Multicenter external validation of the ABCD
            <sup>2</sup>
            score in triaging TIA patients

Tsivgoulis, Georgios; Stamboulis, Elefterios; Sharma, Vijay K.; Heliopoulos, Ioannis; Voumvourakis, Konstantinos; Teoh, Hock Luen; Patousi, Athanasia; Andrikopoulou, A.; Lim, EeMun; Stilou, L.; Sim, Terence; Chan, Bernard P.L.; Stefanis, Leonidas; Vadikolias, Κonstantinos; Piperidou, Charitomeni

doi:10.1212/wnl.0b013e3181dad63e

Cited by 55 publications

(64 citation statements)

References 21 publications

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“…The ascertainment of stroke events after TIA was carried out by face-to-face patient assessment or telephone interviews in 25 studies, 9,21,24,61,69,81,119,122,128,[132][133][134][137][138][139]144,[149][150][151][152]155,156,161,164,165 by medical records in 15 studies, 23,62,87,120,126,127,129,130,130,135,136,140,143,145,157,159 by mixed methods involving face-to-face assessment plus another method (i.e. telephone interviews, medical records, letters) in 11 studies, 65,131,[146][147][148]153,154,158,…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

“…178 To reduce the impact of any between-study heterogeneity, we considered separately the 10 studies that provided data on stroke risk at both 7 and 90 days. 62,137,139,143,[149][150][151][152]158,163 The study by Asimos and colleagues was published in two reports. 136,143 Even although the same cohort of patients was studied in both publications, data on risk of stroke at 7 days were reported in the 2010 publication, whereas data on risk of stroke at 90 days were reported in the 2009 publication.…”

Section: Main Findingsmentioning

confidence: 99%

“…67 However, the ability of ABCD2 score to distinguish between TIA and non-TIA/mimics and to predict risk of stroke early after TIA has been questioned. Some independent validation studies of ABCD and ABCD2 scores have shown conflicting results in their discriminatory ability to predict stroke, 69,70,151,152 and, in particular, a number of studies have suggested that high ABCD2 scores do not reliably identify patients with high stroke risk conditions, such as the presence of severe carotid stenosis. 132,170,174 The ABCD/ABCD2 scores have spawned numerous other variants (ABCD2-I, ABCD3, ABCD3-I), 147,150 which add either more clinical or brain or carotid imaging variables, most of which have not been tested independently.…”

Section: Introductionmentioning

confidence: 99%

“…Similarly, information on how many TIA patients received secondary prevention drugs was rarely reported in the included studies. Only five studies stated that approximately 45-50% of TIA patients were administered antithrombotic therapy, 143,152,153,158,162 and another study that 15% of patients received aspirin.…”

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confidence: 99%

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An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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BackgroundPatients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.ObjectivesIs MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as ‘one-stop’ brain-carotid imaging? What is the current UK availability of services for stroke prevention?Data sourcesPublished literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.Review methodsSystematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.ResultsThe pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35–41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40–45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51–54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with ‘CT scan all patients’ MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. ‘One-stop’ CT/MR angiographic-plus-brain imaging was not cost-effective.LimitationsData on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.ConclusionsMagnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Characteristics Of Included Studiesmentioning

confidence: 99%

Section: Main Findingsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

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An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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“…8 It has been validated both retrospectively and prospectively in numerous cohorts. [9][10][11][12] Although widely implemented, the ABCD2 score had not yet been validated prospectively in the emergency department setting.…”

Section: Introductionmentioning

confidence: 99%

The ABCD2 score: a poor predictor of stroke risk in the emergency department

Robichaud

Saluja

2014

CJEM

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Clinical questionIn patients presenting with transient ischemic attack in the emergency department, what is the accuracy of the ABCD2 score for predicting stroke? Article chosen Perry JJ, Sharma M, Sivilotti ML, et al. Prospective validation of the ABCD2 score for patients in the emergency department with TIA. CMAJ 2011;183:1137-45. Objective The study collaborators sought to externally validate the ABCD2 score as a tool for identifying patients seen in the emergency department with transient ischemic attack who are at high risk for stroke within 7 (primary outcome) and 90 (one of the secondary outcomes) days.

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Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack

et al. 2022

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Multicenter external validation of the ABCD ² score in triaging TIA patients

Cited by 55 publications

References 21 publications

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

The ABCD2 score: a poor predictor of stroke risk in the emergency department

Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack

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Multicenter external validation of the ABCD 2 score in triaging TIA patients

Cited by 55 publications

References 21 publications

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

The ABCD2 score: a poor predictor of stroke risk in the emergency department

Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack

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Multicenter external validation of the ABCD ² score in triaging TIA patients