Published online before print January 18, 2007, doi: 10.1161/01.STR.0000257306.00512.d3
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(Stroke. 2007;38:855.)
© 2007 American Heart Association, Inc.
Letters to the Editor |
Absence of Usefulness of ABCD Score in the Early Risk of Stroke of Transient Ischemic Attack Patients
Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Universitat de Lleida, Lleida, Spain
Neurovascular Unit, Hospital Universitari de la Vall d’Hebron, Barcelona, Spain
To the Editor:
With great interest we read the study of Cucchiara et al1 about the usefulness of the ABCD score,2 developed by Rothwell et al. A 6-point score derived from the Oxfordshire Community Stroke Project cohort (age [
60 years=1], blood pressure [systolic >140 mmHg and/or diastolic 90 mmHg=1], clinical features [unilateral weakness=2, speech disturbance without weakness=1, other=0], and duration of symptoms in minutes [60=2, 10 to 59=1, <10=0]; ABCD) was highly predictive of 7-day risk of stroke in the Oxfordshire cohort. In contrast to the Oxfordshire series, the ABCD score is not useful in a North American cohort of transient ischemic attack (TIA) patients. We are pleased to present a study with similar results. We test the ABCD score in 345 consecutive TIA patients attended within 24 hours by the vascular neurologist in the emergency room. Clinical data, symptom duration, neuroimaging and ultrasonographic (carotid and transcranial) findings were prospectively collected wihin the first 24 hours after symptoms onset. A total of 17 (4.9%) patients had a stroke recurrence within the first 7 days after symptoms onset. Seven of 17 (42.2%) strokes occurred in 124 (35.9%) patients with a score of 5 or greater, whereas 7-day risk was 4.5% (95% CI, 3.38 to 6.68) in 221 (64.1%) patients with a score <5 (Table). In Cox proportional hazards multivariate analyses in which age, sex, vascular risk factors and variables showing P<0.1 on univariate models were included, only large-artery occlusive disease remained independent predictor for stroke recurrence (hazard ratio 5.88 [95% CI, 2.17 to 15.89; P<0.001]).
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After a first TIA up to 20% of patients had a stroke within the next 90 days, and in 50% of them, the stroke recurrence occurs within the first 24 to 72 hours after the event.3–5 Consequently, TIA must be considered a medical emergency. However, only a small number of clinical factors have been found to be weakly associated with an increased risk of stroke after TIA (advanced age, diabetes mellitus, symptoms lasting >10 minutes, weakness and impaired speech) and consequently patients at highest risk of recurrent events cannot be reliably identified.6 We previously demonstrated that TIA patients with moderate to severe intracranial or extracranial stenoses have a higher risk of stroke recurrence7 which may indicate that clinical data are not enough to identify those patients at higher risk.8,9 Moreover, MR diffusion-weighted imaging which assesses the presence or absence of true ischemia could be a useful prognostic method.10,11 The combination of clinical, radiological and vascular information may improve the predictive accuracy of stroke recurrence risk.10 The routine use of combined carotid/transcranial ultrasound testing performed early will be useful for identifying high risk individuals in order to plan urgent aggressive prevention therapies.
Acknowledgments
Disclosures
None.
References
1. Cucchiara BL, Messe SR, Taylor RA, Pacelli J, Maus D, Shah Q, Kasner SE. Is the ABCD score useful for risk stratification of patients with acute transient ischemic attack? Stroke. 2006; 37: 1710–1714.
2. Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, Mehta Z. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 2005; 366: 29–36.[CrossRef][Medline] [Order article via Infotrieve]
3. Eliasziw M, Kennedy J, Hill MD, Buchan AM, Barnett HJ. Early risk of stroke after a transient ischemic attack in patients with internal carotid artery disease. CMAJ. 2004; 170: 1105–1109.
4. Coull AJ, Lovett JK, Rothwell PM. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ. 2004; 328: 326.
5. Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000; 284: 2901–2906.
6. Johnston SC, Sidney S, Bernstein AL, Gress DR. A comparison of risk factors for recurrent TIA and stroke in patients diagnosed with TIA. Neurology. 2003; 60: 280–285.
7. Purroy F, Montaner J, Delgado P, Arenillas JF, Molina CA, Santamarina E, Quintana M, Alvarez-Sabin J. Usefulness of urgent combined carotid/transcranial ultrasound testing in early prognosis of TIA patients. Med Clin (Barc). 2006; 126: 647–650.[CrossRef][Medline] [Order article via Infotrieve]
8. Kernan WN, Viscoli CM, Brass LM, Makuch RW, Sarrel PM, Roberts RS, Gent M, Rothwell P, Sacco RL, Liu R-C, Boden-Albala B, Horwitz RI. The stroke prognosis instrument II (SPI-II): a clinical prediction instrument for patients with transient ischemia and nondisabling ischemic stroke. Stroke. 2000; 31: 456–462.
9. Hankey GJ, Slattery JM, Warlow CP. Can the long term outcome of individual patients with transient ischaemic attacks be predicted accurately? J Neurol Neurosurg Psychiatry. 1993; 56: 752–759.
10. Purroy F, Montaner J, Rovira A, Delgado P, Quintana M, Alvarez-Sabin J. Higher risk of further vascular events among transient ischemic attack patients with diffusion-weighted imaging acute ischemic lesions. Stroke. 2004; 35: 2313–2319.
11. Ay H, Koroshetz WJ, Benner T, Vangel MG, Wu O, Schwamm LH, Sorensen AG. Transient ischemic attack with infarction: a unique syndrome? Ann Neurol. 2005; 57: 679–686.[CrossRef][Medline] [Order article via Infotrieve]
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