Background: Prognostic clinical scores (ABCD2 and ABCD3-I), as well as specific clinical signs and symptoms (e.g. fluctuations) have been used to predict early stroke risk in patients admitted to hospital after transient ischemic attacks (TIAs). We compared the utility of these scores and signs for prognosis and outcome. Methods: 235 patients with TIAs admitted to our Comprehensive Stroke Center entered the study. Patients were monitored over 3 days with detailed brain imaging [diffusion-weighted imaging (DWI) was performed either directly on admission or within 24 h from admission and was repeated in cases of stroke recurrence], vascular ultrasound imaging, repeated neurological scoring and continuous ECG monitoring. Duration, fluctuation of symptoms, clinical patterns of initial signs and/or symptoms as well as general patient characteristics and stroke risk factors, including atrial fibrillation (AF), were analyzed and recorded in our stroke databank. Fluctuation of symptoms was defined as the complete remitting and relapsing of TIA symptoms for ≥2 times in the acute phase within the first 24 h. This differs from the ‘dual TIA' definition of the ABCD3-I score, which is defined as ‘an earlier TIA within 7 days of the index event'. ABCD2 and ABCD3-I scores were calculated and the patients were placed into three categories: ‘low', ‘moderate' and ‘high' risk for every score. Risk associations were assessed by the χ2 test and the φ-coefficient. Results: Out of 235 patients, 17 patients (7.2%) experienced an early stroke during hospitalization (mean duration 7.4 ± 2.7 days). ABCD2 scores failed to predict early stroke (p = 0.544). ABCD3-I scores correlated better with early stroke recurrences (p = 0.021). Positive DWI findings (6/17; 35.3%), presence of carotid stenosis (3/17; 17.6%) or AF (1/17; 5.9%) alone failed to predict early stroke. Fluctuations of symptoms, however, showed a significant prediction for early stroke after TIA: 13/17 (76.5%) patients (p < 0.001). The combination of symptom fluctuation and MR-DWI-positive findings (4/17; 23.5%) also turned out to be statistically significant in this regard (p = 0.003), while the combination of symptom fluctuations with carotid stenosis ≥50% did not (p = 0.151). Combining fluctuations with carotid stenosis and DWI-positive findings did not improve the result (p = 0.029). Conclusions: While the ABCD3-I score is indeed very useful, symptom fluctuations seem to be the best available and an easily accessible and applicable parameter for individual prediction of a high early stroke risk after TIAs.

1.
Daffertshofer M, Mielke O, Pullwitt A, Felsenstein M, Hennerici M: Transient ischemic attacks are more than ‘ministrokes'. Stroke 2004;35:2453-2458.
2.
Giles MF, Rothwell PM: Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2007;6:1063-1072.
3.
Johnston SC, Gress DR, Browner WS, Sidney S: Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901-2906.
4.
Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA: Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med 2007;167:2417-2422.
5.
Prabhakaran S, Chong JY, Sacco RL: Impact of abnormal diffusion-weighted imaging results on short-term outcome following transient ischemic attack. Arch Neurol 2007;64:1105-1109.
6.
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.
7.
Giles MF, Albers GW, Amarenco P, Arsava EM, Asimos AW, Ay H, Calvet D, Coutts SB, Cucchiara BL, Demchuk AM, Johnston SC, Kelly PJ, Kim AS, Labreuche J, Lavallee PC, Mas JL, Merwick A, Olivot JM, Purroy F, Rosamond WD, Sciolla R, Rothwell PM: Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: a multicenter study. Neurology 2011;77:1222-1228.
8.
Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S: Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007;369:283-292.
9.
Giles MF, Albers GW, Amarenco P, Arsava MM, Asimos A, Ay H, Calvet D, Coutts S, Cucchiara BL, Demchuk AM, Johnston SC, Kelly PJ, Kim AS, Labreuche J, Lavallee PC, Mas JL, Merwick A, Olivot JM, Purroy F, Rosamond WD, Sciolla R, Rothwell PM: Addition of brain infarction to the ABCD2 score (ABCD2I): a collaborative analysis of unpublished data on 4,574 patients. Stroke 2010;41:1907-1913.
10.
Merwick A, Albers GW, Amarenco P, Arsava EM, Ay H, Calvet D, Coutts SB, Cucchiara BL, Demchuk AM, Furie KL, Giles MF, Labreuche J, Lavallee PC, Mas JL, Olivot JM, Purroy F, Rothwell PM, Saver JL, Sheehan OC, Stack JP, Walsh C, Kelly PJ: Addition of brain and carotid imaging to the ABCD(2) score to identify patients at early risk of stroke after transient ischaemic attack: a multicentre observational study. Lancet Neurol 2010;9:1060-1069.
11.
Chatzikonstantinou A, Willmann O, Jager T, Szabo K, Hennerici MG: Transient ischemic attack patients with fluctuations are at highest risk for early stroke. Cerebrovasc Dis 2009;27:594-598.
12.
Nakajima M, Hirano T, Naritomi H, Minematsu K: Symptom progression or fluctuation in transient ischemic attack patients predicts subsequent stroke. Cerebrovasc Dis 2010;29:221-227.
13.
Bray JE, Coughlan K, Bladin C: Can the ABCD score be dichotomised to identify high-risk patients with transient ischaemic attack in the emergency department? Emerg Med J 2007;24:92-95.
14.
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.
15.
Tsivgoulis G, Stamboulis E, Sharma VK, Heliopoulos I, Voumvourakis K, Teoh HL, Patousi A, Andrikopoulou A, Lim EL, Stilou L, Sim TB, Chan BP, Stefanis L, Vadikolias K, Piperidou C: Multicenter external validation of the ABCD2 score in triaging TIA patients. Neurology 2010;74:1351-1357.
16.
Coutts SB, Simon JE, Eliasziw M, Sohn CH, Hill MD, Barber PA, Palumbo V, Kennedy J, Roy J, Gagnon A, Scott JN, Buchan AM, Demchuk AM: Triaging transient ischemic attack and minor stroke patients using acute magnetic resonance imaging. Ann Neurol 2005;57:848-854.
17.
Calvet D, Touze E, Oppenheim C, Turc G, Meder JF, Mas JL: DWI lesions and TIA etiology improve the prediction of stroke after TIA. Stroke 2009;40:187-192.
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