Prospective Validation of Computed Tomography to Identify Patients at High Risk for Stroke After Transient Ischemic Attack or Minor Stroke

Emma Ferguson¹, Krishan Yadav^#^{1

2}, Mukul Sharma^#³, Marco L A Sivilotti⁴, Marcel Émond^{5

6}, Ian G Stiell^{1

2}, Grant Stotts⁷, Jacques S Lee⁸, Andrew Worster⁹, Judy Morris¹⁰, Ka Wai Cheung¹¹, Albert Y Jin¹², Wieslaw J Oczkowski³, Demetrios J Sahlas³, Heather E Murray⁴, Ariane Mackey^{5

13}, Steve Verreault^{5

13}, Marie-Christine Camden^{5

13}, Samuel Yip¹⁴, Philip Teal¹⁴, David J Gladstone¹⁵, Mark I Boulos¹⁵, Nicolas Chagnon¹⁶, Elizabeth Shouldice¹⁷, Clare Atzema^{18

19}, Tarik Slaoui¹⁰, Jeanne Teitelbaum¹⁰, Marie-Joe Nemnom², George A Wells²⁰, Avik Nath¹, Jeffrey J Perry^{1

2}

Affiliations

¹ Department of Emergency Medicine (E.F., K.Y., I.G.S., A.N., J.J.P.), University of Ottawa, Ontario, Canada.
² Ottawa Hospital Research Institute, Ontario, Canada (K.Y., I.G.S., M.-J.N., J.J.P.).
³ Division of Neurology, McMaster University, Hamilton, Ontario, Canada (M.S., W.J.O., D.J.S.).
⁴ Department of Emergency Medicine (M.L.A.S., H.E.M.), Queen's University, Kingston, Ontario, Canada.
⁵ CHU de Québec, Hôpital de l'Enfant-Jésus, Canada (M.É., A.M., S.V., M.-C.C.).
⁶ Division of Emergency Medicine (M.É.), Laval University, Quebec City, Quebec, Canada.
⁷ Division of Neurology, Department of Medicine (G.S.), University of Ottawa, Ontario, Canada.
⁸ Schwartz\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada (J.S.L.).
⁹ Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada (A.W.).
¹⁰ Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Quebec, Canada (J.M., T.S., J.T.).
¹¹ Department of Emergency Medicine (K.W.C.), University of British Columbia, Vancouver, Canada.
¹² Division of Neurology (A.Y.J.), Queen's University, Kingston, Ontario, Canada.
¹³ Division of Neurology (A.M., S.V., M.-C.C.), Laval University, Quebec City, Quebec, Canada.
¹⁴ Division of Neurology (S.Y., P.T.), University of British Columbia, Vancouver, Canada.
¹⁵ Sunnybrook Research Institute and Division of Neurology (D.J.G., M.I.B.), Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Ontario, Canada.
¹⁶ Department of Emergency Medicine, Montfort Hospital (N.C.), University of Ottawa, Ontario, Canada.
¹⁷ Queensway Carleton Hospital (E.S.), University of Ottawa, Ontario, Canada.
¹⁸ Sunnybrook Research Institute, ICES, Toronto, Canada (C.A.).
¹⁹ Division of Emergency Medicine (C.A.), Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Ontario, Canada.
²⁰ University of Ottawa Heart Institute, Ottawa, Ontario, Canada (G.A.W.).

^# Contributed equally.

PMID: 36779338
DOI: 10.1161/STROKEAHA.121.038000

Prospective Validation of Computed Tomography to Identify Patients at High Risk for Stroke After Transient Ischemic Attack or Minor Stroke

Emma Ferguson et al. Stroke. 2023 Apr.

. 2023 Apr;54(4):1030-1036.

doi: 10.1161/STROKEAHA.121.038000. Epub 2023 Feb 13.

Authors

Affiliations

¹ Department of Emergency Medicine (E.F., K.Y., I.G.S., A.N., J.J.P.), University of Ottawa, Ontario, Canada.
² Ottawa Hospital Research Institute, Ontario, Canada (K.Y., I.G.S., M.-J.N., J.J.P.).
³ Division of Neurology, McMaster University, Hamilton, Ontario, Canada (M.S., W.J.O., D.J.S.).
⁴ Department of Emergency Medicine (M.L.A.S., H.E.M.), Queen's University, Kingston, Ontario, Canada.
⁵ CHU de Québec, Hôpital de l'Enfant-Jésus, Canada (M.É., A.M., S.V., M.-C.C.).
⁶ Division of Emergency Medicine (M.É.), Laval University, Quebec City, Quebec, Canada.
⁷ Division of Neurology, Department of Medicine (G.S.), University of Ottawa, Ontario, Canada.
⁸ Schwartz\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada (J.S.L.).
⁹ Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada (A.W.).
¹⁰ Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Quebec, Canada (J.M., T.S., J.T.).
¹¹ Department of Emergency Medicine (K.W.C.), University of British Columbia, Vancouver, Canada.
¹² Division of Neurology (A.Y.J.), Queen's University, Kingston, Ontario, Canada.
¹³ Division of Neurology (A.M., S.V., M.-C.C.), Laval University, Quebec City, Quebec, Canada.
¹⁴ Division of Neurology (S.Y., P.T.), University of British Columbia, Vancouver, Canada.
¹⁵ Sunnybrook Research Institute and Division of Neurology (D.J.G., M.I.B.), Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Ontario, Canada.
¹⁶ Department of Emergency Medicine, Montfort Hospital (N.C.), University of Ottawa, Ontario, Canada.
¹⁷ Queensway Carleton Hospital (E.S.), University of Ottawa, Ontario, Canada.
¹⁸ Sunnybrook Research Institute, ICES, Toronto, Canada (C.A.).
¹⁹ Division of Emergency Medicine (C.A.), Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Ontario, Canada.
²⁰ University of Ottawa Heart Institute, Ottawa, Ontario, Canada (G.A.W.).

^# Contributed equally.

PMID: 36779338
DOI: 10.1161/STROKEAHA.121.038000

Abstract

Background: Computed tomography (CT) findings of acute and chronic ischemia are associated with subsequent stroke risk in patients with transient ischemic attack. We sought to validate these associations in a large prospective cohort of patients with transient ischemic attack or minor stroke.

Methods: This prospective cohort study enrolled emergency department patients from 13 hospitals with transient ischemic attack who had CT imaging. Primary outcome was stroke within 90 days. Secondary outcomes were stroke within 2 or 7 days. CT findings were abstracted from radiology reports and classified for the presence of acute ischemia, chronic ischemia, or microangiopathy. Multivariable logistic regression was used to test associations with primary and secondary end points.

Results: From 8670 prospectively enrolled patients between May 2010 and May 2017, 8382 had a CT within 24 hours. From this total population, 4547 (54%) patients had evidence of acute ischemia, chronic ischemia, or microangiopathy on CT, of whom 175 had a subsequent stroke within 90 days (3.8% subsequent stroke rate; adjusted odds ratio [aOR], 2.33 [95% CI, 1.62-3.36]). This was in comparison to those with CT imaging without ischemia. Findings associated with an increased risk of stroke at 90 days were isolated acute ischemia (6.0%; aOR, 2.42 [95% CI, 1.03-5.66]), acute ischemia with microangiopathy (10.7%; aOR, 3.34 [95% CI, 1.57-7.14]), chronic ischemia with microangiopathy (5.2%; aOR, 1.83 [95% CI, 1.34-2.50]), and acute ischemia with chronic ischemia and microangiopathy (10.9%; aOR, 3.49 [95% CI, 1.54-7.91]). Acute ischemia with chronic ischemia and microangiopathy were most strongly associated with subsequent stroke within 2 days (aOR, 4.36 [95% CI, 1.31-14.54]) and 7 days (aOR, 4.50 [95% CI, 1.73-11.69]).

Conclusions: In patients with transient ischemic attack or minor stroke, CT evidence of acute ischemia with chronic ischemia or microangiopathy significantly increases the risk of subsequent stroke within 90 days of index visit. The combination of all 3 findings results in the greatest early risk.

Keywords: brain infarction; ischemia; ischemic attack, transient; odds ratio; stroke.

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Prospective Validation of Computed Tomography to Identify Patients at High Risk for Stroke After Transient Ischemic Attack or Minor Stroke

Affiliations

Prospective Validation of Computed Tomography to Identify Patients at High Risk for Stroke After Transient Ischemic Attack or Minor Stroke

Authors

Affiliations

Abstract

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical