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Predicting Recurrent Stroke After Minor Stroke and Transient Ischemic Attack

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Predicting Recurrent Stroke After Minor Stroke and Transient Ischemic Attack Review For reprint orders, please contact [email protected] Predicting recurrent stroke after minor stroke and transient ischemic attack Expert Rev. Cardiovasc. Ther. 7(10), 1273–1281 (2009) Philippe Couillard, The risk of a subsequent stroke following an acute transient ischemic attack or minor stroke is Alexandre Y Poppe high, with 90-day risk at approximately 10%. Identification of those patients at the highest risk and Shelagh B Coutts† for recurrent stroke following a transient ischemic attack or minor stroke may allow risk-specific †Author for correspondence management strategies to be implemented, such as hospital admission with expedited work-up Department of Clinical for those at high risk and emergency room discharge for those at low risk. Predictors of recurrent Neurosciences and Radiology, stroke, including the ABCD2 score, brain imaging and the stroke mechanism, are reviewed in University of Calgary, C1261, this article, with a focus on recent literature. An emphasis is placed on the importance of early Foothills Medical Centre, imaging of the brain parenchyma (diffusion-weighted imaging) and vascular imaging to identify 1403 29th St NW, Calgary, patients at high risk for recurrence. The need for identification of the cause of the initial event, AB, T2N 2T9, Canada allowing therapies to be tailored to the individual patient, is discussed. Tel.: 1 403 944 1594 Fax: 1 403 283 2270 KEYWORDS: imaging • prevention • prognosis • recurrence • stroke • transient ischemic attack shelagh.coutts@ albertahealthservices.ca Stroke is the second leading cause of death and is present very quickly after symptom onset. This a major cause of adult disability in the world [1,2]. provides both an opportunity and a challenge: The incidence of stroke varies throughout the an opportunity to identify high-risk patients world from 240 per 100,000 people in Dijon, early, especially when their deficits are transient; France, to approximately 600 per 100,000 peo- a challenge in managing and triaging a large ple in Novosibirsk, Russia [3]. In the USA contingent of patients in a system often already alone, there are approximately 795,000 new overloaded. This review will focus on deter- strokes each year [101]. In some stroke patients, minants of stroke recurrence, prediction rules the symptoms are mild (minor stroke) or even and imaging in minor stroke and TIA. Most transient – a transient ischemic attack (TIA). of the evidence described in this review is level- Tragically, many of these patients with mild two evidence, as it is derived from single-center stroke experience either progression of their cohort studies. symptoms or a second, more severe stroke that leaves them disabled. One in five ischemic stroke Definition of recurrent stroke patients report a TIA in the hours to days pre- Ischemic stroke and TIA are on a spectrum of ceding the stroke [4–6]. In addition, 15–30% of serious conditions involving brain ischemia. disabling strokes are heralded by nondisabling Both represent inadequate cerebral blood flow stroke or TIAs, usually within 1 week [4]. After and cause patients to incur disability and death a TIA or minor stroke, there is an approximately at higher rates. There are various definitions of 10% risk of subsequent stroke within 90 days, stroke recurrence, but the one that we find of with 4–5% of this risk occurring in the first most practical use is a ‘functional deterioration 48 h [7–15]. Patients with strokes considered too in neurological status or a new sudden focal minor for tissue plasminogen activator represent neurological deficit of vascular origin lasting an interesting group. Studies show that up to a more than 24 h’. This could represent either third of patients die or become dependent at recurrent ischemia or hemorrhage; however, in hospital discharge [16,17]. most cases, the recurrent event after an ischemic With the advent of thrombolysis for acute stroke will be ischemic. The neurologic dysfunc- ischemic stroke, systems of care have improved tion is implicitly ischemic in nature and not epi- and patients with mild or transient deficits often leptic or related to a migrainous phenomenon www.expert-reviews.com 10.1586/ERC.09.105 © 2009 Expert Reviews Ltd ISSN 1477-9072 1273 Review Couillard, Poppe & Coutts or other stroke mimics (e.g., infections, drug abuse and side • Duration of symptoms lasting longer than 60 min (2 points) effects, or intercurrent illnesses). In this article, for the most or 10–59 min (1 point) part, we consider TIA and minor stroke together as a spectrum • Diabetes mellitus (1 point) of the same disease, as patients presenting very early in their event cannot be classified by the traditional method (symptoms The ability of the ABCD2 score to predict recurrent stroke risk resolved within 24 h of symptom onset) [14]. Rather than defining has been validated in independent cohorts, with AUC values rang- TIA and minor stroke as distinct syndromes, we prefer to look ing from 0.62 to 0.83. It allows the stratification of patients into upon these as events causing minimal or no deficits. The Effect high risk (score: 6–7; 8.1% 2-day risk of stroke), moderate risk of Urgent Treatment of Transient Ischemic Attack and Minor (score: 4–5; 4.1% 2-day risk of stroke) and low risk (score: 0–3; Stroke on Early Recurrent Stroke (EXPRESS) study found no 1% 2-day risk of stroke) (FIGURE 1). These scores are particularly difference in recurrent stroke outcomes in TIA or minor stroke useful for screening by nonexperts, but have some limitations: patients [18]. Other studies have also examined at patients in this Validation studies assessing the ABCD and ABCD2 scores have manner rather than making an arbitrary distinction between the generated mixed results; the applicability is potentially limited to two conditions [19,20]. TIA (although this is not clear), and the score is not informative on event mechanism [28,29]. TABLE 1 describes some of the factors Short-term stroke risk after TIA? that increase the stroke recurrence. Studies of prognosis after TIA from the early 1990s quoted annual stroke recurrence risk as between 3.7 and 7.8% per year [21]. Recently, Impact of mechanism on risk of recurrence more ominous results have been reported [22]. A Californian study Strokes can be subdivided according to their mechanism for differ- of 1707 patients diagnosed with TIA in the emergency depart- ent purposes: clinical trials, epidemiological studies and for thera- ment found a 10.5% incidence of stroke at 90 days, with half of peutic decision-making. The Trial of Org 10172 in Acute Stroke the strokes occurring in the first 2 days [14]. A Canadian study of Treatment (TOAST) classification, although imperfect, is often 2285 TIA patients produced similar findings, with a 90-day rate of used in clinical practice and research protocols [30]. It uses five stroke of 9.5% and a 1-year stroke risk of 14.5% [13]. A re-analysis categories: large-artery atherosclerosis, small-vessel disease, car- of the Oxford Community Stroke project showed an 8.6% risk of dioembolic, other determined and other undetermined. The risk stroke within 7 days after TIA [6]. Moreover, a large proportion of stroke recurrence is partly dependent on the mechanism under- of ischemic events will recur in the first 24 h, with a risk of 5.1% lying the index event [26]. Early identification of a mechanism at 24 h [23]. National stroke care guidelines echo this need for may, therefore, improve our ability to prognosticate recurrence urgent assessment, in an effort to reduce disability associated with and deterioration. Events due to large-artery disease (primarily disease recurrence [24]. extracranial) have the highest risk of early recurrence, approaching eight times that of those due to small-vessel disease, which have Clinical characteristics the lowest risk. Cardioembolic events fall somewhere in between Studies to identify patients who are at high risk for recurrent these two extremes [26,31]. The early risk of stroke after TIA due stroke after TIA have investigated the features of the patient to large-artery disease has been well demonstrated in a study of (e.g., diabetes mellitus [14] and hypertension [14,25]), of the event patients with more than 50% carotid stenosis, among whom 20% (e.g., symptom duration > 10 min or weakness or speech distur- had a stroke in the first 2 weeks prior to endarterectomy [9]. A bance [14,25]), of the mechanism [26], of the vascular territory and post hoc analysis of the Warfarin versus Aspirin for Symptomatic of imaging to predict the risk of recurrence. Intracranial Disease study found a 6.7% risk of stroke within Patient variables and event characteristics are used to predict 90 days after TIA in patients with symptom-relevant 50–99% the risk of recurrent stroke. Using a combination of many of intracranial artery stenosis [32]. these factors, clinical stratification tools (e.g., California, ABCD The vascular territory involved in a TIA also has prognostic sig- and ABCD2 scores [14,25,27]) have been developed to help identify nificance. This is perhaps best described as the fact that retinal patients at high risk of recurrent events, with the aim of urgent TIAs (amaurosis fugax) have a more favorable prognosis than events hospitalization and investigation.Conversely, the scoring systems in other vascular territories [33,26]. Vertebrobasilar events may be could identify patients at low risk, who could be managed in the associated with a higher risk of early recurrence [20,34,35], especially outpatient setting (or not enrolled in clinical trials). Recently, if stenosis is demonstrated in the posterior circulation [26,34]. the California and ABCD scores were combined to produce the ABCD2 score. The total ABCD2 score, ranging from 0 to 7, relies Cerebral & vascular imaging as a predictor on the summation of points associated with five clinical factors: of recurrence The limitations of previous predictive clinical scores may be due • Aged 60 years or over (1 point) to the omission of hyperacute imaging data.
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