Background Patients 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. Objectives Is 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 sources Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. Review methods Systematic reviews and meta-analyses of published/unpublished data.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. Results The 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  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. Limitations Data 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. Conclusions Magnetic 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. Funding The National Institute for Health Research Health Technology Assessment programme.

https://njl-admin.nihr.ac.uk/document/download/2002499

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

Background and Purpose— Among patients with transient ischemic attack, the ABCD2 score predicts short-term stroke risk. Use of the ABCD2 score assumes the underlying diagnosis to be transient ischemic attack; however, most transient ischemic attack services assess a variety of diagnoses. We hypothesized that patients with low ABCD2 score predominantly have noncerebrovascular diagnoses. Methods— Our transient ischemic attack clinics assess all suspected cerebrovascular events referred. Comprehensive clinical and investigation details are prospectively recorded. We collated data for patients seen between August 1992 and January 2005 inclusive. We calculated ABCD2 scores and compared proportions of noncerebrovascular diagnoses for each ABCD2 grade using χ2 analysis. We ran similar analyses for atrial fibrillation, vascular lesions on brain imaging, and carotid stenosis. We calculated positive predictive value of low (0 to 1) ABCD2 score for noncerebrovascular diagnosis and described properties of ABCD2 as a ...

ABCD2 Scores and Prediction of Noncerebrovascular Diagnoses in an Outpatient Population: A Case–Control Study

Vestibular migraine is a chameleon among the episodic vertigo syndromes because considerable variation characterizes its clinical manifestation. The attacks may last from seconds to days. About one-third of patients presents with monosymptomatic attacks of vertigo or dizziness without headache or other migrainous symptoms. During attacks most patients show spontaneous or positional nystagmus and in the attack‐free interval minor ocular motor and vestibular deficits. Women are significantly more often affected than men. Symptoms may begin at any time in life, with the highest prevalence in young adults and between the ages of 60 and 70. Over the last 10 years vestibular migraine has evolved into a medical entity in dizziness units. It is the most common cause of spontaneous recurrent episodic vertigo and accounts for approximately 10% of patients with vertigo and dizziness. Its broad spectrum poses a diagnostic problem of how to rule out Meniere's disease or vestibular paroxysmia. Vestibular migraine should be included in the International Headache Classification of Headache Disorders (ICHD) as a subcategory of migraine. It should, however, be kept separate and distinct from basilar-type migraine and benign paroxysmal vertigo of childhood. We prefer the term “vestibular migraine” to “migrainous vertigo,” because the latter may also refer to various vestibular and non-vestibular symptoms. Antimigrainous medication to treat the single attack and to prevent recurring attacks appears to be effective, but the published evidence is weak. A randomized, double-blind, placebo-controlled study is required to evaluate medical treatment of this condition.

Chapter 62 - Vestibular migraine

Summary Background: Scoring systems exist to assist rapid identification of acute stroke but not for the more challenging diagnosis of transient ischaemic attack (TIA). Aim: To develop a clinical scoring system to assist with diagnosis of TIA. Methods: We developed and validated a clinical scoring system for identification of TIA patients. Logistic regression analysis was employed. Results: Our development cohort comprised 3216 patients. The scoring system included nine clinically useful predictive variables. After adjustment to reflect the greater seriousness of missing true TIA patients (a 2:1 cost ratio), 97% of TIA and 24% of non-TIA patients were accurately identified. Our results were confirmed during prospective validation. Conclusions: This simple scoring system performs well and could be used to facilitate accurate detection of TIA.

/pdf/a-recognition-tool-for-transient-ischaemic-attack-3llbvnr80e.pdf

A recognition tool for transient ischaemic attack

OBJECTIVE To compare serum lipid profile between patients of ischaemic and haemorrhagic strokes STUDY DESIGN Cross sectional, comparative study PLACE AND DURATION OF STUDY Military Hospital, Rawalpindi, from August 2004 to February 2005 METHODOLOGY Patients with diagnosis of stroke comprising 100 consecutive patients each of ischaemic and haemorrhagic strokes were included in the study while patients on lipid lowering therapy were excluded from study To determine the subtype of stroke, clinical examination followed by CT scan of brain was done A serum sample after 8 hours of overnight fasting was taken on the next day of admission for both groups of patients Total serum cholesterol, triglycerides, LDLcholesterol, VLDL-cholesterol and HDL-cholesterol was determined, using enzymatic colorimetric method Statistical analysis was done by comparison of lipid profile in two subgroups, using proportion test for any significant difference RESULTS The mean age at presentation of patients with stroke was 642 + or - 12 years with a male to female ratio of 36:1 In 100 ischaemic stroke patients, raised serum total cholesterol was seen in 42, triglyceride in 04, LDL-cholesterol in 05 and VLDL-cholesterol in 07 patients Serum HDL-cholesterol was below the normal reference in 31 cases On the other hand, serum total cholesterol and triglycerides was raised in 05 patients each, LDL-cholesterol in 09 and VLDL-cholesterol in 03 patients of haemorrhagic stroke Serum HDL-cholesterol was below normal in 04 patients of haemorrhagic stroke On comparison, there were significantly greater number of patients with raised serum cholesterol and low HDL-cholesterol in ischaemic stroke than haemorrhagic stroke (p < 005) No statistical significance was found on comparing serum values of ischaemic and haemorrhagic stroke for triglycerides, LDL-cholesterol and VLDL-cholesterol CONCLUSION Ischaemic stroke patients had high serum total cholesterol and lower HDL-cholesterol levels as compared to haemorrhagic stroke High risk patients of stroke may be screened using serum lipid profile and further studies are suggested to evaluate the effect of lipid lowering therapy in terms of morbidity and mortality in ischaemic stroke patients

/pdf/comparison-of-serum-lipid-profile-in-ischaemic-and-c20fgc1mlp.pdf

Comparison of Serum Lipid Profile in Ischaemic and Haemorrhagic Stroke

A retrospective cohort study was carried out of new referrals to transient ischaemic attack (TIA) clinics in Glasgow. The aims of the study were to describe the profile of referrals and to assess the odds ratios for TIA, minor stroke or amaurosis fugax of both cardiovascular risk factors and clinical features. In total, data were collected for 813 new referrals in a period of six months. Thirteen point eight percent of referrals were from other Health Boards. The overall referral rate among residents of Greater Glasgow NHS Board was 165.6 per 100,000 per year. About 20% of referrals were made by clinicians in secondary care. The specialties from which referrals were most commonly made were accident and emergency, general medicine, ophthalmology and geriatric assessment. The most common risk factors in patients referred were hypertension (52.9%), smoking (31.7%), ischaemic heart disease (22.7%) and former smokers (22.4%). The most common clinical features were hemiparesis (13.3%), weakness of an upper limb (8.7%), vertigo (7.9%) and dysphasia (7.3%). In 48.7% of cases, a non-cerebrovascular diagnosis was made. Separate multivariate models were established for risk factors and clinical features. In the model for risk factors, five factors were significant for risk of TIA, stroke or amaurosis fugax. These were hyperlipidaemia, age over 64 years, hypertension, smoking and ex-smoking. In the model for clinical features, five factors were also significant. These were visual field defect, speech defact, facial weakness and hemiparesis.

Epidemiological aspects of referral to TIA clinics in Glasgow

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Epidemiological aspects of referral to TIA clinics in Glasgow