Prospective observational cohort study of early recurrent TIA

Abstract

Objectives:To evaluate frequency, clinical and etiological features, short- and long-term outcomesofearly recurrent TIA.Methods:Prospective observational cohort study enrolling all consecutive patients with TIAreferred to our emergency department (ED) and diagnosed by a vascular neurologist. Expedite assessment and best secondary prevention were performed within 24h. Primary endpoints were stroke and a composite outcome including stroke, acute coronary syndrome and vascular death at 3, 12 and,for a subset of patients, 60 months; secondary outcomeswere TIA relapse, cerebral hemorrhage, new onset atrial fibrillation and death from other causes. Concordance between index TIA and subsequent stroke etiologies was also evaluated.Results:A total of 1035 patients (822 single TIA, 213 recurrent TIA =21%) were enrolled from August2010 to December 2017. Capsular warning syndrome and large-artery atherosclerosis showed the strongest relationship with early recurrent TIA. The risk of stroke was significantly higher in the early recurrent TIA subgroup at each follow-upand most stroke episodes occurred within 48h of index TIA. TIA with lesion, dysarthria and leukoaraiosiswere 3- and 12-month independent predictors of stroke incidence after early recurrent TIA subgroup. Index TIA and subsequent stroke etiologies showed substantial concordance. An ABCD3 score>6 predictedahigher risk of stroke rcurrenceover the entire follow-up.Conclusions:Our study was the first to evaluate long-term outcome after early recurrentTIA. Our observations support the importance of promptly detecting and treating patients with earlyrecurrent TIAs in order to reduce the high early and long-term risk of poor clinical outcomes.

Attack Interval Is the Key to the Likely Pathogenesis of Multiple Transient Ischemic Attacks

“…A number of investigators have suggested that cardioembolism may be the presumed cause in 10–17%, large-artery atherosclerosis in 18–25%, and SVD in 14–37% of cases [2, 3, 6, 7]. Some have suggested that a SVD etiology was more likely in patients with multiple TIAs in comparison to those with a single TIA [3, 6], while this finding was not supported by others [2]. This discrepancy may be due to difficulty in the etiological classification of all many patients with TIA.…”

“…This discrepancy may be due to difficulty in the etiological classification of all many patients with TIA. The Trial of Org 10,172 in Acute Stroke Treatment classification is often used to determine etiological subtypes of TIA [2, 3, 7], in which diagnoses of SVD are based on clinical lacunar syndromes and CT or MRI findings corresponding to small subcortical infarcts [8]. According to DWI-based studies using the 24 h time-based definition of TIA, the frequency of positive DWI findings ranged from 9 to 67% [9].…”

“…The original definition of CWS was 3 or more events of motor, sensory, or sensorimotor symptoms affecting face, arm, and leg simultaneously, with no cortical signs, all within 24 h [4]. Due to the infrequency of CWS; however, the original definition has been modified by a number of investigators to extend the time period beyond 24 h [3, 14, 15] or reduce number of events [7, 16]. Even so, the prevalence of CWS is less than 10% among all TIAs (Table 3).…”

“…Even so, the prevalence of CWS is less than 10% among all TIAs (Table 3). Some authors have proposed the concept of dual or multiple TIAs consisting of repetitive focal neurological deficits regardless of lacunar syndrome or other phenotypic expressions [2, 3, 6, 7, 17, 18]. Overall, multiple TIAs are more common as a form of TIA than CWS, the latter of which form only a small subset.…”

“…In addition to the ABCD2 items, some clinical variables have been proposed to enhance the prediction of stroke. For example, multiple TIAs, also called crescendo TIAs, or dual TIAs when the attacks occur twice, have been recognized as contributors to early stroke risk [2, 3].…”