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Meta-Analysis
. 2021 Jan 1;78(1):77-87.
doi: 10.1001/jamaneurol.2020.3627.

A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis

Shima Shahjouei  1 , Alireza Sadighi  1 , Durgesh Chaudhary  1 , Jiang Li  2 , Vida Abedi  2   3 , Neil Holland  1 , Michael Phipps  4 , Ramin Zand  1
Affiliations
Meta-Analysis

A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis

Shima Shahjouei et al. JAMA Neurol. .

Erratum in

  • Error in Data in Abstract.
    [No authors listed] [No authors listed] JAMA Neurol. 2021 Jan 1;78(1):120. doi: 10.1001/jamaneurol.2020.4582. JAMA Neurol. 2021. PMID: 33226416 Free PMC article. No abstract available.

Abstract

Importance: Management of transient ischemic attack (TIA) has gained significant attention during the past 25 years after several landmark studies indicated the high incidence of a subsequent stroke.

Objective: To calculate the pooled event rate of subsequent ischemic stroke within 2, 7, 30, and 90 days of a TIA and compare this incidence among the population with TIA recruited before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C).

Data sources: All published studies of TIA outcomes were obtained by searching PubMed from 1996, to the last update on January 31, 2020, irrespective of the study design, document type, or language.

Study selection: Of 11 516 identified citations, 175 articles were relevant to this review. Both the classic time-based definition of TIA and the new tissue-based definition were accepted. Studies with a combined record of patients with TIA and ischemic stroke, without clinical evaluation for the index TIA, with diagnosis of index TIA event after ischemic stroke occurrence, with low suspicion for TIA, or duplicate reports of the same database were excluded.

Data extraction and synthesis: The study was conducted and reported according to the PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality assessment used the Quality in Prognosis Studies tool. Publication bias was visualized by funnel plots and measured by the Begg-Mazumdar rank correlation Kendall τ2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models.

Main outcomes and measures: The proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size.

Results: Systematic review yielded 68 unique studies with 223 866 unique patients from 1971 to 2019. The meta-analysis included 206 455 patients (58% women) during a span of 4 decades. The overall subsequent ischemic stroke incidence rates were estimated as 2.4% (95% CI, 1.8%-3.2%) within 2 days, 3.8% (95% CI, 2.5%-5.4%) within 7 days, 4.1% (95% CI, 2.4%-6.3%) within 30 days, and 4.7% (95% CI, 3.3%-6.4%) within 90 days. There was a recurrence risk of 3.4% among group A in comparison with 2.1% in group B or 2.1% in group C within 2 days; 5.5% in group A vs 2.9% in group B or 3.2% in group C within 7 days; 6.3% in group A vs 2.9% in group B or 3.4% in group C within 30 days, and 7.4% in group A vs 3.9% in group B or 3.9% in group C within 90 days.

Conclusions and relevance: These findings suggest that TIA continues to be associated with a high risk of early stroke; however, the rate of post-TIA stroke might have decreased slightly during the past 2 decades.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Zand reported receiving grants from Genentech, Geisinger Health Plan, and Bucknell University outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Forest Plots of Pooled Incidence Rates of Subsequent Ischemic Stroke Incidence After Transient Ischemic Attack (TIA) Within 7 Days
Data are stratified by population recruitment intervals. The boxes illustrate the effect estimates from each single study; the horizontal lines through the boxes, length of the 95% CI; and the diamonds, the overall estimates. NA indicates not available; RE, random effects.
Figure 2.
Figure 2.. Forest Plots of Pooled Incidence Rates of Subsequent Ischemic Stroke Incidence After Transient Ischemic Attack (TIA) Within 90 Days
Data are stratified by population recruitment intervals. The boxes illustrate the effect estimates from each single study; the horizontal lines through the boxes, length of the 95% CI; and the diamonds, the overall estimates. NA indicates not available; RE, random effects; OCSP, Oxfordshire Community Stroke Project; OXVASC-Ph1, Oxford Vascular Study Phase 1; OXVASC-Ph2, Oxford Vascular Study Phase 2; QugSS2, Quality of Treatment of Stroke in Schleswig-Holstein “Qualitätsgemeinschaft Schlaganfallver- sorgung in Schleswig-Holstein”; WASID, Warfarin-Aspirin Symptomatic Intracranial Disease Study.
Figure 3.
Figure 3.. Trend of Subsequent Ischemic Stroke Incidence After Transient Ischemic Attack
Data were stratified by recruitment intervals before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C).
See this image and copyright information in PMC

References

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