be a [[stroke]], (or black-out), pass quickly and ''completely''. A TIA is often a warning sign of an impending stroke, however, and like a true stroke, is a neurological emergency. None the less, a TIA is ''not'' a true stroke.  


It may first be seen by an [[emergency physician]], who will obtain [[neurology|neurological]] consultation.


==Diagnosis==
===History and physical examination===
The history and physical examination of patients with a possible TIA is difficult to interpret. Two neurologists interviewing the same patient have statistically 'substantial' but imperfect [[Kappa statistic|agreement]] about whether the patient had a TIA.<ref name="pmid6464066">{{cite journal |author=Kraaijeveld CL, van Gijn J, Schouten HJ, Staal A |title=Interobserver agreement for the diagnosis of transient ischemic attacks |journal=Stroke |volume=15 |issue=4 |pages=723–5 |year=1984 |pmid=6464066 |doi=}}</ref> Disagreement may occur even when a 'standardized' patient is trained to give identical histories to each neurologist.<ref name="pmid2919420">{{cite journal |author=Koudstaal PJ, Gerritsma JG, van Gijn J |title=Clinical disagreement on the diagnosis of transient ischemic attack: is the patient or the doctor to blame? |journal=Stroke |volume=20 |issue=2 |pages=300–1 |year=1989 |pmid=2919420 |doi=}}</ref>
===Differential diagnosis===
Other disorders that may cause similar symptoms are syncope, seizure, migraine, vestibulopathy, and conversion disorder.<ref name="pmid18159062">{{cite journal |author=Johnston SC |title=Transient Neurological Attack: A Useful Concept? |journal=JAMA |volume=298 |issue=24 |pages=2912–2913 |year=2007 |pmid=18159062 |doi=10.1001/jama.298.24.2912|url=http://jama.ama-assn.org/cgi/content/full/298/24/2912}}</ref>


==Treatment==
===Anti-platelet drugs===
The most effective anti-platelet treatment is probably to combine aspirin, 25 mg twice a day with extended-release dipyridamole 200 mg twice a day according to the ESPRIT<ref name="pmid16714187">{{cite journal |author=Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A |title=Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial |journal=Lancet |volume=367 |issue=9523 |pages=1665–73 |year=2006 |pmid=16714187 |doi=10.1016/S0140-6736(06)68734-5 |issn=}}</ref>


The combination of aspirin and clopidogrel should probably be avoided according to the MATCH<ref name="pmid15276392">{{cite journal |author=Diener HC, Bogousslavsky J, Brass LM, ''et al'' |title=Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial |journal=Lancet |volume=364 |issue=9431 |pages=331–7 |year=2004 |pmid=15276392 |doi=10.1016/S0140-6736(04)16721-4 |issn=}}</ref> and CHARISMA<ref name="pmid16531616">{{cite journal |author=Bhatt DL, Fox KA, Hacke W, ''et al'' |title=Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events |journal=N. Engl. J. Med. |volume=354 |issue=16 |pages=1706–17 |year=2006 |pmid=16531616 |doi=10.1056/NEJMoa060989 |issn=}}</ref> studies.


[[Category:Health Sciences Workgroup]]
===Invasive treatment===
Carotid endarterectomy may prevent stroke in patients with more than 70% stenosis of the carotid artery.<ref name="pmid1852179">{{cite journal |author= |title=Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators |journal=N. Engl. J. Med. |volume=325 |issue=7 |pages=445–53 |year=1991 |pmid=1852179 |doi= |issn=}}</ref>
 
===Expedited care protocol===
A before and after comparison study found reduced mortality fell from 10% to 2% with the following protocol started the day the patient presents for medical care:<ref name="pmid17928046">{{cite journal |author=Rothwell PM, Giles MF, Chandratheva A, ''et al'' |title=Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison |journal=Lancet |volume=370 |issue=9596 |pages=1432–42 |year=2007 |pmid=17928046 |doi=10.1016/S0140-6736(07)61448-2 |issn=}}</ref>
* "antiplatelet therapy: aspirin in patients not already on antiplatelet therapy (75 mg daily), or clopidogrel if aspirin was contraindicated" (loading dose of clopidogrel 300 mg).
** * "In patients seen within 48 h of their event, or those seen within 7 days who were thought to be at particularly high early risk", clopidogrel (75 mg daily, to be stopped after 30 days; loading dose of clopidogrel 300 mg) was recommended in addition to aspirin."<ref name="pmid15851601">{{cite journal |author=Markus HS, Droste DW, Kaps M, ''et al'' |title=Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial |journal=Circulation |volume=111 |issue=17 |pages=2233–40 |year=2005 |pmid=15851601 |doi=10.1161/01.CIR.0000163561.90680.1C |issn=}}</ref>
**'''''However''''', as noted above combining aspirin 25 mg twice a day with extended-release dipyridamole 200 mg twice a day might be a better choice than either aspirin alone or aspirin combined with clopidogrel.
* simvastatin 40 mg daily
* "blood pressure lowering unless systolic blood pressure was below 130 mm Hg on repeated measurement (either by increases in existing medication, or by commencement of perindopril 4 mg daily with or without indapamide 1·25 mg daily)"
* anticoagulation as required
* "Brain imaging was required before starting combination antiplatelet treatment or anticoagulation after a minor stroke"
 
Another approach is based on the ABCD2 score (see below).
If score 6-7, hospitalize patient
If score 4-5, image carotids and admit if significant stenosis.<ref name="pmid21617143">{{cite journal| author=Olivot JM, Wolford C, Castle J, Mlynash M, Schwartz NE, Lansberg MG et al.| title=TWO ACES: Transient Ischemic Attack Work-Up as Outpatient Assessment of Clinical Evaluation and Safety. | journal=Stroke | year= 2011 | volume= 42 | issue= 7 | pages= 1839-43 | pmid=21617143 | doi=10.1161/STROKEAHA.110.608380 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21617143  }} </ref>
 
== Prognosis ==
Overall, about 10% of patients will have a stroke within 7 days.<ref name="pmid22972645">{{cite journal| author=Paul NL, Simoni M, Chandratheva A, Rothwell PM| title=Population-based study of capsular warning syndrome and prognosis after early recurrent TIA. | journal=Neurology | year= 2012 | volume= 79 | issue= 13 | pages= 1356-62 | pmid=22972645 | doi=10.1212/WNL.0b013e31826c1af8 | pmc=PMC3448742 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972645  }} </ref> This is especially true in patients with TIA due to small-vessel disease (SVD) etiology with motor weakness (capsular warning syndrome).<ref name="pmid22972645"/>
 
A [[meta-analysis]] of 18 [[cohort study|cohort studies]] found the risk of stroke after 7 days varies from 0% to 13%. The lowest rates were in studies of emergency treatment by specialist stroke services.<ref name="pmid17993293">{{cite journal |author=Giles MF, Rothwell PM |title=Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis |journal=Lancet Neurol |volume=6 |issue=12 |pages=1063–72 |year=2007 |pmid=17993293 |doi=10.1016/S1474-4422(07)70274-0}}</ref>
 
The risk of stroke among patients presenting to the emergency room with a TIA is approximately 3% to 5% in the next 2 days and 4% to 7% over the next week according to a second [[meta-analysis]].<ref name="pmid18282526">{{cite journal |author=Shah KH, Kleckner K, Edlow JA |title=Short-term prognosis of stroke among patients diagnosed in the emergency department with a transient ischemic attack |journal=Ann Emerg Med |volume=51 |issue=3 |pages=316-23 |year=2008 |pmid=18282526 |doi=10.1016/j.annemergmed.2007.08.016 |url=http://linkinghub.elsevier.com/retrieve/pii/S0196-0644(07)01445-X |issn=}}</ref> This [[meta-analysis]] thought the ABCD<sup>2</sup> (below) provided the best estimate.
 
Prognosis is worse if the [[carotid artery]] has a greater than 70% obstruction.<ref name="pmid19498196">{{cite journal| author=Ois A, Cuadrado-Godia E, Rodríguez-Campello A, Jimenez-Conde J, Roquer J| title=High risk of early neurological recurrence in symptomatic carotid stenosis. | journal=Stroke | year= 2009 | volume= 40 | issue= 8 | pages= 2727-31 | pmid=19498196
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19498196 | doi=10.1161/STROKEAHA.109.548032
}} </ref>
 
===Calculating estimated prognosis===
====History and physical====
"The simpler FAST scale could replace the more complex ROSIER for the initial assessment of patients with suspected acute stroke in the emergency department.". <ref name="pmid21402744">{{cite journal| author=Whiteley WN, Wardlaw JM, Dennis MS, Sandercock PA| title=Clinical scores for the identification of stroke and transient ischaemic attack in the emergency department: a cross-sectional study. | journal=J Neurol Neurosurg Psychiatry | year= 2011 | volume= 82 | issue= 9 | pages= 1006-10 | pmid=21402744 | doi=10.1136/jnnp.2010.235010 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21402744  }} </ref>
=====ABCD<sup>2</sup>=====
The ABCD<sup>2</sup> score (http://www.stroke.org/site/DocServer/NSA_ABCD2_tool.pdf) is a [[clinical prediction rule]] that can predict likelihood of subsequent [[stroke]] over short term<ref name="pmid19556026">{{cite journal| author=Asimos AW, Johnson AM, Rosamond WD, Price MF, Rose KM, Catellier D et al.| title=A multicenter evaluation of the ABCD2 score's accuracy for predicting early ischemic stroke in admitted patients with transient ischemic attack. | journal=Ann Emerg Med | year= 2010 | volume= 55 | issue= 2 | pages= 201-210.e5 | pmid=19556026
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=19556026 | doi=10.1016/j.annemergmed.2009.05.002 }} </ref><ref name="pmid17258668">{{cite journal |author=Johnston SC, Rothwell PM, Nguyen-Huynh MN, ''et al'' |title=Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack |journal=Lancet |volume=369 |issue=9558 |pages=283-92 |year=2007 |pmid=17258668 |doi=10.1016/S0140-6736(07)60150-0}}</ref><ref name="pmid15993230">{{cite journal |author=Rothwell PM, Giles MF, Flossmann E, ''et al'' |title=A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack |journal=Lancet |volume=366 |issue=9479 |pages=29-36 |year=2005 |pmid=15993230 |doi=10.1016/S0140-6736(05)66702-5}}</ref><ref name="pmid19487652">{{cite journal |author=Chandratheva A, Mehta Z, Geraghty OC, Marquardt L, Rothwell PM |title=Population-based study of risk and predictors of stroke in the first few hours after a TIA |journal=Neurology |volume=72 |issue=22 |pages=1941–7 |year=2009 |month=June |pmid=19487652 |doi=10.1212/WNL.0b013e3181a826ad |url= |issn=}}</ref> or long term<ref name="pmid20814011">{{cite journal| author=Wijnhoud AD, Maasland L, Lingsma HF, Steyerberg EW, Koudstaal PJ, Dippel DW| title=Prediction of major vascular events in patients with transient ischemic attack or ischemic stroke: a comparison of 7 models. | journal=Stroke | year= 2010 | volume= 41 | issue= 10 | pages= 2178-85 | pmid=20814011 | doi=10.1161/STROKEAHA.110.580985 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20814011  }} </ref>.
 
The risk of stroke depends on the study setting and how the data for the score was collected.<ref  name="pmid20185786">{{cite journal| author=Giles MF, Rothwell PM|  title=Systematic review and pooled analysis of published and unpublished  validations of the ABCD and ABCD2 transient ischemic attack risk  scores. | journal=Stroke | year= 2010 | volume= 41 | issue= 4 | pages=  667-73 | pmid=20185786
|  url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20185786  | doi=10.1161/STROKEAHA.109.571174 }} </ref> It may not work as well in a group with only a 2% risk of stroke within one week.<ref name="pmid21646462">{{cite journal| author=Perry JJ, Sharma M, Sivilotti ML, Sutherland J, Symington C, Worster A et al.| title=Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack. | journal=CMAJ | year= 2011 | volume= 183 | issue= 10 | pages= 1137-45 | pmid=21646462 | doi=10.1503/cmaj.101668 | pmc=PMC3134721 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21646462  }} </ref>
 
;Calculation of score
The score is calculated as:
* Age ≥ 60 years = 1 point
* Blood pressure at presentation ≥ 140/90 mm Hg = 1 point
* Clinical features
: unilateral weakness = 2 points
: speech disturbance without weakness = 1 point
* Duration of attack
: ≥ 60 minutes = 2 points
: 10-59 minutes = 1 point
* Diabetes = 1 point
 
Interpretation of score, the risk for stroke from the original study:
* Score 0-3 (low)
** 2 day risk = 1.0%
** 7 day risk = 1.2%
* Score 4-5 (moderate)
** 2 day risk = 4.1%
** 7 day risk = 5.9%
* Score 6–7 (high)
** 2 day risk = 8.1%
** 7 day risk = 11.7%
 
=====Improvements to the ABCD<sup>2</sup>=====
The ABCD<sup>2</sup> score may be improved by adding the results of diffusion-weighted [[magnetic resonance imaging]] (MRI) to look for infarction.<ref name="pmid21865578">{{cite journal|  author=Giles MF, Albers GW, Amarenco P, Arsava EM, Asimos AW, Ay H et  al.| title=Early stroke risk and ABCD2 score performance in tissue- vs  time-defined TIA: A multicenter study. | journal=Neurology | year= 2011 |  volume= 77 | issue= 13 | pages= 1222-8 | pmid=21865578 |  doi=10.1212/WNL.0b013e3182309f91 | pmc=PMC3179650 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21865578  }} </ref>
 
The score may be improved by the ABCD3 score which adds a point for 'dual' attacks within 7 days.<ref name="pmid20934388">{{cite journal| author=Merwick A, Albers GW, Amarenco P, Arsava EM, Ay H, Calvet D et al.| title=Addition 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. | journal=Lancet Neurol | year= 2010 | volume= 9 | issue= 11 | pages= 1060-9 | pmid=20934388 | doi=10.1016/S1474-4422(10)70240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20934388  }} </ref>
 
The ABCD and ABCD<sup>2</sup> may be improved by adding hyperglycemia and a history of [[hypertension]].<ref name="pmid19520983">{{cite journal| author=Fothergill A, Christianson TJ, Brown RD, Rabinstein AA| title=Validation and refinement of the ABCD2 score: a population-based analysis. | journal=Stroke | year= 2009 | volume= 40 | issue= 8 | pages= 2669-73 | pmid=19520983
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19520983 | doi=10.1161/STROKEAHA.109.553446 }}</ref>
 
====Diagnostic imaging====
The rule may be improved by adding the presence of brain infarction visualized on [[diagnostic imaging]] using either brain infarction on either [[diffusion-weighted magnetic resonance imaging]] or [[computed tomography]]<ref name="pmid20634480">{{cite journal| author=Giles MF, Albers GW, Amarenco P, Arsava MM, Asimos A, Ay H et al.| title=Addition of brain infarction to the ABCD2 Score (ABCD2I): a collaborative analysis of unpublished data on 4574 patients. | journal=Stroke | year= 2010 | volume= 41 | issue= 9 | pages= 1907-13 | pmid=20634480 | doi=10.1161/STROKEAHA.110.578971 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20634480  }} </ref> or brain imaging combined with imaging of the [[carotid artery]] (ABCD<sup>3</sup>-I).<ref name="pmid20934388">{{cite journal| author=Merwick A, Albers GW, Amarenco P, Arsava EM, Ay H, Calvet D et al.| title=Addition 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. | journal=Lancet Neurol | year= 2010 | volume= 9 | issue= 11 | pages= 1060-9 | pmid=20934388 | doi=10.1016/S1474-4422(10)70240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20934388  }} </ref>
 
==References==
<references/>
 
[[Category:Suggestion Bot Tag]]

Latest revision as of 06:01, 30 October 2024

This article is a stub and thus not approved.
 Main Article
 Discussion
Related Articles  [?]
Bibliography  [?]
External Links  [?]
Citable Version  [?]
 
https://en.citizendium.org/wiki/index.php?title=Transient_ischemic_attack&printable=yes
This editable Main Article is under development and subject to a disclaimer.

A transient ischemic attack (TIA) is a type of transient neurological attack. In a TIA, the focal area of brain cells were not killed, but only transiently deprived of blood supply and the signs of what seems to be a stroke, (or black-out), pass quickly and completely. A TIA is often a warning sign of an impending stroke, however, and like a true stroke, is a neurological emergency. None the less, a TIA is not a true stroke.

It may first be seen by an emergency physician, who will obtain neurological consultation.

Diagnosis

History and physical examination

The history and physical examination of patients with a possible TIA is difficult to interpret. Two neurologists interviewing the same patient have statistically 'substantial' but imperfect agreement about whether the patient had a TIA.[1] Disagreement may occur even when a 'standardized' patient is trained to give identical histories to each neurologist.[2]

Differential diagnosis

Other disorders that may cause similar symptoms are syncope, seizure, migraine, vestibulopathy, and conversion disorder.[3]

Treatment

Anti-platelet drugs

The most effective anti-platelet treatment is probably to combine aspirin, 25 mg twice a day with extended-release dipyridamole 200 mg twice a day according to the ESPRIT[4]

The combination of aspirin and clopidogrel should probably be avoided according to the MATCH[5] and CHARISMA[6] studies.

Invasive treatment

Carotid endarterectomy may prevent stroke in patients with more than 70% stenosis of the carotid artery.[7]

Expedited care protocol

A before and after comparison study found reduced mortality fell from 10% to 2% with the following protocol started the day the patient presents for medical care:[8]

  • "antiplatelet therapy: aspirin in patients not already on antiplatelet therapy (75 mg daily), or clopidogrel if aspirin was contraindicated" (loading dose of clopidogrel 300 mg).
    • * "In patients seen within 48 h of their event, or those seen within 7 days who were thought to be at particularly high early risk", clopidogrel (75 mg daily, to be stopped after 30 days; loading dose of clopidogrel 300 mg) was recommended in addition to aspirin."[9]
    • However, as noted above combining aspirin 25 mg twice a day with extended-release dipyridamole 200 mg twice a day might be a better choice than either aspirin alone or aspirin combined with clopidogrel.
  • simvastatin 40 mg daily
  • "blood pressure lowering unless systolic blood pressure was below 130 mm Hg on repeated measurement (either by increases in existing medication, or by commencement of perindopril 4 mg daily with or without indapamide 1·25 mg daily)"
  • anticoagulation as required
  • "Brain imaging was required before starting combination antiplatelet treatment or anticoagulation after a minor stroke"

Another approach is based on the ABCD2 score (see below). If score 6-7, hospitalize patient If score 4-5, image carotids and admit if significant stenosis.[10]

Prognosis

Overall, about 10% of patients will have a stroke within 7 days.[11] This is especially true in patients with TIA due to small-vessel disease (SVD) etiology with motor weakness (capsular warning syndrome).[11]

A meta-analysis of 18 cohort studies found the risk of stroke after 7 days varies from 0% to 13%. The lowest rates were in studies of emergency treatment by specialist stroke services.[12]

The risk of stroke among patients presenting to the emergency room with a TIA is approximately 3% to 5% in the next 2 days and 4% to 7% over the next week according to a second meta-analysis.[13] This meta-analysis thought the ABCD2 (below) provided the best estimate.

Prognosis is worse if the carotid artery has a greater than 70% obstruction.[14]

Calculating estimated prognosis

History and physical

"The simpler FAST scale could replace the more complex ROSIER for the initial assessment of patients with suspected acute stroke in the emergency department.". [15]

ABCD2

The ABCD2 score (http://www.stroke.org/site/DocServer/NSA_ABCD2_tool.pdf) is a clinical prediction rule that can predict likelihood of subsequent stroke over short term[16][17][18][19] or long term[20].

The risk of stroke depends on the study setting and how the data for the score was collected.[21] It may not work as well in a group with only a 2% risk of stroke within one week.[22]

Calculation of score

The score is calculated as:

  • Age ≥ 60 years = 1 point
  • Blood pressure at presentation ≥ 140/90 mm Hg = 1 point
  • Clinical features
unilateral weakness = 2 points
speech disturbance without weakness = 1 point
  • Duration of attack
≥ 60 minutes = 2 points
10-59 minutes = 1 point
  • Diabetes = 1 point

Interpretation of score, the risk for stroke from the original study:

  • Score 0-3 (low)
    • 2 day risk = 1.0%
    • 7 day risk = 1.2%
  • Score 4-5 (moderate)
    • 2 day risk = 4.1%
    • 7 day risk = 5.9%
  • Score 6–7 (high)
    • 2 day risk = 8.1%
    • 7 day risk = 11.7%
Improvements to the ABCD2

The ABCD2 score may be improved by adding the results of diffusion-weighted magnetic resonance imaging (MRI) to look for infarction.[23]

The score may be improved by the ABCD3 score which adds a point for 'dual' attacks within 7 days.[24]

The ABCD and ABCD2 may be improved by adding hyperglycemia and a history of hypertension.[25]

Diagnostic imaging

The rule may be improved by adding the presence of brain infarction visualized on diagnostic imaging using either brain infarction on either diffusion-weighted magnetic resonance imaging or computed tomography[26] or brain imaging combined with imaging of the carotid artery (ABCD3-I).[24]

References

  1. ↑ Kraaijeveld CL, van Gijn J, Schouten HJ, Staal A (1984). "Interobserver agreement for the diagnosis of transient ischemic attacks". Stroke 15 (4): 723–5. PMID 6464066. [e]
  2. ↑ Koudstaal PJ, Gerritsma JG, van Gijn J (1989). "Clinical disagreement on the diagnosis of transient ischemic attack: is the patient or the doctor to blame?". Stroke 20 (2): 300–1. PMID 2919420. [e]
  3. ↑ Johnston SC (2007). "Transient Neurological Attack: A Useful Concept?". JAMA 298 (24): 2912–2913. DOI:10.1001/jama.298.24.2912. PMID 18159062. Research Blogging.
  4. ↑ Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A (2006). "Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial". Lancet 367 (9523): 1665–73. DOI:10.1016/S0140-6736(06)68734-5. PMID 16714187. Research Blogging.
  5. ↑ Diener HC, Bogousslavsky J, Brass LM, et al (2004). "Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial". Lancet 364 (9431): 331–7. DOI:10.1016/S0140-6736(04)16721-4. PMID 15276392. Research Blogging.
  6. ↑ Bhatt DL, Fox KA, Hacke W, et al (2006). "Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events". N. Engl. J. Med. 354 (16): 1706–17. DOI:10.1056/NEJMoa060989. PMID 16531616. Research Blogging.
  7. ↑ (1991) "Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators". N. Engl. J. Med. 325 (7): 445–53. PMID 1852179. [e]
  8. ↑ Rothwell PM, Giles MF, Chandratheva A, et al (2007). "Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison". Lancet 370 (9596): 1432–42. DOI:10.1016/S0140-6736(07)61448-2. PMID 17928046. Research Blogging.
  9. ↑ Markus HS, Droste DW, Kaps M, et al (2005). "Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial". Circulation 111 (17): 2233–40. DOI:10.1161/01.CIR.0000163561.90680.1C. PMID 15851601. Research Blogging.
  10. ↑ Olivot JM, Wolford C, Castle J, Mlynash M, Schwartz NE, Lansberg MG et al. (2011). "TWO ACES: Transient Ischemic Attack Work-Up as Outpatient Assessment of Clinical Evaluation and Safety.". Stroke 42 (7): 1839-43. DOI:10.1161/STROKEAHA.110.608380. PMID 21617143. Research Blogging.
  11. ↑ 11.0 11.1 Paul NL, Simoni M, Chandratheva A, Rothwell PM (2012). "Population-based study of capsular warning syndrome and prognosis after early recurrent TIA.". Neurology 79 (13): 1356-62. DOI:10.1212/WNL.0b013e31826c1af8. PMID 22972645. PMC PMC3448742. Research Blogging.
  12. ↑ Giles MF, Rothwell PM (2007). "Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis". Lancet Neurol 6 (12): 1063–72. DOI:10.1016/S1474-4422(07)70274-0. PMID 17993293. Research Blogging.
  13. ↑ Shah KH, Kleckner K, Edlow JA (2008). "Short-term prognosis of stroke among patients diagnosed in the emergency department with a transient ischemic attack". Ann Emerg Med 51 (3): 316-23. DOI:10.1016/j.annemergmed.2007.08.016. PMID 18282526. Research Blogging.
  14. ↑ Ois A, Cuadrado-Godia E, Rodríguez-Campello A, Jimenez-Conde J, Roquer J (2009). "High risk of early neurological recurrence in symptomatic carotid stenosis.". Stroke 40 (8): 2727-31. DOI:10.1161/STROKEAHA.109.548032. PMID 19498196. Research Blogging.
  15. ↑ Whiteley WN, Wardlaw JM, Dennis MS, Sandercock PA (2011). "Clinical scores for the identification of stroke and transient ischaemic attack in the emergency department: a cross-sectional study.". J Neurol Neurosurg Psychiatry 82 (9): 1006-10. DOI:10.1136/jnnp.2010.235010. PMID 21402744. Research Blogging.
  16. ↑ Asimos AW, Johnson AM, Rosamond WD, Price MF, Rose KM, Catellier D et al. (2010). "A multicenter evaluation of the ABCD2 score's accuracy for predicting early ischemic stroke in admitted patients with transient ischemic attack.". Ann Emerg Med 55 (2): 201-210.e5. DOI:10.1016/j.annemergmed.2009.05.002. PMID 19556026. Research Blogging.
  17. ↑ Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al (2007). "Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack". Lancet 369 (9558): 283-92. DOI:10.1016/S0140-6736(07)60150-0. PMID 17258668. Research Blogging.
  18. ↑ Rothwell PM, Giles MF, Flossmann E, et al (2005). "A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack". Lancet 366 (9479): 29-36. DOI:10.1016/S0140-6736(05)66702-5. PMID 15993230. Research Blogging.
  19. ↑ Chandratheva A, Mehta Z, Geraghty OC, Marquardt L, Rothwell PM (June 2009). "Population-based study of risk and predictors of stroke in the first few hours after a TIA". Neurology 72 (22): 1941–7. DOI:10.1212/WNL.0b013e3181a826ad. PMID 19487652. Research Blogging.
  20. ↑ Wijnhoud AD, Maasland L, Lingsma HF, Steyerberg EW, Koudstaal PJ, Dippel DW (2010). "Prediction of major vascular events in patients with transient ischemic attack or ischemic stroke: a comparison of 7 models.". Stroke 41 (10): 2178-85. DOI:10.1161/STROKEAHA.110.580985. PMID 20814011. Research Blogging.
  21. ↑ Giles MF, Rothwell PM (2010). "Systematic review and pooled analysis of published and unpublished validations of the ABCD and ABCD2 transient ischemic attack risk scores.". Stroke 41 (4): 667-73. DOI:10.1161/STROKEAHA.109.571174. PMID 20185786. Research Blogging.
  22. ↑ Perry JJ, Sharma M, Sivilotti ML, Sutherland J, Symington C, Worster A et al. (2011). "Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack.". CMAJ 183 (10): 1137-45. DOI:10.1503/cmaj.101668. PMID 21646462. PMC PMC3134721. Research Blogging.
  23. ↑ Giles MF, Albers GW, Amarenco P, Arsava EM, Asimos AW, Ay H et al. (2011). "Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: A multicenter study.". Neurology 77 (13): 1222-8. DOI:10.1212/WNL.0b013e3182309f91. PMID 21865578. PMC PMC3179650. Research Blogging.
  24. ↑ 24.0 24.1 Merwick A, Albers GW, Amarenco P, Arsava EM, Ay H, Calvet D et al. (2010). "Addition 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.". Lancet Neurol 9 (11): 1060-9. DOI:10.1016/S1474-4422(10)70240-4. PMID 20934388. Research Blogging.
  25. ↑ Fothergill A, Christianson TJ, Brown RD, Rabinstein AA (2009). "Validation and refinement of the ABCD2 score: a population-based analysis.". Stroke 40 (8): 2669-73. DOI:10.1161/STROKEAHA.109.553446. PMID 19520983. Research Blogging.
  26. ↑ Giles MF, Albers GW, Amarenco P, Arsava MM, Asimos A, Ay H et al. (2010). "Addition of brain infarction to the ABCD2 Score (ABCD2I): a collaborative analysis of unpublished data on 4574 patients.". Stroke 41 (9): 1907-13. DOI:10.1161/STROKEAHA.110.578971. PMID 20634480. Research Blogging.
Retrieved from "https://citizendium.org/wiki/index.php?title=Transient_ischemic_attack&oldid=991525"