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.

Keywords:
Transient ischemic attack, Prognosis, Outcome, Stroke recurrence
1.
Ovbiagele B, Kidwell CS, Saver JL: Epidemiological impact in the United States of a tissue-based definition of transient ischemic attack. Stroke 2003;34:919–924.
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.
Purroy F, Montaner J, Molina CA, Delgado P, Ribo M, Alvarez-Sabin J: Patterns and predictors of early risk of recurrence after transient ischemic attack with respect to etiologic subtypes. Stroke 2007;38:3225–3229.
4.
Purroy F, Begue R, Quilez A, Pinol-Ripoll G, Sanahuja J, Brieva L, Seto E, Gil MI: Diagnostic lessons of recurrence pattern after transient ischemic attacks (in Spanish). Med Clin (Barc) 2009;133:283–289.
5.
Ois A, Gomis M, Rodriguez-Campello A, Cuadrado-Godia E, Jimenez-Conde J, Pont-Sunyer C, Cuccurella G, Roquer J: Factors associated with a high risk of recurrence in patients with transient ischemic attack or minor stroke. Stroke 2008;39:1717–1721.
6.
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.
7.
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.
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 J-L, 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.
Johnston SC, Gress DR, Browner WS, Sidney S: Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901–2906.
11.
Weimar C, Goertler M, Rother J, Ringelstein EB, Darius H, Nabavi DG, Kim IH, Theobald K, Diener HC: Systemic risk score evaluation in ischemic stroke patients (SCALA): a prospective cross sectional study in 85 German stroke units. J Neurol 2007;254:1562–1568.
12.
Weimar C, Benemann J, Michalski MD, Muller M, Luckner K, Katsarava Z, Weber R, Diener HC: Prediction of recurrent stroke and vascular death in patients with transient ischemic attack or nondisabling stroke. A prospective comparison of validated prognostic scores. Stroke 2010;41:487–493.
13.
Fitzek S, Leistritz L, Witte OW, Heuschmann PU, Fitzek C: The Essen stroke risk score in one-year follow-up acute ischemic stroke patients. Cerebrovasc Dis 2011;31:400–407.
14.
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.
15.
Tsivgoulis G, Heliopoulos I: Potential and failure of the ABCD2 score in stroke risk prediction after transient ischemic attack. Stroke 2010;41:836–838.
16.
Giles MF, Rothwell PM: Systematic review and pooled analysis of published and unpublished validations of the ABCD and ABCD2 transient ischemic attack risk scores. Stroke 2010;41:667–673.
17.
Schrock JW, Victor A, Losey T: Can the ABCD2 risk score predict positive diagnostic testing for emergency department patients admitted for transient ischemic attack. Stroke 2009;40:3202–3205.
18.
Fothergill A, Christianson TJ, Brown RD Jr: Rabinstein AA: Validation and refinement of the ABCD2 score: a population-based analysis. Stroke 2009;40:2669–2673.
19.
Asimos AW, Johnson AM, Rosamond WD, Price MF, Rose KM, Catellier D, Murphy CV, Singh S, Tegeler CH, Felix A: A multicenter evaluation of the ABCD2 score’s accuracy for predicting early ischemic stroke in admitted patients with transient ischemic attack. Ann Emerg Med 2010;55:201–2010.
20.
Amarenco P, Labreuche J, Lavallee PC, Meseguer E, Cabrejo L, Slaoui T, Guidoux C, Olivot JM, Abboud H, Lapergue B, Klein IF, Mazighi M, Touboul PJ: Does ABCD2 score below 4 allow more time to evaluate patients with a transient ischemic attack? Stroke 2009;40:3091–3095.
21.
Purroy F, Molina CA, Montaner J, Alvarez Sabin J: Absence of usefulness of ABCD score in the early risk of stroke of transient ischemic attack patients. Stroke 2007;38:855–856.
22.
Koton S, Rothwell PM: Performance of the ABCD and ABCD2 scores in TIA patients with carotid stenosis and atrial fibrillation. Cerebrovasc Dis 2007;24:231–235.
23.
Tsivgoulis G, Spengos K, Manta P, Karandreas N, Zambelis T, Zakopoulos N, Vassilopoulos D: Validation of the ABCD score in identifying individuals at high early risk of stroke after a transient ischemic attack: a hospital-based case series study. Stroke 2006;37:2892–2897.
24.
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.
25.
Sheehan OC, Merwick A, Kelly LA, Hannon N, Marnane M, Kyne L, McCormack PME, Duggan J, Moore A, Moroney J, Daly L, Harris D, Horgan G, Kelly PJ: Diagnostic usefulness of the ABCD2 score to distinguish transient ischemic attack and minor ischemic stroke from noncerebrovascular events: the North Dublin TIA study. Stroke 2009;40:3449–3454.
26.
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 ABCD2 score to identify patients at early risk of stroke after transient ischaemic attack: a multicentre observational study. Lancet Neurol 2010;9:1060–1069.
27.
Special report from the National Institute of Neurological Disorders and Stroke. Classification of cerebrovascular diseases III. Stroke 1990;21:637–676.
28.
Sciolla R, Melis F; SINPAC Group: Rapid identification of high-risk transient ischemic attacks: prospective validation of the ABCD score. Stroke 2008;39:297–302.
29.
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.
30.
Van Wijk I, Kappelle LJ, van Gijn J, Koudstaal PJ, Franke CL, Vermeulen M, Gorter JW, Algra A: Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study. Lancet 2005;365:2098–2104.
31.
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.
32.
Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, Hatsukami TS, Higashida RT, Johnston SC, Kidwell CS, Lutsep HL, Miller E, Sacco RL; American Heart Association; American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Interdisciplinary Council on Peripheral Vascular Disease: Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009;40:2276–2293.
33.
Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T; American Heart Association; American Stroke Association Council on Stroke; Council on Cardiovascular Radiology and Intervention; American Academy of Neurology: Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006;37:577–617.
34.
Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA, Hankey GJ, Hart RG, Levine SR, Biller J, Brown RD Jr, Sacco RL, Kappelle LJ, Koudstaal PJ, Bogousslavsky J, Caplan LR, van Gijn J, Algra A, Rothwell PM, Adams HP, Albers GW: National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol 2006;60:301–313.
35.
European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee: Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:457–507.
36.
Purroy F, Begue R, Quilez A, Pinol-Ripoll G, Sanahuja J, Brieva L, Seto E, Gil MI: The California, ABCD, and unified ABCD2 risk scores and the presence of acute ischemic lesions on diffusion-weighted imaging in TIA patients. Stroke 2009;40:2229–2232.
37.
Purroy F, Begue R, Gil MI, Quilez A, Sanahuja J, Brieva L, Pinol-Ripoll G: Patterns of diffusion-weighted magnetic resonance imaging associated with etiology improve the accuracy of prognosis after transient ischaemic attack. Eur J Neurol 2011;18:121–128.
38.
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.
© 2012 S. Karger AG, Basel
2012
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.