Is the ABCD Score Truly Useful?
2006; Lippincott Williams & Wilkins; Volume: 37; Issue: 7 Linguagem: Inglês
10.1161/01.str.0000230125.04355.e5
ISSN1524-4628
AutoresMichael D. Hill, Nicolas U. Weir,
Tópico(s)Intracranial Aneurysms: Treatment and Complications
ResumoHomeStrokeVol. 37, No. 7Is the ABCD Score Truly Useful? Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBIs the ABCD Score Truly Useful? Michael D. Hill, MD, MSc and Nicolas U. Weir, MD, MSc Michael D. HillMichael D. Hill From the University of Calgary, Department of Clinical Neuroscience, Foothills Medical Centre, Calgary, AL, Canada. and Nicolas U. WeirNicolas U. Weir From the University of Calgary, Department of Clinical Neuroscience, Foothills Medical Centre, Calgary, AL, Canada. Originally published8 Jun 2006https://doi.org/10.1161/01.STR.0000230125.04355.e5Stroke. 2006;37:1636Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 8, 2006: Previous Version 1 The understanding of transient ischemic attack (TIA) has changed. The high early risk of stroke demands rapid assessment and treatment. Some patients, such as those with TIA attributable to an active carotid artery plaque, appear to be at higher risk than others.1 The direct result of this paradigm shift is the need to develop tools for stratifying patients according to risk. Although some have adopted a strategy of admitting all TIA patients, this approach may not be the most efficient. Clinical prediction rules may be the most helpful in triaging patients. Factors that are risks for early stroke include clinical ones such as age, diabetes mellitus, longer duration TIA, motor or speech symptoms of TIA, and imaging factors such as the presence of carotid artery disease or a diffusion-weighted imaging lesion on MRI.2–4 The clinical imperative is to sort out those patients who need immediate attention and those who do not.Why must we risk stratify? A large number of TIA patients do not go on to experience an early stroke. These patients do not need to be exposed to potentially risky therapies from which they will derive no benefit, nor do they need to use scarce and high-intensity resources. The corollary is that we need to learn how to identify those patients who truly are at high risk and offer them emergent assessment, imaging and therapies where the benefit clearly outweighs the risk.The ABCD score, developed in England, is a clinical tool to stratify TIA patients according to their 7-day risk of stroke.5 The score is derived as follows:Age >60=1 point.BP >140/90=1 point.Clinical features: unilateral weakness=2 points; language disturbance without weakness=1 point; Other=0 points.Duration: >60 minutes=2 points; 10 to 59 minutes=1 point; <10 minutes=0 points.The score was derived from the OCSP cohort from 2 decades ago and validated in a more recent cohort in Oxfordshire. A score 50% or a cardioembolic source warranting anticoagulation. Although this choice of outcome is a pragmatic one, it is different than the stroke or death outcome on which the ABCD score was validated.In contrast to the risk of stroke of 10% in the Oxfordshire series, the risk of stroke was slightly <2% in this Pennsylvania series, perhaps because some patients with stroke in the first 24 hours were not included in the cohort. Only 2 patients with ABCD scores of 3 and 6 experienced stroke. This observation makes the point that an ABCD score <4 does not imply an absence of risk, but the number of outcomes is too small to comment further.It is certainly possible that the populations are different. This is the major reason why clinical prediction rules must be cross-validated in different populations of patients. What appears an excellent rule in one population may not be so useful in another because of inherent differences in risk profile. Although the ABCD rule, without a doubt, will work well in the Oxfordshire and perhaps British population, further work is needed on the ABCD rule to assess its global validity.How best to triage TIA/minor stroke patients? Our view is that it seems likely that the clinical features of longer duration and motor/speech symptoms are the key criteria warranting more urgent assessment. MR diffusion-weighted imaging then provides the natural technique for assessing the presence or absence of true ischemia. At the same time the neurovasculature can be assessed to understand potential mechanisms and identify the need for carotid revascularization.The opinions in this editorial are not necessarily those of the editors or of the American Heart Association.See related article, pages 1710–1714.DisclosuresNone.FootnotesCorrespondence to Michael D. Hill, MD, University of Calgary, Department of Clinical Neuroscience, Rm 1242A, Foothills Medical Centre, 1403 29th Street NW, Calgary, Al T2N 2T9, Canada. E-mail [email protected] References 1 Eliasziw M, Kennedy J, Hill MD, Buchan AM, Barnett HJ. Early risk of stroke after a transient ischemic attack in patients with internal carotid artery disease. CMAJ. 2004; 170: 1105–1109.CrossrefMedlineGoogle Scholar2 Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000; 284: 2901–2906.CrossrefMedlineGoogle Scholar3 Johnston SC, Sidney S. Validation of a 4-point prediction rule to stratify short-term stroke risk after TIA. Stroke. 2005; 36: 430. Abstract.Google Scholar4 Coutts SB, Simon JE, Eliasziw M, Sohn CH, Hill MD, Barber PA, Palumbo V, Kennedy J, Roy J, Gagnon A, Scott JN, Buchan AM, Demchuk AM. Triaging transient ischemic attack and minor stroke patients using acute magnetic resonance imaging. Ann Neurol. 2005; 57: 848–854.CrossrefMedlineGoogle Scholar5 Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, Mehta Z. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 2005; 366: 29–36.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Dolmans L, Kappelle L, Bartelink M, Hoes A and Rutten F (2019) Delay in patients suspected of transient ischaemic attack: a cross-sectional study, BMJ Open, 10.1136/bmjopen-2018-027161, 9:2, (e027161), Online publication date: 1-Feb-2019. Ghandehari K, Ahmadi F, Ebrahimzadeh S, Shariatinezhad K and Ghandehari K (2012) Assessment of ABCD2 scale in patients with transient ischaemic attack or stroke, Neurologia i Neurochirurgia Polska, 10.5114/ninp.2012.31351, 46:5, (421-427), . Ghandehari K, Ahmadi F, Ebrahimzadeh S, Shariatinezhad K and Ghandehari K (2012) The ABCD2 Score is Highly Predictive of Stroke in Minor Ischemic Stroke Patients, Translational Stroke Research, 10.1007/s12975-012-0146-0, 3:2, (273-278), Online publication date: 1-Jun-2012. Quinn T, Cameron A, Dawson J, Lees K and Walters M (2009) ABCD2 Scores and Prediction of Noncerebrovascular Diagnoses in an Outpatient Population, Stroke, 40:3, (749-753), Online publication date: 1-Mar-2009. Sylaja P and Hill M (2007) Current Management of Transient Ischemic Attack, American Journal of Cardiovascular Drugs, 10.2165/00129784-200707010-00006, 7:1, (67-74), . Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P and Dennis M (2014) An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation, Health Technology Assessment, 10.3310/hta18270, 18:27, (1-368) July 2006Vol 37, Issue 7 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000230125.04355.e5PMID: 16763174 Originally publishedJune 8, 2006 Keywordstransient ischemic attackacute strokePDF download Advertisement
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