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Vol. 33, No. 2, 2012
Issue release date: February 2012
Cerebrovasc Dis 2012;33:182–189

Prediction of Early Stroke Recurrence in Transient Ischemic Attack Patients from the PROMAPA Study: A Comparison of Prognostic Risk Scores

Purroy F. · Jiménez Caballero P.E. · Gorospe A. · Torres M.J. · Álvarez-Sabin J. · Santamarina E. · Martínez-Sánchez P. · Cánovas D. · Freijo M.M. · Egido J.A. · Girón J.M. · Ramírez-Moreno J.M. · Alonso A. · Rodríguez-Campello A. · Casado I. · Delgado-Medeiros R. · Martí-Fàbregas J. · Fuentes B. · Silva Y. · Quesada H. · Cardona P. · Morales A. · de la Ossa N. · García-Pastor A. · Arenillas J.F. · Segura T. · Jiménez C. · Masjuán J. · on behalf of the Stroke Project of the Spanish Cerebrovascular Diseases Study Group
aStroke Unit, Department of Neurology, Universitat de Lleida, Hospital Universitari Arnau de Vilanova de Lleida, IRBLleida Research Institute, Lleida, bDepartment of Neurology, Hospital San Pedro de Alcántara de Cáceres, Cáceres, cDepartment of Neurology, Hospital Universitario Son Dureta, Palma de Mallorca, dStroke Unit, Department of Neurology, Hospital Universitari Vall d’Hebron, Barcelona, eStroke Center, Department of Neurology, La Paz University Hospital, Autónoma de Madrid Universtiy, IdiPAZ Research Institute, Madrid, fDepartment of Neurology, Hospital Parc Taulí, Sabadell, gDepartment of Neurology, Hospital de Basurto, Bilbao, hDepartment of Neurology, Hospital Clínico San Carlos, Madrid, iHospital de Jerez, Jerez de la Frontera, jDepartment of Neurology, Hospital Universitario Infanta Cristina, Badajoz, kStroke Unit, Hospital Universitario Ramón y Cajal, Madrid, lStroke Unit, Hospital del Mar, Barcelona, mDepartment of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, nStroke Unit, Department of Neurology, Hospital Josep Trueta, Girona, oStroke Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospital de Llobregat, Barcelona, pDepartment of Neurology, Hospital Universitario Virgen de la Arrixaca, Murcia, qStroke Unit, Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, rStroke Unit, Neurology Department, Hospital General Universitario Gregorio Marañón, Madrid, sStroke Unit and Stroke Program, Department of Neurology, University Hospital, University of Valladolid, Valladolid, and tDepartment of Neurology, Hospital Universitario de Albacete, Albacete, Spain

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Background: Several clinical scales have been developed for predicting stroke recurrence. These clinical scores could be extremely useful to guide triage decisions. Our goal was to compare the very early predictive accuracy of the most relevant clinical scores [age, blood pressure, clinical features and duration of symptoms (ABCD) score, ABCD and diabetes (ABCD2) score, ABCD and brain infarction on imaging score, ABCD2 and brain infarction on imaging score, ABCD and prior TIA within 1 week of the index event (ABCD3) score, California Risk Score, Essen Stroke Risk Score and Stroke Prognosis Instrument II] in consecutive transient ischemic attack (TIA) patients. Methods: Between April 2008 and December 2009, we included 1,255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). A neurologist treated all patients within the first 48 h after symptom onset. The duration and typology of clinical symptoms, vascular risk factors and etiological work-ups were prospectively recorded in a case report form in order to calculate established prognostic scores. We determined the early short-term risk of stroke (at 7 and 90 days). To evaluate the performance of each model, we calculated the area under the receiver operating characteristic curve. Cox proportional hazards multivariate analyses determining independent predictors of stroke recurrence using the different components of all clinical scores were calculated. Results: We calculated clinical scales for 1,137 patients (90.6%). Seven-day and 90-day stroke risks were 2.6 and 3.8%, respectively. Large-artery atherosclerosis (LAA) was observed in 190 patients (16.7%). We could confirm the predictive value of the ABCD3 score for stroke recurrence at the 7-day follow-up [0.66, 95% confidence interval (CI) 0.54–0.77] and 90-day follow-up (0.61, 95% CI 0.52–0.70), which improved when we added vascular imaging information and derived ABCD3V scores by assigning 2 points for at least 50% symptomatic stenosis on carotid or intracranial imaging (0.69, 95% CI 0.57–0.81, and 0.63, 95% CI 0.51–0.69, respectively). When we evaluated each component of all clinical scores using Cox regression analyses, we observed that prior TIA and LAA were independent predictors of stroke recurrence at the 7-day follow-up [hazard ratio (HR) 3.97, 95% CI 1.91–8.26, p < 0.001, and HR 3.11, 95% CI 1.47–6.58, p = 0.003, respectively] and 90-day follow-up (HR 2.35, 95% CI 1.28–4.31, p = 0.006, and HR 2.20, 95% CI 1.15–4.21, p = 0.018, respectively). Conclusion: All published scores that do not take into account vascular imaging or prior TIA when identifying stroke risk after TIA failed to predict risk when applied by neurologists. Clinical scores were not able to replace extensive emergent diagnostic evaluations such as vascular imaging, and they should take into account unstable patients with recent prior transient episodes.

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