Validating the ABCD2 Score for predicting stroke risk after transient ischemic attack in the ED

Ong, Marcus Eng Hock; Chan, Yiong Huak; Lin, Wan Ping; Chung, Wan Ling

doi:10.1016/j.ajem.2008.09.027

Cited by 27 publications

(28 citation statements)

References 21 publications

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“…Eleven were population-based studies including cohorts from the UK (Oxford), Ireland (Dublin), USA (Texas and Minnesota), Canada (Alberta) and northern Portugal. 9 23,127,129,131,135,136,143,149,153,159 and by both in four; 62,158,162,163 in three studies 120,138,155 this information was not reported.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 88%

“…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%

“…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%

“…Four studies assessed population-based cohorts, 132,140,144,151 three studies hospital-based cohorts, 142,155,160 nine studies patients from EDs, 87,134,135,143,149,153,158,162,163 and 10 studies patients from specialist stroke or neurology units. 62,[137][138][139]145,146,150,152,164,177 Full-text papers assessed (n = 61)…”

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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: 88%

Section: Main Findingsmentioning

confidence: 99%

Section: Characteristics Of Included Studiesmentioning

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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“…[17][18][19][20][21][22] Unfortunately, the ACBD2 Score has not performed well in prospective validation (c-statistic: 0.56). 23 We recently conducted a prospective, multicentre study to determine clinical features of TIA patients presenting to emergency departments (EDs), associated with high risk of stroke and to develop a new clinical prediction score for impending stroke.…”

Section: Introductionmentioning

confidence: 99%

National survey of emergency physicians for transient ischemic attack (TIA) risk stratification consensus and appropriate treatment for a given level of risk

Perry

Losier

Stiell

et al. 2015

CJEM

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Introduction: Five percent of transient ischemic attack (TIA) patients have a subsequent stroke within 7 days. The Canadian TIA Score uses clinical findings to calculate the subsequent stroke risk within 7 days. Our objectives were to assess 1) anticipated use; 2) component face validity; 3) risk strata for stroke within 7 days; and 4) actions required, for a given risk for subsequent stroke. Methods: After a rigorous development process, a survey questionnaire was administered to a random sample of 300 emergency physicians selected from those registered in a national medical directory. The surveys were distributed using a modified Dillman technique. Results: From a total of 271 eligible surveys, we received 131 (48.3%) completed surveys; 96.2% of emergency physicians would use a validated Canadian TIA Score; 8 of 13 components comprising the Canadian TIA Score were rated as Very Important or Important by survey respondents. Risk categories for subsequent stroke were defined as minimalrisk: <1%; low-risk: 1%-4.9%; high-risk 5%-10%; critical-risk: > 10% risk of subsequent stroke within 7 days. Conclusion: A validated Canadian TIA Score will likely be used by emergency physicians. Most components of the TIA Score have high face validity. Risk strata are definable, which may allow physicians to determine immediate actions, based on subsequent stroke risk, in the emergency department.

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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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Validating the ABCD2 Score for predicting stroke risk after transient ischemic attack in the ED

Cited by 27 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

National survey of emergency physicians for transient ischemic attack (TIA) risk stratification consensus and appropriate treatment for a given level of risk

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

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