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Imaging parameters linked to recurrent cerebrovascular events in minor stroke
In patients with minor stroke, risk for early recurrent cerebrovascular events was predicted by vessel imaging and in some cases neuroimaging, but not by clinical scores, according to new data.
Researchers conducted a retrospective cohort study to determine predictors of early recurrent stroke in patients with minor stroke, defined as stroke or transient ischemic attack with an NIH Stroke Scale score of 0 to 3.
They analyzed 1,258 patients presenting to the ED between 2010 and 2014 at two centers, Columbia University Medical Center and Tulane University Medical Center. The primary outcome was recurrent cerebrovascular events, defined as neurological deterioration absent a medical explanation or recurrent TIA or stroke during hospitalization.
Shadi Yaghi, MD, from the department of neurology at Warren Alpert Medical School at Brown University, and colleagues reported that 71 patients in the study population had a recurrent cerebrovascular event during hospitalization. Of those that had an event, 54.9% were aged 60 years or older vs. 63.2% of those who did not have an event.
In the Columbia cohort (n = 505), 31 patients (6.1%) had a recurrent cerebrovascular event, 15 with neurological deterioration only, 11 with TIA or stroke only and four with both. In the Tulane cohort (n = 753), 40 patients (5.3%) had a recurrent cerebrovascular event, 24 with neurological deterioration only, 16 with both TIA or stroke and neurological deterioration.
Imaging, etiology
When the researchers conducted a multivariate model, they found that predictors of recurrent cerebrovascular events in both cohorts were infarct on neurological imaging — CT scan or diffusion-weighted MRI scan (OR for Tulane cohort = 1.75; 95% CI, 0.82-3.74; not applicable for Columbia cohort) — and large-vessel disease etiology (OR for Columbia cohort = 6.69; 95% CI, 3.1-14.5; OR for Tulane cohort = 8.13; 95% CI, 3.86-17.12).
When both predictors were present, the percentage of patients with recurrent cerebrovascular events was higher than when one or none were present, they wrote, noting that the rate when neither predictor was present was no more than 2%.
Clinical and demographic parameters including age, race, sex, hypertension, diabetes, atrial fibrillation, CHD, congestive HF, peripheral vascular disease, smoking, systolic BP and history of stroke or TIA were not predictors of recurrent cerebrovascular events before discharge, according to the researchers.
No reliable score
In a related editorial, Deena M. Nasr, DO, and Robert D. Brown Jr., MD, MPH, both from the department of neurology at Mayo Clinic, wrote that: “As clinicians consider the level of urgency and the optimal setting for evaluating patients with TIA or minor cerebral infarction, it is apparent that the reported risk-stratification scores may not adequately delineate the patients at highest risk. ... The available data suggest that we do not have a consistently reliable predictive score.”
They concluded that, “Given the prediction score challenges noted thus far, it is unlikely that any predictive scale will entirely replace the expertise and clinical judgment of a well-trained stroke specialist in making a decision regarding the optimal setting, evaluation type and level of urgency following presentation with TIA or minor ischemic stroke.” – by Erik Swain
Disclosure: Yaghi, Nasr and Brown report no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures.