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Observational Study
. 2019 Dec 1;76(12):1439-1445.
doi: 10.1001/jamaneurol.2019.3063.

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

Shelagh B Coutts  1   2   3   4   5 , Francois Moreau  6 , Negar Asdaghi  7 , Jean-Martin Boulanger  8 , Marie-Christine Camden  9 , Bruce C V Campbell  10 , Andrew M Demchuk  1   2   4 , Thalia S Field  11 , Mayank Goyal  1   2   4 , Martin Krause  12 , Jennifer Mandzia  13 , Bijoy K Menon  1   2   3   4   5 , Robert Mikulik  14 , Andrew M Penn  15 , Richard H Swartz  16 , Michael D Hill  1   2   3   4   5   17 ; Diagnosis of Uncertain-Origin Benign Transient Neurological Symptoms (DOUBT) Study Group
Affiliations
Observational Study

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

Shelagh B Coutts et al. JAMA Neurol. .

Erratum in

  • Error in Results.
    [No authors listed] [No authors listed] JAMA Neurol. 2020 Mar 1;77(3):394. doi: 10.1001/jamaneurol.2019.4873. JAMA Neurol. 2020. PMID: 31930354 Free PMC article. No abstract available.

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Coutts reported receiving grants from the Canadian Institute of Health Research during the conduct of the study; and receiving grants from the Heart and Stroke Foundation of Canada, Genome Canada, Boehringer Ingelheim outside the submitted work. Dr Moreau reported receiving grants from the Canadian Institutes of Health Research during the conduct of the study; and receiving grants from the Canadian Stroke Consortium outside the submitted work. Dr Boulanger reported receiving conference travel support from Pfizer during the conduct of the study. Dr Camden reported receiving conference travel support from the University of Calgary during the conduct of the study. Dr Demchuk reported receiving grants from the University of Calgary during the conduct of the study; and receiving personal fees from Medtronic, Pfizer/Bristol-Myers Squibb, and Bayer outside the submitted work. Dr Field reported receiving grants from the Canadian Institutes of Health Research during the conduct of the study. Dr Goyal reported receiving grants from Stryker; receiving personal fees from Medtronic, Stryker, and Microvention outside the submitted work; and holding a licensing agreement with GE Healthcare on “Systems of acute stroke diagnosis.” Dr Mikulik reported grants from project no. LQ1605 during the conduct of the study. Dr Hill reported receiving grants from Medtronic, Boehringer Ingelheim, and NoNO Inc outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Association Between Neurologist’s Assessment of Results of the Neurologic Examination and Magnetic Resonance Imaging (MRI)
This assessment was completed prior to the MRI scan. The presence of neurologic findings and suspicion of a stroke was associated with having a diffusion-weighted imaging (DWI)–positive lesion detected on an MRI scan. However, a substantial portion of patients with normal examination results or abnormal examination results with another explanation also had a DWI-positive lesion detected on an MRI scan.
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Comment in

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