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.

Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Alberta Canada

Department of Clinical Neurosciences Foothills Medical Centre Calgary Alberta Canada

Department of Clinical Neurosciences Western University London Ontario Canada

Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary Alberta Canada

Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne Hospital University of Melbourne Parkville Australia

Department of Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada

Department of Medicine Neurology Centre intégré universitaire de santé et de services sociaux de l'Estrie Centre hospitalier universitaire de Sherbrooke Sherbrooke University Sherbrooke Quebec Canada

Department of Medicine Sunnybrook Health Sciences Centre University of Toronto Toronto Ontario Canada

Department of Neurology Charles LeMoyne Hospital Sherbrooke University Longeuil Quebec Canada

Department of Neurology Leonard M Miller School of Medicine University of Miami Miami Florida

Department of Neurosciences Enfant Jésus Hospital Laval University Quebec City Quebec Canada

Department of Radiology Cumming School of Medicine University of Calgary Calgary Alberta Canada

Division of Neurology Vancouver Island Health Authority Victoria British Columbia Canada

Hotchkiss Brain Institute Cumming School of Medicine University of Calgary Calgary Alberta Canada

International Clinical Research Center Neurological Department St Anne's University Hospital and Masaryk University Brno Czech Republic

Northern Clinical School University of Sydney Royal North Shore Hospital Sydney Australia

Vancouver Stroke Program Djavad Mowafaghian Centre for Brain Health University of British Columbia Vancouver British Columbia Canada

JAMA Neurol. 2019 Dec 1;76(12):1421-1423. doi: 10.1001/jamaneurol.2019.2963. PubMed

JAMA Neurol. 2020 Mar 1;77(3):394. doi: 10.1001/jamaneurol.2019.4873. PubMed

MMW Fortschr Med. 2020 Mar;162(4):36. doi: 10.1007/s15006-020-0212-6. PubMed

JAMA Neurol. 2020 Jun 1;77(6):775-776. doi: 10.1001/jamaneurol.2020.0661. PubMed

Zobrazit více v PubMed

Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284(22):2901-2906. doi:10.1001/jama.284.22.2901 PubMed DOI

Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA. Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med. 2007;167(22):2417-2422. doi:10.1001/archinte.167.22.2417 PubMed DOI

Rothwell PM, Giles MF, Flossmann E, et al. . A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 2005;366(9479):29-36. doi:10.1016/S0140-6736(05)66702-5 PubMed DOI

Prabhakaran S, Silver AJ, Warrior L, McClenathan B, Lee VH. Misdiagnosis of transient ischemic attacks in the emergency room. Cerebrovasc Dis. 2008;26(6):630-635. doi:10.1159/000166839 PubMed DOI

Bravata DM, Myers LJ, Arling G, et al. . Quality of care for veterans with transient ischemic attack and minor stroke. JAMA Neurol. 2018;75(4):419-427. doi:10.1001/jamaneurol.2017.4648 PubMed DOI PMC

Castle J, Mlynash M, Lee K, et al. . Agreement regarding diagnosis of transient ischemic attack fairly low among stroke-trained neurologists. Stroke. 2010;41(7):1367-1370. doi:10.1161/STROKEAHA.109.577650 PubMed DOI

Amarenco P, Lavallée PC, Labreuche J, et al. ; TIAregistry.org Investigators . One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016;374(16):1533-1542. doi:10.1056/NEJMoa1412981 PubMed DOI

Rothwell PM, Giles MF, Chandratheva A, et al. ; Early use of Existing Preventive Strategies for Stroke (EXPRESS) study . Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison [published correction appears in Lancet. 2008;371(9610):386]. Lancet. 2007;370(9596):1432-1442. doi:10.1016/S0140-6736(07)61448-2 PubMed DOI

Lavallée PC, Meseguer E, Abboud H, et al. . A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6(11):953-960. doi:10.1016/S1474-4422(07)70248-X PubMed DOI

Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. . Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007;369(9558):283-292. doi:10.1016/S0140-6736(07)60150-0 PubMed DOI

Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814 PubMed DOI PMC

Johnston SC, Easton JD, Farrant M, et al. ; Clinical Research Collaboration, Neurological Emergencies Treatment Trials Network, and the POINT Investigators . Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA. N Engl J Med. 2018;379(3):215-225. doi:10.1056/NEJMoa1800410 PubMed DOI PMC

Yu AYX, Coutts SB. Role of brain and vessel imaging for the evaluation of transient ischemic attack and minor stroke. Stroke. 2018;49(7):1791-1795. doi:10.1161/STROKEAHA.118.016618 PubMed DOI

Ay H, Arsava EM, Johnston SC, et al. . Clinical- and imaging-based prediction of stroke risk after transient ischemic attack: the CIP model. Stroke. 2009;40(1):181-186. doi:10.1161/STROKEAHA.108.521476 PubMed DOI

Coutts SB, Simon JE, Eliasziw M, et al. . Triaging transient ischemic attack and minor stroke patients using acute magnetic resonance imaging. Ann Neurol. 2005;57(6):848-854. doi:10.1002/ana.20497 PubMed DOI

Brazzelli M, Shuler K, Quayyum Z, et al. . Clinical and imaging services for TIA and minor stroke: results of two surveys of practice across the UK. BMJ Open. 2013;3(8):e003359. doi:10.1136/bmjopen-2013-003359 PubMed DOI PMC

Coutts SB, Modi J, Patel SK, Demchuk AM, Goyal M, Hill MD; Calgary Stroke Program . CT/CT angiography and MRI findings predict recurrent stroke after transient ischemic attack and minor stroke: results of the prospective CATCH study. Stroke. 2012;43(4):1013-1017. doi:10.1161/STROKEAHA.111.637421 PubMed DOI

Jeerakathil T, Shuaib A, Majumdar SR, et al. ; ASPIRE Investigators . The Alberta Stroke Prevention in TIAs and mild strokes (ASPIRE) intervention: rationale and design for evaluating the implementation of a province-wide TIA triaging system. Int J Stroke. 2014;9(SA100)(Suppl A100):135-143. doi:10.1111/j.1747-4949.2012.00881.x PubMed DOI

WHO MONICA Project Principal Investigators The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. J Clin Epidemiol. 1988;41(2):105-114. doi:10.1016/0895-4356(88)90084-4 PubMed DOI

Calvet D, Touzé E, Oppenheim C, Turc G, Meder JF, Mas JL. DWI lesions and TIA etiology improve the prediction of stroke after TIA. Stroke. 2009;40(1):187-192. doi:10.1161/STROKEAHA.108.515817 PubMed DOI

Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: updated statistics from government health surveillance studies. Headache. 2015;55(1):21-34. doi:10.1111/head.12482 PubMed DOI

Waters MJ, Cheong E, Jannes J, Kleinig T. Ischaemic stroke may symptomatically manifest as migraine aura. J Clin Neurosci. 2018;55:62-64. doi:10.1016/j.jocn.2018.07.017 PubMed DOI

McNeil JJ, Wolfe R, Woods RL, et al. ; ASPREE Investigator Group . Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med. 2018;379(16):1509-1518. doi:10.1056/NEJMoa1805819 PubMed DOI PMC

Sex Differences in Diagnosis and Diagnostic Revision of Suspected Minor Cerebral Ischemic Events