There was a revolution in Transient Ischemic Attack (TIA) care in 2000 with the publication of the seminal report by SC Johnson and colleagues (JAMA 2000;284:29012906) of the high risks of stroke and vascular events following an index event. In the following years TIA risk scores such as the ABCD2 (Lancet 2007;369:283-292 ) were developed and promulgated throughout routine neurological care. At the European Stroke Conference in Nice Professor Pierre Amarenco presented the results of a modern TIA cohort collected through the use of the TIAregistry.org web-site, and the results were very interesting and likely to inform clinical practice.
The TIAregistry.org project evaluated short and long-term outcomes and refine risk assessment paradigms. Subjects had to be free of disability at baseline and have been evaluated for thei TIA in <7 days from onset, ideally <24 hours. A total of 4798 were recruited over 2.5 years: 4581 had complete data. The mean age was 66, 60% were men, 60% hypertensive and over half presented with a motor weakness syndrome. The ABCD2 scores were on the higher end with >70% scoring 4 or more. Imaging-demonstrated acute infarction was seen in 33% of cases, 16% had extracranial stenosis. Treatment was excellent with >90% on antithrombolic and >70% on antihypertensive and dyslipidemic agents. During follow-up <6% had a major vascular event, 4.7% had a stroke.
This study further validated the ABCD2 score in a real-world cohort obtained from a registry. Of note when the ABCD<4, 40% had a major finding (vessel stenosis, atrial fibrillation, infarct on imaging), when ABCD>=4, 75% had a major finding. Even in the low-risk group the hazard ratio for stroke was 3.5 when any major finding was revealed.
Although modern prevention therapy has cut the number or recurrent events by half, this important work demonstrates that TIA is a neurological emergency requiring immediate evaluation. The current paradigm is using the ABCD2 score to risk stratify, followed by screening of the brain with MRI, the cervical arteries, fasting lipids and heart rhythm monitoring. The timing and location of the evaluation may vary based on the risk score. TIAregistry.org has shown us that we have come a long way in preventing stroke after TIA, but it remains a dangerous and important disease process.