If you have a minor stroke or a transient-ischemic attack* (TIA) your chances of having a subsequent major stroke are hugely reduced if you are assessed and treated quickly, according to two articles published in The Lancet.
A patient who has a minor stroke runs a 10% risk of a major subsequent stroke during the month following his/her minor stroke. This study demonstrates that prompt treatment for a minor stroke or TIA lowers the risk of a subsequent major stroke by 80%. If minor strokes or TIAs were assessed and treated quickly in the UK there would be 10,000 fewer strokes each year, say the authors.
Professor Peter Rothwell, Stroke Prevention Research Unit, Radcliffe Infirmary, University of Oxford, UK, and team carried out a prospective before-and-after study. Phase I ran from April 2002 to September 2004, Phase II ran from October 2004 to March 2007. The team studied the effect of urgent assessment and immediate treatment in specialist clinics, versus subsequent initiation of such treatment in primary care, in patients with minor stroke or TIA who were not sent straight to hospital.
The researchers used a rigorous population based study of TIA and stroke – The Oxford Vascular Study, or OXVASC – and as such case investigation and follow-up were complete and identical in both phases.
The median delay of assessment in clinic in Phase I was three days, and the median time to first prescription of treatment was 20 days. In Phase II these values were decreased to 1 day for both assessment and prescription.
The scientists found that the risk of recurrent stroke, within 90 days, for Phase I patients was 10.3% – 32 out of 310 patients. The same risk for Phase II patients was 2.1% – 6 out of 281 patients. In other words, immediate assessment and treatment reduced the risk of stroke recurrence by 80%. This reduction of risk, according to the researchers, was regardless of age and sex. They also found that early treatment did not lead to a greater risk of bleeding or other complications.
“Our data indicate that urgent assessment and early initiation of a combination of existing preventative treatments can reduce risk of early recurrent stroke after TIA or minor stroke by about 80% – extrapolated across the UK population, this equates to the prevention of nearly 10,000 strokes per year,” the authors wrote.
“Further follow-up is required to determine long-term outcome, but these results have immediate implications for the service provision and public education about TIA and minor stroke,” the researchers concluded.
These findings “..are very important and should promote renewed attention to urgent care of patients with TIAs and minor strokes,” Dr Naeem Dean, Royal Alexandra Hospital, Edmonton, Canada, and Dr Ashfaq Shuaib, University of Alberta, Edmonton, Canada, wrote in an Accompanying Comment. They added that there is an urgent need to complete the proposed larger randomized trials (FASTER and CAISTA trials and conclude “We hope these trials will confirm and complement the findings presented by Rothwell and colleagues, and revolutionize the way we manage cerebrovascular disease. Patients with TIAs and minor strokes are not disabled. If the risk of a disabling stroke can be substantially reduced in this population, we strongly recommend that patients should receive the same urgent attention as is provided for those with acute coronary syndromes.”
Another Study
In another study, Dr Pierre Amarenco, Bichat-Claude Bernard University Hospital, Denis Diderot University and Medical School, Paris, France, and team established a hospital clinic aimed specifically at treating patients with suspected cerebral or retinal TIAs – the clinic was open 24 hours a day.
They admitted patients if they had sudden retinal or cerebral focal symptoms related to ischemia, and if they recovered completely. 15,000 primary care physicians, neurologists, ophthalmologists and cardiologists in the Paris area had been told about this clinic – the patients were referred by one of these doctors.
At the clinic the patients underwent neurological, arterial and cardiac imaging – within four hours of being admitted. The researchers measured stroke recurrence within 90 days, plus stroke, heart attack and vascular death within twelve months.
The 90 day stroke rate for those who had been admitted to the clinic was 1.24%, compared to a rate predicted by ABCD2** scores of 5.96%. The study demonstrated that prompt assessment and treatment at a dedicated center reduced TIA recurrence risk by nearly 80%. The clinic admitted 1,085 patients, 74% (808) went home on the same day.
“We show that prompt evaluation and treatment of patients with TIA in a dedicated outpatient unit is associated with a lower than expected risk of subsequent stroke. Because almost three-quarters of patients were discharged home on the same day as diagnosis, the TIA clinic is also likely to involve lower costs and greater patient satisfaction about their management than is treatment without such a clinic,” the authors concluded.
“By reaching out to physicians in the area and by initiating preventative therapy at the point of care, the neurologists in the study by Amarenco and colleagues have modeled a new, more active approach to stroke prevention after TIA,” Wrote Drs Walter Kernan and Joseph Schindler, Yale University School of Medicine, New Haven, CT, USA in an accompanying Comment.
“Rapid assessment and intervention is emerging as the new standard for TIA care…we believe that the time is right to accept this new standard and to begin use of rapid access as a platform for rigorous testing of innovative strategies for TIA care,” they concluded.
*A transient ischemic attack (TIA) causes symptoms that are similar to a stroke, such as slurred speech, dizziness, or numbness on one side of the body, but unlike a stroke symptoms disappear completely over several hours. It is caused by a temporary interruption in blood flow to the brain and can be a warning sign of a major stroke.
** ABCD2 scores are seven point scores calculated on the basis of age, blood pressure, clinical features, diabetes, and duration of symptoms.”
“Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison”
Peter M Rothwell, Matthew F Giles, Arvind Chandratheva, Lars Marquardt, Olivia Geraghty, Jessica NE Redgrave, Caroline E Lovelock, Lucy E Binney, Linda M Bull, Fiona C Cuthbertson, Sarah JV Welch, Shelley Bosch, Faye Carasco-Alexander, Louise E Silver, Sergei A Gutnikov, Ziyah Mehta
“Transient ischaemic attacks: unstable, treatable, neglected”
Naeem Dean, Ashfaq Shuaib
“A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects”
Philippa C Lavallée, Elena Meseguer, Halim Abboud, Lucie Cabrejo, Jean-Marc Olivot, Olivier Simon, Mikael Mazighi, Chantal Nifle, Philippe Niclot, Bertrand Lapergue, Isabelle F Klein, Eric Brochet, Philippe Gabriel Steg, Guy Lesèche, Julien Labreuche, Pierre-Jean Touboul, Pierre Amarenco
“Rapid intervention for TIA: a new standard emerges”
Walter N Kernan, Joseph L Schindler
Written by: Christian Nordqvist