European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack

The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

Correlation between stromal cell-derived factor 1 and the prognosis of transient ischemic attack

Background: Transient Ischemic Attack (TIA) (1) is a neurological dysfunction of transient cerebrovascular ischemia, which is more common in clinical practice. The risk of further progression to ischemic stroke after a higher TIA can be used as a strong early warning signal of cerebral infarction. Objectives: To explore the correlation between stromal cell-derived factor 1 (SDF-1) and the prognosis of TIA. Methods: A number of 65 patients with TIA were collected, the ABCD2 clinical risk prediction score was implemented, relevant tests and nuclear magnetic resonance imaging (MRI) were performed, and the SDF-1 was recorded in serum levels. End-point events were selected in patients after cerebral infarction in the short term. The statistical analysis method was used to evaluate TIA short-term development for the occurrence of cerebral infarction after risk, the severity of serum level of SDF-1, and infarction. Results: Based on the results, the high-risk group, middle-risk group, and low-risk group had statistically significant differences in serum SDF-1 levels (F=3.820; P<0.05). Correlation analysis demonstrated that ABCD2 score was positively correlated with serum SDF-1 (r=0.349; P<0.05). End-point events were included in the occurrence group and not included in the non-occurrence group. The SDF-1 level of the occurrence group was significantly higher than that of the non-occurrence group. Based on the cranial MRI results as the gold standard, the areas under the curve of the receiver operating characteristic curve (ROC) drawn based on the SDF-1, ABCD2 score, SDF-1 combined with the ABCD2 score, and the occurrence of end-point events were obtained at 0.717, 0.697, and 0.762, respectively. The sensitivity and specificity of SDF-1 were reported as 77.8% and 68.1%, respectively. The sensitivity and specificity of the ABCD2 score were 83.3% and 48.9%, respectively. The sensitivity and specificity of SDF-1 combined with the ABCD2 score were 72.2% and 76.6%, respectively. Conclusion: As evidenced by the obtained results, SDF-1 is associated with ABCD2 score risk classification. Patients with high levels of SDF-1 combined with the ABCD2 score have a higher risk of cerebral infarction. Elevated SDF-1 levels may indicate that TIA patients have a poor short-term prognosis and have a certain predictive value for the diagnosis of the risk of ischemic stroke in the short term.

European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack

The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

Abstract P136: Feasibility and Safety of an Expedited Emergency Department TIA Evaluation

Introduction: Transient ischemic attack (TIA) can portend impending stroke, but it is unclear whether a TIA evaluation necessitates inpatient admission. We assessed feasibility and safety of a TIA protocol in the emergency room for low-risk TIA patients. Methods: We studied low-risk TIA patients (ABCD2 score < 4, no significant vessel stenosis) before (January 2018-July 2019) and after (August 2019-March 2020) the implementation of an expedited, emergency room TIA protocol at a comprehensive stroke center. The pre-intervention cohort consisted of TIA patients in the institutional Get-With-The-Guidelines database who met pre-specified criteria ( Figure ) and were admitted. The post-intervention patients met the same criteria and underwent an expedited MRI with selected sequences. If the MRI showed no ischemia, patients were scheduled with rapid, outpatient stroke clinic follow-up and outpatient echocardiogram as indicated. We compared differences in outcomes of interest between the pre-and post-intervention cohorts including length of stay, radiographic and echocardiogram findings, and recurrent neurovascular events within 30 days. Results: In total, 120 TIA patients met criteria (71 pre-intervention, 49 patient post-intervention). Demographic and clinical characteristics were similar except the pre-intervention pathway had a higher proportion of patients with a smoking history and presenting symptom of aphasia and dysarthria. Median time from MRI order to completion was 2.3 hours in the post-intervention cohort. Median length of stay was 7.7 hours (IQR 5.2-9.7) in the post-intervention cohort compared to 28.8 hours (IQR 24.4-42.4) pre-intervention. There were no differences in neuroimaging or echocardiographic findings and 30-day re-presentation for stroke, TIA, or mortality. Conclusions: Our study demonstrates the feasibility and suggests safety of an expedited TIA protocol. Further study is needed to determine its generalizability.

ABCD3-I and ABCD2 Scores in a TIA Population with Low Stroke Risk

Objectives. We aimed to evaluate the ABCD3-I score and compare it with the ABCD2 score in short- (1 week) and long-term (3 months; 1 year) stroke risk prediction in our post-TIA stroke risk study, MIDNOR TIA. Materials and Methods. We performed a prospective, multicenter study in Central Norway from 2012 to 2015, enrolling 577 patients with TIA. In a subset of patients with complete data for both scores ( n = 305 ), we calculated the AUC statistics of the ABCD3-I score and compared this with the ABCD2 score. A telephone follow-up and registry data were used for assessing stroke occurrence. Results. Within 1 week, 3 months, and 1 year, 1.0% ( n = 3 ), 3.3% ( n = 10 ), and 5.2% ( n = 16 ) experienced a stroke, respectively. The AUCs for the ABCD3-I score were 0.72 (95% CI, 0.54 to 0.89) at 1 week, 0.66 (95% CI, 0.53 to 0.80) at 3 months, and 0.68 (0.95% CI, 0.56 to 0.79) at 1 year. The corresponding AUCs for the ABCD2 score were 0.55 (95% CI, 0.24 to 0.86), 0.55 (95% CI, 0.42 to 0.68), and 0.63 (95% CI, 0.50 to 0.76). Conclusions. The ABCD3-I score had limited value in a short-term prediction of subsequent stroke after TIA and did not reliably discriminate between low- and high-risk patients in a long-term follow-up. The ABCD2 score did not predict subsequent stroke accurately at any time point. Since there is a generally lower stroke risk after TIA during the last years, the benefit of these clinical risk scores and their role in TIA management seems limited. Clinical Trial Registration. This trial is registered with NCT02038725 (retrospectively registered, January 16, 2014).

Patients with isolated vertigo attack preceding stroke have different clinic characteristics: a retrospective study

Background Isolated vertigo attack history preceding the acute stroke were frequently accompanying with other focal neurological symptoms. To clarify the different clinical characteristics between isolated vertigo attack and vertigo symptom accompanying hemiplegia preceding stroke, we performed this 4-year retrospective study. Methods Medical records of 1283 patients hospitalized with vertigo symptom had been screened. Patients were divided into two groups: isolated vertigo attack history preceding the stroke defined as IVA group, vertigo symptom accompanying hemiplegia attack defined as VAH group. Clinic characteristics including ABCD2 score, infarction volume and location, relative risk factors and the following medical intervention were compared between the group. Results Patients featured with VAH had higher extracranial stenosis (21.2% vs. 9.0%, P < 0.01) and ABCD2 score (3.7 ± 1.9 vs. 2.3 ± 1.5, P = 0.03), patient with IVA showed a higher diabetic prevalence (40.9% vs. 29.7%, P = 0.02). The frequency of vertigo events tended to be more commonly in patient with VAH (median 3.1 vs. 5.5, p < 0.03). The total cerebral infarction volume in IVA group tended to be larger than VAH with a median of 4.56 cm3 versus 2.32 cm3 (p = 0.02). Additionally, less patients with IVA sought medical intervention when vertigo symptom occurred. Conclusions Clinical characteristics including ABCD2 score, total cerebral infarction volume and the location were different between AVH and IVH group. In addition, less patients in IVH cohort sought medical intervention when vertigo symptom occurred.

ABCD2 and ABCD3-I scores in a TIA population with low stroke risk

Background Several clinical risk scores have been developed to predict stroke risk after transient ischemic attack (TIA). We aimed to evaluate the ABCD3-I score and compare it with the ABCD2 score in short and long-term stroke risk prediction in our post TIA stroke risk study, MIDNOR TIA. Methods We performed a prospective, multicenter study in Central Norway from October, 2012, to July, 2015, enrolling 577 patients with TIA. In a subset of patients (n=305) we calculated the AUC statistics of the ABCD3-I score and compared this with the ABCD2 score at 1 week, 3 months and 1 year. To assess stroke occurrences, data obtained by telephone follow-up and registry data from the Norwegian Stroke Register was used. Results Three hundred and five patients had complete data for both ABCD3-I and ABCD2 scores. Within 1 week, 3 months and 1 year, 1.0% (n=3), 3.3% (n=10) and 5.2% (n=16) experienced a stroke, respectively. The AUCs for the ABCD3-I score were 0.72 (95% CI, 0.54 to 0.89) at 1 week (compared with ABCD2 score p =0.019), 0.66 (95% CI, 0.53 to 0.80) at 3 months ( p =0.11), and 0.68 (0.95% CI, 0.56 to 0.79) at 1 year ( p =0.39). Conclusions The ABCD3-I score had limited value in short term prediction of subsequent stroke after TIA and did not reliably discriminate between low and high-risk patients in long-term follow-up. The ABCD2 score did not predict subsequent stroke accurately at any time point. Since modern treatment regimens and a decrease in risk factors in the population have contributed to a generally lower stroke risk after TIA during the last years, the benefit of these clinical risk scores and their role in TIA management seems limited.

Abstract WP62: Delayed Appearance of DWI Lesions in Clinically Suspected DWI-Negative Stroke: DWI-CONVERSION Score

Introduction: Our aim was to determine the prevalence and factors associated with delayed appearance of DWI lesion among initially DWI-negative clinically suspected stroke patients in the follow-up DWIs during in-hospital care. Method: Among 5271 patients admitted to stroke unit as clinically suspected stroke/TIA within 7 days from symptom onset in our hospital via ER for 2010~2017, we selected subjects based on the following criteria 1) initial negative DWI (n=827), 2) follow-up DWI within 14 days (n=751). Then, we excluded 57 cases (hemorrhagic cases (n=4), cerebral angiography studies between MRIs (n=53)). Finally-included 694 cases were divided into two cohorts for temporal external validation (2010~2015 (n=488) as derivation; 2016~2017 (n=206) as validation). Results: Of 5271 cases, 827 cases (15.7%) showed initial negative DWI. In 694 finally-included cases, 22.5% (n=156) showed delayed appearance of DWI lesion. In derivation cohort, factors showing significant relationship with positive conversion comprised: medical histories such as atrial fibrillation (aOR 6.17, 3.23-12.01); symptoms including objective hemiparesis (aOR 4.39, 1.90-10.32) (Table 1). These factors were used to construct DWI-CONVERSION score (Table 2a). Its c-statistic was 0.813 in derivation cohort and 0.808 in validation cohort, which is significantly higher than that of ABCD2 score in validation cohort (c-statistic=0.678; P<0.01 for comparison; Table 2b). Conclusion: We identified prevalence and clinical factors significantly associated with delayed appearance of DWI lesions in clinically suspicious stroke patients. DWI-CONVERSION score is a simple tool to predict it.

Vertigo Due to Vascular Mechanisms

Isolated dizziness and vertigo due to vascular mechanisms are frequently misdiagnosed as peripheral vestibulopathy or vestibular migraine. For diagnosis of strokes presenting with an acute prolonged (≥ 24 hours) vestibular syndrome, findings on clinical examination, such as HINTS (negative head impulse tests, detection of direction-changing gaze-evoked nystagmus, and presence of skew deviation), are more sensitive than findings on neuroimaging. Since HINTS alone cannot securely detect anterior inferior cerebellar artery strokes, additional attention should be paid to the patients with unexplained hearing loss in addition to acute prolonged vestibulopathy. For diagnosis of transient (< 24 hours) spontaneous vestibular syndrome due to vascular mechanisms, the presence of associated craniocervical pain and focal neurological symptoms/signs is the clue. Even without these symptoms or signs, however, vascular imaging combined with perfusion- and diffusion-weighted MRI should be performed in patients with multiple vascular risk factors or a high ABCD2 score (age, blood pressure, clinical features, duration of symptom, and presence of diabetes).