Who’s at Risk for Stroke After TIA?

Summary and Comment |
February 23, 2007

Who’s at Risk for Stroke After TIA?

  1. Kristi L. Koenig, MD, FACEP

A risk-stratification system is effective for determining a patient’s risk for stroke within 2 days.

  1. Kristi L. Koenig, MD, FACEP

From 4% to 20% of patients with transient ischemic attacks (TIAs) progress to stroke within 90 days, half within the first 48 hours. How do we identify patients at greatest risk? Researchers first validated two recently developed prognostic scores — the California score (designed to predict stroke within 90 days) and the ABCD score (designed to predict stroke within 7 days; see Journal Watch Emergency Medicine Aug 23 2005) — and then combined the two systems and validated the resulting new score, termed ABCD2 (designed to predict stroke within 2 days).

The scores were derived in two groups of patients (totaling 1916) and validated in four groups of patients (totaling 2893) from emergency departments, clinics, and population-based cohorts in California and Oxford, England.

The ABCD2 score assigns 0 to 7 points based on Age (≥60 years, 1 point), Blood pressure at presentation (≥140/90 mm Hg, 1 point), Clinical features (unilateral weakness, 2 points; speech disturbance without weakness, 1 point), Duration of symptoms (≥60 minutes, 2 points; 10–59 minutes, 1 point), and Diabetes (1 point).

Strokes occurred in 3.9% of patients within 2 days, 5.5% within 7 days, 7.5% within 30 days, and 9.2% within 90 days. When applied to the validation groups, the ABCD2 score stratified 21% of patients as high risk (score, 6–7), 45% as moderate risk (score, 4–5), and 34% as low risk (score, 0–3). The 2-day risks for stroke in the high-, moderate-, and low-risk groups were 8.1%, 4.1%, and 1.0%, respectively.

An editorialist suggests that the ABCD2 system is the best available method for determining which patients are at short-term risk for stroke after TIA but notes that the score should be used as an adjunct to, rather than a replacement for, clinical judgment and data from other sources, such as imaging.


TIAs are like angina of the brain, and symptoms lasting longer than 1 hour are highly likely to represent stroke (see Journal Watch Emergency Medicine Mar 12 2003). The ABCD2 prediction score helps us to risk-stratify patients. Patients with a score of less than 4 might be suitable for discharge on aspirin therapy with close follow-up, but most patients with new-onset TIA should be admitted to a hospital.


Reader Comments (1)

Sharon Bray home

Although loss of sight and directional disorientation are listed as possible TIA symptoms in several sources, this article does not seem to take these seriously. Estimated risk of future TIAs would also be helpful.

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