Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Observational Study
. 2018;50(1-2):23-28.
doi: 10.1159/000486174. Epub 2018 Jan 11.

Adjudication of Transient Ischemic Attack and Stroke in the Multi-Ethnic Study of Atherosclerosis

W T Longstreth Jr  1 , Natalie C Gasca  2 , Rebecca F Gottesman  3 , John B Pearce  2 , Ralph L Sacco  4
Affiliations
Observational Study

Adjudication of Transient Ischemic Attack and Stroke in the Multi-Ethnic Study of Atherosclerosis

W T Longstreth Jr et al. Neuroepidemiology. 2018.

Abstract

Background: To describe adjudication of transient ischemic attack (TIA) and stroke in an observational study.

Methods: We detail the process used to adjudicate TIA and stroke in the Multi-Ethnic Study of Atherosclerosis (MESA), a large longitudinal cohort study. Two of three vascular neurologists adjudicated each event using specific protocols. We examined the initial agreement, effect of imaging on diagnosis of TIA versus ischemic stroke, and effect of strict and less strict criteria on the number of ischemic stroke subtypes classified as undetermined.

Results: Of 573 adjudicated events over 13.5 years of follow-up, 95 (16.5%) had TIA and 269 (47.0%) had stroke: 211 (78.4%) ischemic, 43 (16.0%) hemorrhagic, and 15 (5.6%) other. Disagreements occurred on 16% of initial adjudication of events. Using results from imaging, the number with TIA decreased by 8.6% and with ischemic stroke increased by 4.1%. Using less strict criteria to classify ischemic stroke subtypes reduced the number classified as undetermined, from 137 to 59, and numbers classified as cardioembolic and small vessel doubled.

Conclusions: We hope that this work will motivate and facilitate investigators to use MESA data to investigate issues concerning TIA and stroke and will inform investigators seeking to adjudicate TIA and stroke in other studies.

Keywords: Adjudication; Longitudinal study; Stroke; Transient ischemic attack.

PubMed Disclaimer

Conflict of interest statement

Disclosure Statement

The authors claimed that they had no conflict of interests to disclose.

Figures

Figure 1
Figure 1. Ischemic stroke subtype classifications based on three criteria
Ischemic stroke subtypes are: large vessel, extracranial (LV EC); large vessel, intracranial (LV IC); cardioembolic (CE); small vessel (SV); other specific mechanisms (Other); multiple mechanisms (Multiple); or undetermined. The diagonal arrows show how those in the undetermined subtype in the first row and multiple subtype in the second row are redistributed. In the first row (N=211), strict criteria were applied, and the undetermined subtype included those in the multiple subtype. In the second row (N=211), less strict criteria were applied to those classified as undetermined based on strict criteria. For the multiple subtype with less strict criteria, all 7 had SV combined with LV EC in 2, LV IC in 2, CE in 2 and Other in 1. These 14 additional subtypes were added to the numbers in the second row to yield the Less Strict+ criteria listed in the third row (N=218), allowing each event to have 2 subtypes.
Figure 2
Figure 2. Frequency of ischemic stroke subtypes based on strict or less strict criteria
Ischemic stroke subtypes are: large vessel, extracranial (LV EC); large vessel, intracranial (LV IC); cardioembolic (CE); small vessel (SV); other specific mechanisms (Other); multiple mechanisms (Multiple); or undetermined.
See this image and copyright information in PMC

References

    1. Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, Hatsukami TS, Higashida RT, Johnston SC, Kidwell CS, Lutsep HL, Miller E, Sacco RL. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. 2009;40:2276–2293. - PubMed
    1. Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, Elkind MS, George MG, Hamdan AD, Higashida RT, Hoh BL, Janis LS, Kase CS, Kleindorfer DO, Lee JM, Moseley ME, Peterson ED, Turan TN, Valderrama AL, Vinters HV. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:2064–2089. - PMC - PubMed
    1. Bild DE, Bluemke DA, Burke GL, Detrano R, Diez Roux AV, Folsom AR, Greenland P, Jacob DR, Jr, Kronmal R, Liu K, Nelson JC, O’Leary D, Saad MF, Shea S, Szklo M, Tracy RP. Multi-Ethnic Study of Atherosclerosis: objectives and design. Am J Epidemiol. 2002;156:871–881. - PubMed
    1. Adams HP, Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE., 3rd Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24:35–41. - PubMed
    1. Madden KP, Karanjia PN, Adams HP, Jr, Clarke WR. Accuracy of initial stroke subtype diagnosis in the TOAST study. Trial of ORG 10172 in Acute Stroke Treatment. Neurology. 1995;45:1975–1979. - PubMed

Publication types