Rate and Prognosis of Brain Ischemia in Patients with Lower-Risk Transient or Persistent Minor Neurologic Events

Shelagh B. Coutts, Francois Moreau, Negar Asdaghi, Jean Martin Boulanger, Marie Christine Camden, Bruce C.V. Campbell, Andrew M. Demchuk, Thalia S. Field, Mayank Goyal, Martin Krause, Jennifer Mandzia, Bijoy K. Menon, Robert Mikulik, Andrew M. Penn, Richard H. Swartz, Michael D. Hill

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Importance: Early treatment of patients with transient ischemic attack (TIA) reduces the risk of stroke. However, many patients present with symptoms that have an uncertain diagnosis. Patients with motor, speech, or prolonged symptoms are at the highest risk for recurrent stroke and the most likely to undergo comprehensive investigations. Lower-risk patients are much more likely to be cursorily investigated. Objective: To establish the frequency of acute infarct defined by diffusion restriction detected on diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI) scan (DWI positive). Design, Setting, and Participants: The Diagnosis of Uncertain-Origin Benign Transient Neurological Symptoms (DOUBT) study was a prospective, observational, international, multicenter cohort study of 1028 patients with low-risk transient or minor symptoms referred to neurology within 8 days of symptom onset. Patients were enrolled between June 1, 2010, and October 31, 2016. Included patients were 40 years or older and had experienced nonmotor or nonspeech minor focal neurologic events of any duration or motor or speech symptoms of short duration (≤5 minutes), with no previous stroke. Exposures: Patients underwent a detailed neurologic assessment prior to undergoing a brain MRI within 8 days of symptom onset. Main Outcomes and Measures: The primary outcome was restricted diffusion on a brain MRI scan (acute stroke). Results: A total of 1028 patients (522 women and 506 men; mean [SD] age, 63.0 [11.6] years) were enrolled. A total of 139 patients (13.5%) had an acute stroke as defined by diffusion restriction detected on MRI scans (DWI positive). The final diagnosis was revised in 308 patients (30.0%) after undergoing brain MRI. There were 7 (0.7%) recurrent strokes at 1 year. A DWI-positive brain MRI scan was associated with an increased risk of recurrent stroke (relative risk, 6.4; 95% CI, 2.4-16.8) at 1 year. Absence of a DWI-positive lesion on a brain MRI scan had a 99.8% negative predictive value for recurrent stroke. Factors associated with MRI evidence of stroke in multivariable modeling were older age (odds ratio [OR], 1.02; 95% CI, 1.00-1.04), male sex (OR, 2.03; 95% CI, 1.39-2.96), motor or speech symptoms (OR, 2.12; 95% CI, 1.37-3.29), ongoing symptoms at assessment (OR, 1.97; 95% CI, 1.29-3.02), no prior identical symptomatic event (OR, 1.87; 95% CI, 1.12-3.11), and abnormal results of initial neurologic examination (OR, 1.71; 95% CI, 1.11-2.65). Conclusions and Relevance: This study suggested that patients with transient ischemic attack and symptoms traditionally considered low risk carry a substantive risk of acute stroke as defined by diffusion restriction (DWI positive) on a brain MRI scan. Early MRI is required to make a definitive diagnosis..

Original languageEnglish (US)
JournalJAMA Neurology
DOIs
StateAccepted/In press - Jan 1 2019
Externally publishedYes

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Brain Ischemia
Nervous System
Stroke
Magnetic Resonance Imaging
Odds Ratio
Diffusion Magnetic Resonance Imaging
Brain
Transient Ischemic Attack
Symptom Assessment
Sex Ratio
Neurologic Examination
Neurology
Neuroimaging
Multicenter Studies
Cohort Studies
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Clinical Neurology

Cite this

Rate and Prognosis of Brain Ischemia in Patients with Lower-Risk Transient or Persistent Minor Neurologic Events. / Coutts, Shelagh B.; Moreau, Francois; Asdaghi, Negar; Boulanger, Jean Martin; Camden, Marie Christine; Campbell, Bruce C.V.; Demchuk, Andrew M.; Field, Thalia S.; Goyal, Mayank; Krause, Martin; Mandzia, Jennifer; Menon, Bijoy K.; Mikulik, Robert; Penn, Andrew M.; Swartz, Richard H.; Hill, Michael D.

In: JAMA Neurology, 01.01.2019.

Research output: Contribution to journalArticle

Coutts, SB, Moreau, F, Asdaghi, N, Boulanger, JM, Camden, MC, Campbell, BCV, Demchuk, AM, Field, TS, Goyal, M, Krause, M, Mandzia, J, Menon, BK, Mikulik, R, Penn, AM, Swartz, RH & Hill, MD 2019, 'Rate and Prognosis of Brain Ischemia in Patients with Lower-Risk Transient or Persistent Minor Neurologic Events', JAMA Neurology. https://doi.org/10.1001/jamaneurol.2019.3063
Coutts, Shelagh B. ; Moreau, Francois ; Asdaghi, Negar ; Boulanger, Jean Martin ; Camden, Marie Christine ; Campbell, Bruce C.V. ; Demchuk, Andrew M. ; Field, Thalia S. ; Goyal, Mayank ; Krause, Martin ; Mandzia, Jennifer ; Menon, Bijoy K. ; Mikulik, Robert ; Penn, Andrew M. ; Swartz, Richard H. ; Hill, Michael D. / Rate and Prognosis of Brain Ischemia in Patients with Lower-Risk Transient or Persistent Minor Neurologic Events. In: JAMA Neurology. 2019.
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abstract = "Importance: Early treatment of patients with transient ischemic attack (TIA) reduces the risk of stroke. However, many patients present with symptoms that have an uncertain diagnosis. Patients with motor, speech, or prolonged symptoms are at the highest risk for recurrent stroke and the most likely to undergo comprehensive investigations. Lower-risk patients are much more likely to be cursorily investigated. Objective: To establish the frequency of acute infarct defined by diffusion restriction detected on diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI) scan (DWI positive). Design, Setting, and Participants: The Diagnosis of Uncertain-Origin Benign Transient Neurological Symptoms (DOUBT) study was a prospective, observational, international, multicenter cohort study of 1028 patients with low-risk transient or minor symptoms referred to neurology within 8 days of symptom onset. Patients were enrolled between June 1, 2010, and October 31, 2016. Included patients were 40 years or older and had experienced nonmotor or nonspeech minor focal neurologic events of any duration or motor or speech symptoms of short duration (≤5 minutes), with no previous stroke. Exposures: Patients underwent a detailed neurologic assessment prior to undergoing a brain MRI within 8 days of symptom onset. Main Outcomes and Measures: The primary outcome was restricted diffusion on a brain MRI scan (acute stroke). Results: A total of 1028 patients (522 women and 506 men; mean [SD] age, 63.0 [11.6] years) were enrolled. A total of 139 patients (13.5{\%}) had an acute stroke as defined by diffusion restriction detected on MRI scans (DWI positive). The final diagnosis was revised in 308 patients (30.0{\%}) after undergoing brain MRI. There were 7 (0.7{\%}) recurrent strokes at 1 year. A DWI-positive brain MRI scan was associated with an increased risk of recurrent stroke (relative risk, 6.4; 95{\%} CI, 2.4-16.8) at 1 year. Absence of a DWI-positive lesion on a brain MRI scan had a 99.8{\%} negative predictive value for recurrent stroke. Factors associated with MRI evidence of stroke in multivariable modeling were older age (odds ratio [OR], 1.02; 95{\%} CI, 1.00-1.04), male sex (OR, 2.03; 95{\%} CI, 1.39-2.96), motor or speech symptoms (OR, 2.12; 95{\%} CI, 1.37-3.29), ongoing symptoms at assessment (OR, 1.97; 95{\%} CI, 1.29-3.02), no prior identical symptomatic event (OR, 1.87; 95{\%} CI, 1.12-3.11), and abnormal results of initial neurologic examination (OR, 1.71; 95{\%} CI, 1.11-2.65). Conclusions and Relevance: This study suggested that patients with transient ischemic attack and symptoms traditionally considered low risk carry a substantive risk of acute stroke as defined by diffusion restriction (DWI positive) on a brain MRI scan. Early MRI is required to make a definitive diagnosis..",
author = "Coutts, {Shelagh B.} and Francois Moreau and Negar Asdaghi and Boulanger, {Jean Martin} and Camden, {Marie Christine} and Campbell, {Bruce C.V.} and Demchuk, {Andrew M.} and Field, {Thalia S.} and Mayank Goyal and Martin Krause and Jennifer Mandzia and Menon, {Bijoy K.} and Robert Mikulik and Penn, {Andrew M.} and Swartz, {Richard H.} and Hill, {Michael D.}",
year = "2019",
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TY - JOUR

T1 - Rate and Prognosis of Brain Ischemia in Patients with Lower-Risk Transient or Persistent Minor Neurologic Events

AU - Coutts, Shelagh B.

AU - Moreau, Francois

AU - Asdaghi, Negar

AU - Boulanger, Jean Martin

AU - Camden, Marie Christine

AU - Campbell, Bruce C.V.

AU - Demchuk, Andrew M.

AU - Field, Thalia S.

AU - Goyal, Mayank

AU - Krause, Martin

AU - Mandzia, Jennifer

AU - Menon, Bijoy K.

AU - Mikulik, Robert

AU - Penn, Andrew M.

AU - Swartz, Richard H.

AU - Hill, Michael D.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Importance: Early treatment of patients with transient ischemic attack (TIA) reduces the risk of stroke. However, many patients present with symptoms that have an uncertain diagnosis. Patients with motor, speech, or prolonged symptoms are at the highest risk for recurrent stroke and the most likely to undergo comprehensive investigations. Lower-risk patients are much more likely to be cursorily investigated. Objective: To establish the frequency of acute infarct defined by diffusion restriction detected on diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI) scan (DWI positive). Design, Setting, and Participants: The Diagnosis of Uncertain-Origin Benign Transient Neurological Symptoms (DOUBT) study was a prospective, observational, international, multicenter cohort study of 1028 patients with low-risk transient or minor symptoms referred to neurology within 8 days of symptom onset. Patients were enrolled between June 1, 2010, and October 31, 2016. Included patients were 40 years or older and had experienced nonmotor or nonspeech minor focal neurologic events of any duration or motor or speech symptoms of short duration (≤5 minutes), with no previous stroke. Exposures: Patients underwent a detailed neurologic assessment prior to undergoing a brain MRI within 8 days of symptom onset. Main Outcomes and Measures: The primary outcome was restricted diffusion on a brain MRI scan (acute stroke). Results: A total of 1028 patients (522 women and 506 men; mean [SD] age, 63.0 [11.6] years) were enrolled. A total of 139 patients (13.5%) had an acute stroke as defined by diffusion restriction detected on MRI scans (DWI positive). The final diagnosis was revised in 308 patients (30.0%) after undergoing brain MRI. There were 7 (0.7%) recurrent strokes at 1 year. A DWI-positive brain MRI scan was associated with an increased risk of recurrent stroke (relative risk, 6.4; 95% CI, 2.4-16.8) at 1 year. Absence of a DWI-positive lesion on a brain MRI scan had a 99.8% negative predictive value for recurrent stroke. Factors associated with MRI evidence of stroke in multivariable modeling were older age (odds ratio [OR], 1.02; 95% CI, 1.00-1.04), male sex (OR, 2.03; 95% CI, 1.39-2.96), motor or speech symptoms (OR, 2.12; 95% CI, 1.37-3.29), ongoing symptoms at assessment (OR, 1.97; 95% CI, 1.29-3.02), no prior identical symptomatic event (OR, 1.87; 95% CI, 1.12-3.11), and abnormal results of initial neurologic examination (OR, 1.71; 95% CI, 1.11-2.65). Conclusions and Relevance: This study suggested that patients with transient ischemic attack and symptoms traditionally considered low risk carry a substantive risk of acute stroke as defined by diffusion restriction (DWI positive) on a brain MRI scan. Early MRI is required to make a definitive diagnosis..

AB - Importance: Early treatment of patients with transient ischemic attack (TIA) reduces the risk of stroke. However, many patients present with symptoms that have an uncertain diagnosis. Patients with motor, speech, or prolonged symptoms are at the highest risk for recurrent stroke and the most likely to undergo comprehensive investigations. Lower-risk patients are much more likely to be cursorily investigated. Objective: To establish the frequency of acute infarct defined by diffusion restriction detected on diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI) scan (DWI positive). Design, Setting, and Participants: The Diagnosis of Uncertain-Origin Benign Transient Neurological Symptoms (DOUBT) study was a prospective, observational, international, multicenter cohort study of 1028 patients with low-risk transient or minor symptoms referred to neurology within 8 days of symptom onset. Patients were enrolled between June 1, 2010, and October 31, 2016. Included patients were 40 years or older and had experienced nonmotor or nonspeech minor focal neurologic events of any duration or motor or speech symptoms of short duration (≤5 minutes), with no previous stroke. Exposures: Patients underwent a detailed neurologic assessment prior to undergoing a brain MRI within 8 days of symptom onset. Main Outcomes and Measures: The primary outcome was restricted diffusion on a brain MRI scan (acute stroke). Results: A total of 1028 patients (522 women and 506 men; mean [SD] age, 63.0 [11.6] years) were enrolled. A total of 139 patients (13.5%) had an acute stroke as defined by diffusion restriction detected on MRI scans (DWI positive). The final diagnosis was revised in 308 patients (30.0%) after undergoing brain MRI. There were 7 (0.7%) recurrent strokes at 1 year. A DWI-positive brain MRI scan was associated with an increased risk of recurrent stroke (relative risk, 6.4; 95% CI, 2.4-16.8) at 1 year. Absence of a DWI-positive lesion on a brain MRI scan had a 99.8% negative predictive value for recurrent stroke. Factors associated with MRI evidence of stroke in multivariable modeling were older age (odds ratio [OR], 1.02; 95% CI, 1.00-1.04), male sex (OR, 2.03; 95% CI, 1.39-2.96), motor or speech symptoms (OR, 2.12; 95% CI, 1.37-3.29), ongoing symptoms at assessment (OR, 1.97; 95% CI, 1.29-3.02), no prior identical symptomatic event (OR, 1.87; 95% CI, 1.12-3.11), and abnormal results of initial neurologic examination (OR, 1.71; 95% CI, 1.11-2.65). Conclusions and Relevance: This study suggested that patients with transient ischemic attack and symptoms traditionally considered low risk carry a substantive risk of acute stroke as defined by diffusion restriction (DWI positive) on a brain MRI scan. Early MRI is required to make a definitive diagnosis..

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