Recent advances in management of transient ischaemic attacks and minor ischaemic strokes

The risk of recurrent stroke during the first few days after a transient ischaemic attack or minor stroke is much higher than previously estimated. However, there is substantial variation worldwide in how patients with suspected transient ischaemic attack or minor stroke are investigated and treated in the acute phase: some health-care systems provide immediate emergency inpatient care and others provide non-emergency outpatient clinical assessment. This review considers what is known about the early prognosis after transient ischaemic attack and minor ischaemic stroke, what factors identify individuals at particularly high early risk of stroke, and what evidence there is that urgent preventive treatment is likely to be effective in reducing the early risk of stroke.     

Prognosis in patients with transient ischaemic attacks and minor stroke associated with a normal angiogram

61 patients with a transient ischaemic attack (TIA) or minor stroke and a normal angiogram and with no other explanation for the ischaemic event were followed up for a mean period of 6.3 years. Of 19 patients with a TIA 5 suffered further TIAs, and 1 of the 5 also an ischaemic stroke. 3 of 42 patients with a minor stroke had a new ischaemic stroke, in 1 case preceded by a TIA. In 2 stroke patients the lesion affected a new arterial region. 3 patients died of cerebral haematoma, in 1 preceded by an ischaemic stroke. 4 patients suffered myocardial infarction, and 1 of these died. The overall incidence of recurrent cerebral and cardiovascular symptoms was 23% (14 of 61 patients). The mean age was significantly higher (p less than 0.01) in patients with recurrent cerebral and cardiovascular lesions. No correlation emerged between risk factors. Patients with a TIA or minor stroke and a normal angiogram and with no other known source of embolism have a better prognosis than patients with a known source of embolism. However, elderly patients in particular run an increased risk of cardiac and cerebral vascular incidents.     

Night time versus daytime transient ischaemic attack and ischaemic stroke: a prospective study of 110 patients

OBJECTIVE: Ischaemic stroke occurs only in 20%-40% of patients at night. The aim of the study was to compare sleep and stroke characteristics of patients with and without night time onset of acute ischaemic cerebrovascular events. METHODS: A consecutive series of 110 patients with transient ischaemic attack (n=45) or acute ischaemic stroke (n=65) was studied prospectively by means of a standard protocol which included assessment of time of onset of symptoms, sleep, and stroke characteristics. An overnight polysomnography was performed after the onset of transient ischaemic attack/stroke in 71 patients. Stroke and sleep characteristics of patients with and without cerebrovascular events occurring at night (between midnight and 0600) were compared. RESULTS: A night time onset of transient ischaemic attack or stroke was reported by 23 (21%) of 110 patients. Patients with daytime and night time events were similar in demographics; risk factors; associated vascular diseases; clinical and polysomnographic sleep characteristics (including severity of sleep apnoea); and stroke severity, aetiology, and outcome. Only the diastolic blood pressure at admission was significantly lower in patients with night time events (74 v 82 mm Hg, p=0.01). CONCLUSIONS: Patients with night time and daytime transient ischaemic attack/stroke are similar in sleep and stroke characteristics. Diastolic hypotension may predispose to night time cerebrovascular events. Factors not assessed in this study probably account for the circadian variation in the frequency of transient ischaemic attack and acute ischaemic stroke.     

Differential risks of subsequent vascular events for transient ischaemic attack and minor ischaemic stroke.

Using a prospective hospital-based registry, 146 patients with transient ischaemic attack (TIA) were compared with 376 patients with minor first-ever ischaemic stroke with respect to the 3-month risk of subsequent vascular events, in order to clarify the distinctions between the disease entities. All patients were enrolled within 48 h of onset. The risk factor distribution for the two groups was comparable, except that the TIA patients had more previous TIAs. Large artery atherosclerosis (34%) and small vessel occlusion (32%) were the main aetiologies in the TIA group, whereas small vessel occlusion (49%) was the major cause in the stroke group. The 3-month risk of combined endpoints of stroke, myocardial infarction, and vascular death for TIA patients was higher than that for the minor stroke group (15.1% vs. 3.2%; hazard ratio 4.6, 95% confidence interval 2.3-9.3 in multivariate analysis). Large artery atherosclerosis and male sex were the other significant predictors. TIA may demand more urgent management than minor stroke. The fact that aetiology is a predictor, highlights the need for rapid diagnostic tests to establish pathogenesis.     

Patterns of cerebrovascular symptomatology associated with carotid atheroma

The aim of this study was to identify ultrasonic tissue characteristics and stenosis of carotid plaques that correspond to amaurosis fugax, hemispheric transient ischaemic attack, and stroke. At total of 146 symptomatic carotid plaques (136 patients) associated with amaurosis fugax, hemispheric transient ischaemic attack, stroke, and having 50-99% stenosis on duplex, were studied. These plaques were imaged on duplex, captured in a computer and their grey scale median was evaluated to distinguish the dark (low grey scale median) from the bright (high grey scale median) plaques. Stenosis was assessed on duplex. The amaurosis fugax group corresponded to carotid plaques with low grey scale median and severe stenosis, as contrasted with the other two groups (hemispheric transient ischaemic attack and stroke) (P < 0.05). These results suggested that amaurosis fugax was dependent only on the instability of carotid plaques, whereas hemispheric transient ischaemic attack and stroke were both dependent on carotid plaques and other pathogenetic factors.     

Medium intensity oral anticoagulants versus aspirin after cerebral ischaemia of arterial origin (ESPRIT): a randomised controlled trial

BACKGROUND: Oral anticoagulants are better than aspirin for secondary prevention after myocardial infarction and after cerebral ischaemia in combination with non-rheumatic atrial fibrillation. The European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) aimed to determine whether oral anticoagulation with medium intensity is more effective than aspirin in preventing future vascular events in patients with transient ischaemic attack or minor stroke of presumed arterial origin. METHODS: In this international, multicentre trial, patients were randomly assigned within 6 months after a transient ischaemic attack or minor stroke of presumed arterial origin either anticoagulants (target INR range 2.0-3.0; n=536) or aspirin (30-325 mg daily; n=532). The primary outcome was the composite of death from all vascular causes, non-fatal stroke, non-fatal myocardial infarction, or major bleeding complication, whichever occurred first. In a post hoc analysis anticoagulants were compared with the combination of aspirin and dipyridamole (200 mg twice daily). Treatment was open, but auditing of outcome events was blinded. Primary analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial (number ISRCTN73824458) and with ClinicalTrials.gov (NCT00161070). FINDINGS: The anticoagulants versus aspirin comparison of ESPRIT was prematurely ended because ESPRIT reported previously that the combination of aspirin and dipyridamole was more effective than aspirin alone. Mean follow-up was 4.6 years (SD 2.2). The mean achieved INR was 2.57 (SD 0.86). A primary outcome event occurred in 99 (19%) patients on anticoagulants and in 98 (18%) patients on aspirin (hazard ratio [HR] 1.02, 95% CI 0.77-1.35). The HR for ischaemic events was 0.73 (0.52-1.01) and for major bleeding complications 2.56 (1.48-4.43). The HR for the primary outcome event comparing anticoagulants with the combination treatment of aspirin and dipyridamole was 1.31 (0.98-1.75). INTERPRETATION: Oral anticoagulants (target INR range 2.0-3.0) are not more effective than aspirin for secondary prevention after transient ischaemic attack or minor stroke of arterial origin. A possible protective effect against ischaemic events is offset by increased bleeding complications.     

Long‐term follow‐up of patients with asymptomatic occlusion of the internal carotid artery with good and impaired cerebral vasomotor reactivity

Background: Cerebral hemodynamic status might be prognostic for either the symptomatic or asymptomatic course of carotid occlusive disease. It is determined by evaluating cerebral vasomotor reactivity (VMR). We assessed VMR in asymptomatic patients with total occlusion of the internal carotid artery (ICA) and followed them to evaluate the role of impaired VMR in predicting ischaemic stroke (IS). Methods: Thirty‐five patients (21 men, mean age ± SD 68 ± 7.5 years) with unilateral asymptomatic ICA occlusion were studied by transcranial Doppler and the Diamox test (intravenous 1.0 g acetazolamide) and followed for 48 months or until reaching the end‐points of IS, transient ischaemic attack, or vascular death. VMR% was evaluated by recording the percent differences in peak systolic blood flow velocities in each middle cerebral artery at baseline and after Diamox administration. Results: Based on VMR% calculations, 14 (40%) patients had good VMRs and 21 (60%) had impaired VMRs. The global annual risk of ipsilateral ischaemic events was 5.7%. The annual ipsilateral ischaemic event risk was 1.8% in patients with good VMRs, whilst it was 7.1% in patients with impaired VMRs. An impaired VMR was significantly correlated with ipsilateral IS (Kaplan–Meier log rank statistic, P = 0.04). Conclusions: Our results support the value of VMR assessment for identifying asymptomatic patients with carotid occlusion who belong to a high‐risk subgroup for IS. New trials using extracranial‐to‐intracranial bypass surgery in patients with asymptomatic ICA occlusion and impaired VMRs are warranted.     

Early transoesophageal echocardiography in cryptogenic and lacunar stroke and transient ischaemic attack

OBJECTIVES—To test the hypothesis thattransoesophageal echocardiography (TOE) carried out within three daysof a first stroke or transient ischaemic attack of cryptogenic orlacunar type may disclose more thrombi or spontaneous echo contrast(SEC) than previously reported. This finding may help early treatment decisions.
METHODS—Patients aged between 40 and 80 years,admitted for transient ischaemic attack or ischaemic stroke during a 40 month period, were prospectively considered. TOE was carried out within72 hours of symptom onset with a 5 MHz biplanar transducer. Subjectswith recurring events, very severe strokes, large artery obstructions, or obvious cardiac sources of embolism were excluded.
RESULTS—Sixty five patients were studied, 43 witha cryptogenic stroke or transient ischaemic attack (66.2%), and 22 with a lacunar stroke (33.8%). The mean (SD) interval between symptomonset and TOE was 43.4 (17.2) hours for cryptogenic, and 48.5 (19.5)hours for lacunar patients. Atrial thrombi were found in one patient with a cryptogenic stroke (2.32% of cryptogenic events; 95%confidence interval 0.06-12.29), whereas SEC was found in fivepatients (7.7% overall), two with a lacunar and three with acryptogenic stroke.
CONCLUSIONS—An early TOE does not seem to increasesubstantially the detection of atrial thrombi or SEC in patients with afirst stroke or transient ischaemic attack of cryptogenic or lacunarnature. Therefore, this examination can be carried out when thepatients' conditions are stable, and without overloading thecardiovascular laboratory daily schedule.

     

Bilateral carotid artery occlusion with transient or moderately disabling ischaemic stroke: clinical features and long-term outcome

Information on the prognosis of patients with transient ischaemic attack or moderately disabling ischaemic stroke associated with bilateral internal carotid artery (ICA) occlusion is scarce. We prospectively studied 57 consecutive patients (46 men; mean age 60 ± 9 years) with bilateral ICA occlusion who had presented with unilateral transient or moderately disabling cerebral or retinal ischaemic symptoms. We determined the long-term risk of recurrent ischaemic stroke and the composite outcome of stroke, myocardial infarction or vascular death. Four patients had a recurrent ischaemic stroke during a mean follow-up of 5.9 years, resulting in an annual stroke rate of 1.2% (95% confidence interval (CI) 0.3–3.1). Risk factors for recurrent ischaemic stroke could not be identified. Eighteen patients suffered a stroke, myocardial infarction or vascular death, resulting in an annual rate for major vascular events of 5.3% (95% CI 3.1–8.3). Age and a history of ischaemic heart disease were significant risk factors for future vascular events. Patients with transient or moderately disabling symptoms of cerebral or retinal ischaemia associated with bilateral ICA occlusion have a relatively low risk of recurrent ischaemic stroke. Although this study was not designed to compare conservative treatment with surgical intervention, the favourable outcome suggests that a policy of medical therapy and control of risk factors may be justified in these patients.     

Significance of microbleeds in patients with transient ischaemic attack

Background and purpose: The aim of this study was to determine the prognostic significance of microbleeds in TIA‐patients. In patients with a transient ischaemic attack (TIA), the prognostic value of microbleeds is unknown. Methods: In 176 consecutive TIA patients, the number, size, and location of microbleeds with or without acute ischaemic lesions were assessed. We compared microbleed‐positive and microbleed‐negative patients with regard to the end‐point stroke within 3 months. Results: Four of the seven patients with subsequent stroke had microbleeds. Microbleed‐positive patients had a higher risk for stroke [odds ratios (OR) 8.91, 95% CI 1.87–42.51, P < 0.01] than those without microbleeds. Microbleed‐positive patients with accompanying acute ischaemic lesions had a higher stroke risk than those with neither an acute ischaemia nor a microbleed (OR 6.20, 95% CI 1.10–35.12; P = 0.04). Conclusion: Microbleeds alone or in combination with acute ischaemic lesions may increase the risk for subsequent ischaemic stroke after TIA within 3 months.     

Abnormalities on diffusion weighted magnetic resonance imaging performed several weeks after a minor stroke or transient ischaemic attack

OBJECTIVES: Diffusion weighted brain imaging (DWI) is used in acute stroke, and also shows an acute ischaemic lesion in most transient ischamic attack (TIA) patients scanned acutely. However, it may also be useful in identifying subacute ischaemic lesions in patients with minor stroke or TIA who present several weeks after symptom onset. This study investigated the sensitivity and the observer reproducibility of DWI in cerebral TIA and minor ischaemic stroke patients scanned more than two weeks after the last symptomatic event. METHODS: Consecutive patients underwent magnetic resonance imaging (T2, DWI, ADC). The presence of clinically appropriate lesions was assessed by two independent observers, and related to the type of presenting event, the NIH score, persistence of symptoms and signs, and the time since the presenting event. RESULTS: 101 patients (53 men) were scanned at a median time of 21 days (IQR=17-28) after symptom onset. Reproducibility of the assessment of DWI abnormalities was high: interobserver agreement =97% (kappa=0.94, p<0.0001); intraobserver agreement =94% (kappa=0.88, p<0.0001). DWI showed a clinically appropriate ischaemic lesion in 29 of 51 (57%) minor stroke patients, and in 7 of 50 (14%) TIA patients. The independent predictors of a positive DWI scan were presentation with minor stroke versus TIA (p=0.009) and increasing NIH score (p=0.009), but there was no difference between patients presenting 2-4 weeks compared with >4 weeks after symptom onset. In minor stroke patients, the presence of a clinically appropriate lesion was associated with persistent symptoms (63% versus 36%; p=0.12) and signs (64% versus 33%, p=0.06) at the time of scanning. CONCLUSIONS: DWI shows a clinically appropriate ischaemic lesion in more than half of minor stroke patients presenting more than two weeks after the symptomatic event, but only in a small proportion of patients with TIA. The persistence of lesions on DWI is closely related to markers of severity of the ischaemic event. These results justify larger studies of the clinical usefulness of DWI in subacute minor stroke.     

Intellectual function in patients with transient ischaemic attacks (TIA) or minor stroke

Psychological testing was performed in 25 patients (mean age 56 years) with transient ischaemic attacks and/or minor strokes and with angiographically verified internal carotid artery stenosis. The effects of carotid endarterectomy on intellectual functions were evaluated postoperatively at 2 weeks and 8 months respectively. Preoperatively the mean test values were below the normal level for all tests indicating a general intellectual impairment for the group as a whole. This may reflect multiinfarct dementia in statu nascendi . At the early postoperative test session some test results were statistically significantly worse than the preoperative. 8 months postoperatively the mean values for all tests had improved as compared with the preoperative values. This improvement reached a statistically significant level in 6 tests. When the side of operation was considered a pattern emerged: in the 12 patients with left-sided endarterectomies improvement was significant for tests mainly related to left-hemisphere function (Word Pairs Test, Story Recall, Trail Making B, Similarities) and in the 13 patients with right-sided endarterectomies significant improvement occurred in the functions mainly related to the right hemisphere (Visual Gestalts, Block Design, Digit Span backwards). This relationship between side of operation and improvement in lateralized functions cannot be explained by retest effects.
It is concluded that TIA's and minor strokes per se may impair intellectual function, and that reversal of deterioration and even improved mental state may follow carotid endarterectomy.     

Improved outcome after atherosclerotic stroke in male smoker

BACKGROUND: Smoking is a well-known risk factor for ischaemic stroke or transient ischaemic attack. Paradoxically, smokers have been reported to have better prognosis after myocardial infarction when compared to nonsmokers. This study examined the independent effect of smoking status on long-term prognosis after ischaemic stroke in male patients. METHODS: A total 476 male patients with acute cerebral infarction within the middle cerebral artery territory were reviewed. Baseline characteristics and long-term prognosis were compared among smokers, ex-smokers, and nonsmokers. RESULTS: Although the baseline severity of stroke did not differ among the groups, poor long-term outcome (Barthel index<60 or modified Rankin score>3) at 6 months after ischaemic stroke was more frequently observed in nonsmokers than in smokers (P=0.013); the outcome for ex-smokers was intermediate. After adjustment for age and other variables, current smoking was negatively correlated to poor long-term outcome (odds ratio, 0.286; 95% confidence interval, 0.119-0.686; P=0.005). On subgroup analysis, the impact of smoking on stroke prognosis was significant only in younger patients (<65 years of age) and those with atherosclerotic stroke. CONCLUSIONS: There was a strong independent correlation between smoking status and long-term outcome in patients with ischaemic stroke. Further studies about the impact of smoking habit on stroke outcome depending on the characteristics of patients (ie. age and stroke subtype) are needed.     

Expression of stromal‐cell‐derived factor‐1 (SDF‐1): a predictor of ischaemic stroke?

Background and purpose: Platelet stromal‐cell‐derived factor‐1 (SDF‐1) plays a pivotal role in angiogenesis and the regeneration of ischaemic tissue through the regulation of haematopoietic progenitor cells and is upregulated at the sites of vascular injury and platelet activation. Thus, SDF‐1 has recently been discussed as a predictor in ischaemic diseases such as acute myocardial infarction. However, no clinical data pertinent to the investigation of the platelet SDF‐1 expression in patients with stroke are available. Methods: We consecutively evaluated 196 patients who were admitted to the stroke unit with symptoms suspected for stroke. Surface expression of the platelet activation markers (P‐selectin and GPIb) and the expression of platelet‐bound SDF‐1 were determined by two‐colour whole blood flow cytometry. Results: Patients with transient ischaemic attack (TIA) as well as with ischaemic stroke showed similar levels of SDF‐1 expression on hospital admission compared with patients with non‐ischaemic (NI) events and with 30 healthy controls (TIA (mean fluorescence intensity ± SD): 31.5 ± 18.2 vs. NI: 26.4 ± 15.7; P = 0.361; stroke: 28.7 ± 19.8 vs. NI; P = 0.943; control: 26.1 ± 11.3; P > 0.05 compared with all). Platelet SDF‐1 expression showed a trend with the severity of stroke according to National Institute of Health Stroke Scale score (r = 0.125; P = 0.085), but significantly correlated with the peak levels of C‐reactive protein (r = 0.218; P = 0.002) and with the levels of platelet activation (P‐selectin: r = 0.389; P = 0.001). Multifactorial analysis of covariance revealed a significant influence on platelet SDF‐1 expression by smoking (P = 0.019). Conclusions: Platelet SDF‐1 surface expression did not show any significant difference in patients with TIA and ischaemic stroke compared with patients with NI events. Thus, single biomarker evaluation of platelet SDF‐1 surface expression is not helpful to predict ischaemic stroke.     

A case-control study of transient global amnesia.

To evaluate risk factors and prognosis of transient global amnesia (TGA), three groups of 30 subjects each affected respectively by: (1) first-ever TGA; (2) first-ever transient ischaemic attack (TIA); (3) depressive neurosis, were compared. Prevalence of cerebrovascular risk factors was similar in patients with TGA and TIA, but significantly lower in the third group. CT showed more hypodense lesions in TIA patients than in those with TGA. In a mean follow-up of 36 months, five TGA patients experienced a TIA and three others had recurrence of TGA, but none suffered stroke or myocardial infarction. In the TIA group, four had recurrence of TIA, two suffered a stroke and two others a myocardial infarction, whereas none had TGA attacks. None of the patients of the third group had any ischaemic event during follow-up. The similar prevalence of risk factors, but the different prognosis between TGA and TIA patients, suggest that TGA is an ischaemic event, probably not triggered by thromboembolism but by a different, possibly vasospastic, mechanism.     

Plasma homocysteine is a risk factor for recurrent vascular events in young patients with an ischaemic stroke or TIA

Objectives Young patients with an ischaemic stroke or transient ischaemic attack (TIA) often have no vascular risk factors. Hyperhomocysteinaemia is an established risk factor for stroke in elderly patients but it is uncertain whether it is also important for the prognosis of young ischaemic stroke and TIA patients. We examined the possible effect of the plasma homocysteine level on the risk of recurrent vascular events in patients between 18 and 45 years of age. Methods The study population consisted of 161 consecutive patients with a recent cerebral infarction or TIA. Data on the primary event and the homocysteine level were collected retrospectively from hospital records. General practitioners and patients were contacted by telephone to record vascular events and the type of medication used during the follow–up period. Vascular events included cerebral infarction, TIA, pulmonary embolism, venous thrombosis, myocardial infarction and peripheral arterial disease. Results A Kaplan- Meier curve showed a dose effect relationship between event-free survival time and tertiles of the homocysteine level (Log rank statistic 5.91; p = 0.05). The Cox hazard ratio, after adjustment for homocysteine lowering treatment, was 1.7 (95 % CI, 1.1 to 2.8) for any vascular outcome event, 1.9 (95% CI, 1.1 to 3.0) for arterial outcome events and 1.8 (95 % CI, 1.1 to 2.9) for cerebral outcome events. Conclusions In spite of our small number of outcome events we found a significant association at the 95% confidence level between homocysteine level and the risk of recurrent vascular events in young patients with an ischaemic stroke or TIA. The association is of the same magnitude as in elderly people.     

TIA,RIND, minor stroke: a continuum,or different subgroups? Dutch TIA Study Group.

The results of CT were studied prospectively in 606 patients with a transient ischaemic attack (TIA), 422 patients with a reversible ischaemic neurological deficit (RIND), and 1054 patients with a minor stroke, were all entered into a multi-centre clinical trial. CT scanning showed a relevant ischaemic lesion in 13% (95% confidence interval 10-16%) of TIAs, 35% (95% confidence interval 30-40%) of RINDs, and 49% (95% confidence interval 46-52%) of minor strokes (p less than 0.000001). Even within the 24 hour margin, relevant infarcts occurred more often with longer attacks, but were still found in some patients with attacks lasting less than a minute. The type and location of the infarcts were similar in the three groups. These findings suggest that the differences between TIAs, RINDs, and minor strokes are quantitative rather than qualitative.     

Noninvasive Assessment of Intracranial Perfusion in Acute Cerebral Ischemia

Single-photon emission computed tomography (SPECT) and transcranial Doppler sonography (TCD) may help to determine a target group of patients w1th maximum therapeutiC response for tissue rescue after acute stroke. As previously described, the cerebral perfusion mdex represents a combination of these techniques, and is calculated by multiplying assigned values for TCD and SPECT perfusion patterns. The three grades of cerebral perfusion index (1–5, 6–12, 15–20) may predict short-term outcome if the index is based on SPECT and TCD performed w1thin the first 6 hours after stroke. A total of 30 consecutive patients were studied (18 with middle cerebral artery stroke and 12 with transient ischemic attack or minor stroke) Neurological deficit was scored using the Canadian Neurological Scale. SPECT and TCD were performed 4 ± 2 hours after the onset. Forty-five minutes were required to perform both tests, evaluate the results, and calculate the cerebral perfusion index. The mean score ( ± standard deviation) of the neurological deficit on admission was 84 ± 20 in patients with transient ischemic attack/minor stroke and 54 ± 33 in patients with stroke (p < 0 009) The volume of 1schemic lesion was measured on computed tomography scans performed more than 3 days after the ictus. Patients with transient ischemic attack/minor stroke had lesion volumes of 8 ± 7 cm3 compared to 72 ± 26 cm3 for those with stroke (p < 0.0001). The mean cerebral perfusion index in the transient ischemic attack group was 18 ± 4, while in the stroke group it was 4 ± 1 (p < 0.0001 ). Clinical examination on admission correctly predicted a reversible neurological deficit in 9 of 12 patients in the transient ischemic attack group and the irreversibility of brain damage in 14 of 18 patients in the stroke group. With the three-grades scale, cerebral perfusion index correctly identified 10 transient ischemic attacks and 17 strokes. Noninvasive diagnosis of intracranial perfusion abnormalities using SPECT and TCD correlates with the clinical outcome and the volume of brain damage, and therefore may improve the accuracy of prognosis in the hyperacute phase of cerebral ischemia. Cerebral perfusion index is a fast and qualitative scoring system that may be used for early differentiation of transient ischemic attacks, minor strokes, and strokes durmg the first 6 hours of cerebral ischemia.     

A comparison of risk factors and prognosis for transient ischemic attacks and minor ischemic strokes. The Oxfordshire Community Stroke Project

In a community-based study of transient ischemic attack and stroke, we identified 184 cases of transient ischemic attack and 213 cases of first-ever minor ischemic stroke. A comparison of age, sex, and prevalence of coexistent vascular diseases and risk factors revealed no major differences between the two groups. The risk of further stroke and of further stroke and/or death was greater in patients with minor ischemic stroke although the difference was significant only for the latter. The apparent differences in prognosis could largely be accounted for by the favorable prognosis of patients with amaurosis fugax among those with transient ischemic attack. Although for some purposes it may be useful to distinguish transient ischemic attacks from minor ischemic strokes, the similarity of the two groups suggests that in many situations, including in clinical trials of treatments for the secondary prevention of strokes, the arbitrary distinction between them could be dispensed with.     

Optimizing the risk estimation after a transient ischaemic attack – the ABCDE⊕ score

Background and purpose: The risk of stroke after a transient ischaemic attack (TIA) can be predicted by scores incorporating age, blood pressure, clinical features, duration (ABCD‐score), and diabetes (ABCD2‐score). However, some patients have strokes despite a low predicted risk according to these scores. We designed the ABCDE+ score by adding the variables ‘etiology’ and ischaemic lesion visible on diffusion‐weighted imaging (DWI) –‘DWI‐positivity’– to the ABCD‐score. We hypothesized that this refinement increases the predictability of recurrent ischaemic events. Methods: We performed a prospective cohort study amongst all consecutive TIA patients in a university hospital emergency department. Area under the computed receiver‐operating curves (AUCs) were used to compare the predictive values of the scores with regard to the outcome stroke or recurrent TIA within 90 days. Results: Amongst 248 patients, 33 (13.3%, 95%‐CI 9.3–18.2%) had a stroke (n = 13) or a recurrent TIA (n = 20). Patients with recurrent ischaemic events more often had large‐artery atherosclerosis as the cause for TIA (46% vs. 14%, P < 0.001) and positive DWI (61% vs. 35%; P = 0.01) compared with patients without recurrent events. Patients with and those without events did not differ with regard to age, clinical symptoms, duration, blood pressure, risk factors, and stroke preventive treatment. The comparison of AUCs [95%CI] showed superiority of the ABCDE+ score (0.67[0.55–0.75]) compared to the ABCD²‐score (0.48[0.37–0.58]; P = 0.04) and a trend toward superiority compared to the ABCD‐score (0.50[0.40–0.61]; P = 0.07). Conclusion: In TIA patients, the addition of the variables ‘etiology’ and ‘DWI‐positivity’ to the ABCD‐score seems to enhance the predictability of subsequent cerebral ischaemic events.