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Original Investigation |

Imaging Parameters and Recurrent Cerebrovascular Events in Patients With Minor Stroke or Transient Ischemic Attack

Shadi Yaghi, MD1; Sara K. Rostanski, MD2; Amelia K. Boehme, PhD2; Sheryl Martin-Schild, MD3; Alyana Samai, MPH3; Brian Silver, MD1; Christina A. Blum, MD1; Mahesh V. Jayaraman, MD1,4; Matthew S. Siket, MD5; Muhib Khan, MD1; Karen L. Furie, MD, MPH1; Mitchell S. V. Elkind, MD, MS2,6; Randolph S. Marshall, MD, MS2; Joshua Z. Willey, MD, MS2
[+] Author Affiliations
1Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
2Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York
3Department of Neurology, Tulane University, New Orleans, Louisiana
4Department of Diagnostic Imaging, Warren Alpert Medical School, Brown University, Providence, Rhode Island
5Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
6Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
JAMA Neurol. 2016;73(5):572-578. doi:10.1001/jamaneurol.2015.4906.
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Importance  Neurological worsening and recurrent stroke contribute substantially to morbidity associated with transient ischemic attacks and strokes (TIA-S).

Objective  To determine predictors of early recurrent cerebrovascular events (RCVEs) among patients with TIA-S and National Institutes of Health Stroke Scale scores of 0 to 3.

Design, Setting, and Participants  A retrospective cohort study was conducted at 2 tertiary care centers (Columbia University Medical Center, New York, New York, and Tulane University Medical Center, New Orleans, Louisiana) between January 1, 2010, and December 31, 2014. All patients with neurologist-diagnosed TIA-S with a National Institutes of Health Stroke Scale score of 0 to 3 who presented to the emergency department were included.

Main Outcomes and Measures  The primary outcome (adjudicated by 3 vascular neurologists) was RCVE: neurological deterioration in the absence of a medical explanation or recurrent TIA-S during hospitalization.

Results  Of the 1258 total patients, 1187 had no RCVEs and 71 had RCVEs; of this group, 750 patients (63.2%) and 39 patients (54.9%), respectively, were aged 60 years or older. There were 505 patients with TIA-S at Columbia University; 31 (6.1%) had RCVEs (15 patients had neurological deterioration only, 11 had recurrent TIA-S only, and 5 had both). The validation cohort at Tulane University consisted of 753 patients; 40 (5.3%) had RCVEs (24 patients had neurological deterioration only and 16 had both). Predictors of RCVE in multivariate models in both cohorts were infarct on neuroimaging (computed tomographic scan or diffusion-weighted imaging sequences on magnetic resonance imaging) (Columbia University: not applicable and Tulane University: odds ratio, 1.75; 95% CI, 0.82-3.74; P = .15) and large-vessel disease etiology (Columbia University: odds ratio, 6.69; 95% CI, 3.10-14.50 and Tulane University: odds ratio, 8.13; 95% CI, 3.86-17.12; P < .001). There was an increase in the percentage of patients with RCVEs when both predictors were present. When neither predictor was present, the rate of RCVE was extremely low (up to 2%). Patients with RCVEs were less likely to be discharged home in both cohorts.

Conclusions and Relevance  In patients with minor stroke, vessel imaging and perhaps neuroimaging parameters, but not clinical scores, were associated with RCVEs in 2 independent data sets. Prospective studies are needed to validate these predictors.

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