CT/CT Angiography and MRI Findings Predict Recurrent Stroke After Transient Ischemic Attack and Minor Stroke: Results of the Prospective CATCH Study

Background and Purpose— Transient ischemic attack and minor stroke portend a substantial risk of recurrent stroke. MRI can identify patients at high risk for a recurrent stroke. However, MRI is not commonly available as an emergency. If similarly clinically predictive, a CT/CT angiographic (CTA) imaging strategy would be more widely applicable. Methods— Five hundred ten patients with consecutive transient ischemic attack and minor stroke underwent CT/CTA and subsequent MRI. We assessed the risk of recurrent stroke within 90 days using standard clinical variables and predefined abnormalities on the CT/CTA (acute ischemia on CT and/or intracranial or extracranial occlusion or stenosis ≥50%) and MRI (diffusion-weighted imaging-positive). Results— There were 36 recurrent strokes (7.1%; 95% CI, 5.0–9.6). Median time to the event was 1 day (interquartile range, 7.5). Median time from onset to CTA was 5.5 hours (interquartile range, 6.4 hours) and to MRI was 17.5 hours (interquartile range, 12 hours). Symptoms ongoing at first assessment (hazard ratio, 2.2; 95% CI, 1.02–4.9), CT/CTA abnormalities (hazard ratio, 4.0; 95% CI, 2.0–8.5), and diffusion-weighted imaging positivity (hazard ratio, 2.2; 95% CI, 1.05–4.7) predicted recurrent stroke. In the multivariable analysis, only CT/CTA abnormalities predicted recurrent stroke. In a secondary analysis, CT/CTA and MRI were not significantly different in their discriminative value in predicting recurrent stroke (0.67; (95% CI, 0.59–0.76 versus 0.59; 95% CI, 0.52–0.67; P=0.09). Conclusions— Early assessment of the intracranial and extracranial vasculature using CT/CTA predicts recurrent stroke and clinical outcome in patients with transient ischemic attack and minor stroke. In many institutions, CTA is more readily available than MRI and physicians should access whichever technique is more quickly available at their institution.

[1]  S Claiborne Johnston,et al.  Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack , 2007, The Lancet.

[2]  S. Kasner,et al.  Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. , 2005, The New England journal of medicine.

[3]  H. Barnett,et al.  Carotid endarterectomy and the measurement of stenosis. , 1993, Stroke.

[4]  S. Sidney,et al.  Short-term prognosis after emergency department diagnosis of TIA. , 2000, JAMA.

[5]  Principal Investigators,et al.  The World Health Organization MONICA project (monitoring trends and determinants in cardiovascular disease): a major international collabaration , 1988 .

[6]  A. Demchuk,et al.  Addition of brain and carotid imaging to the ABCD2 score to identify patients at early risk of stroke after transient ischaemic attack: a multicentre observational study , 2010, The Lancet Neurology.

[7]  M. Kornitzer,et al.  The World Health Organization MONICA Project (Monitoring trends and determinants in cardiovascular disease): A major international Collaboration , 1988 .

[8]  A. Demchuk,et al.  Triaging transient ischemic attack and minor stroke patients using acute magnetic resonance imaging , 2005, Annals of neurology.

[9]  Peter M. Rothwell,et al.  Systematic Review of Associations Between the Presence of Acute Ischemic Lesions on Diffusion-Weighted Imaging and Clinical Predictors of Early Stroke Risk After Transient Ischemic Attack , 2007, Stroke.

[10]  K. Furie,et al.  Intracranial Large Vessel Occlusion as a Predictor of Decline in Functional Status After Transient Ischemic Attack , 2011, Stroke.

[11]  R. Gonzalez,et al.  Acute stroke: improved nonenhanced CT detection--benefits of soft-copy interpretation by using variable window width and center level settings. , 1999, Radiology.

[12]  J. Mohr,et al.  Transient ischemic attack--proposal for a new definition. , 2002, The New England journal of medicine.

[13]  A. Demchuk,et al.  Computed Tomography and Computed Tomography Angiography Findings Predict Functional Impairment in Patients with Minor Stroke and Transient Ischaemic Attack , 2009, International journal of stroke : official journal of the International Stroke Society.

[14]  The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA Project Principal Investigators. , 1988, Journal of clinical epidemiology.

[15]  A. Demchuk,et al.  Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial , 2007, The Lancet Neurology.

[16]  P. Rothwell,et al.  Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies , 2004, Neurology.

[17]  P. Rothwell,et al.  Timing of TIAs preceding stroke , 2005, Neurology.

[18]  M. Eliasziw,et al.  Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery , 2004, The Lancet.

[19]  S. Gutnikov,et al.  Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison , 2007, The Lancet.

[20]  K. Furie,et al.  Clinical- and Imaging-Based Prediction of Stroke Risk After Transient Ischemic Attack: The CIP Model , 2009, Stroke.

[21]  K. Furie,et al.  Functional Contrast-Enhanced CT for Evaluation of Acute Ischemic Stroke Does Not Increase the Risk of Contrast-Induced Nephropathy , 2010, American Journal of Neuroradiology.

[22]  David Lee Gordon,et al.  Classification of Subtype of Acute Ischemic Stroke: Definitions for Use in a Multicenter Clinical Trial , 1993, Stroke.

[23]  J. Saver.  A comparison of risk factors for recurrent TIA and stroke in patients diagnosed with TIA , 2003, Neurology.

[24]  R. Sacco,et al.  Impact of abnormal diffusion-weighted imaging results on short-term outcome following transient ischemic attack. , 2007, Archives of neurology.

[25]  Sean I. Savitz,et al.  Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis , 2012 .

[26]  P. Touboul,et al.  A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects , 2007, The Lancet Neurology.

[27]  M. Gomis,et al.  Factors Associated With a High Risk of Recurrence in Patients With Transient Ischemic Attack or Minor Stroke , 2008, Stroke.

[28]  M. Sande.  Population-Based Study of Risk and Predictors of Stroke in the First Few Hours after a TIA , 2009 .