Shelagh B Coutts1,2,3,4,5, Francois Moreau6, Negar Asdaghi7, Jean-Martin Boulanger8, Marie-Christine Camden9, Bruce C V Campbell10, Andrew M Demchuk1,2,4, Thalia S Field11, Mayank Goyal1,2,4, Martin Krause12, Jennifer Mandzia13, Bijoy K Menon1,2,3,4,5, Robert Mikulik14, Andrew M Penn15, Richard H Swartz16, Michael D Hill1,2,3,4,5,17. 1. Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. 2. Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. 3. Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. 4. Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. 5. Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada. 6. 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. 7. Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida. 8. Department of Neurology, Charles LeMoyne Hospital, Sherbrooke University, Longeuil, Quebec, Canada. 9. Department of Neurosciences, Enfant-Jésus Hospital, Laval University, Quebec City, Quebec, Canada. 10. Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. 11. Vancouver Stroke Program, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada. 12. Northern Clinical School, University of Sydney, Royal North Shore Hospital, Sydney, Australia. 13. Department of Clinical Neurosciences, Western University, London, Ontario, Canada. 14. International Clinical Research Center, Neurological Department, St Anne's University Hospital and Masaryk University, Brno, Czech Republic. 15. Division of Neurology, Vancouver Island Health Authority, Victoria, British Columbia, Canada. 16. Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. 17. Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Abstract
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.
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.
Authors: Shelagh B Coutts; Jayesh Modi; Shiel K Patel; Andrew M Demchuk; Mayank Goyal; Michael D Hill Journal: Stroke Date: 2012-02-02 Impact factor: 7.914
Authors: Thomas Jeerakathil; Ashfaq Shuaib; Sumit R Majumdar; Andrew M Demchuk; Kenneth S Butcher; Tim J Watson; Naeem Dean; Deb Gordon; Cathy Edmond; Shelagh B Coutts Journal: Int J Stroke Date: 2012-10-23 Impact factor: 5.266
Authors: John J McNeil; Rory Wolfe; Robyn L Woods; Andrew M Tonkin; Geoffrey A Donnan; Mark R Nelson; Christopher M Reid; Jessica E Lockery; Brenda Kirpach; Elsdon Storey; Raj C Shah; Jeff D Williamson; Karen L Margolis; Michael E Ernst; Walter P Abhayaratna; Nigel Stocks; Sharyn M Fitzgerald; Suzanne G Orchard; Ruth E Trevaks; Lawrence J Beilin; Colin I Johnston; Joanne Ryan; Barbara Radziszewska; Michael Jelinek; Mobin Malik; Charles B Eaton; Donna Brauer; Geoff Cloud; Erica M Wood; Suzanne E Mahady; Suzanne Satterfield; Richard Grimm; Anne M Murray Journal: N Engl J Med Date: 2018-09-16 Impact factor: 91.245
Authors: Alexander Andrea Tarnutzer; Seung-Han Lee; Karen A Robinson; Zheyu Wang; Jonathan A Edlow; David E Newman-Toker Journal: Neurology Date: 2017-03-29 Impact factor: 9.910
Authors: P M Rothwell; M F Giles; E Flossmann; C E Lovelock; J N E Redgrave; C P Warlow; Z Mehta Journal: Lancet Date: 2005 Jul 2-8 Impact factor: 79.321
Authors: Miriam Brazzelli; Kirsten Shuler; Zahid Quayyum; Donald Hadley; Keith Muir; Paul McNamee; Janet De Wilde; Martin Dennis; Peter Sandercock; Joanna M Wardlaw Journal: BMJ Open Date: 2013-08-07 Impact factor: 2.692
Authors: Kathryn M Rexrode; Tracy E Madsen; Amy Y X Yu; Cheryl Carcel; Judith H Lichtman; Eliza C Miller Journal: Circ Res Date: 2022-02-17 Impact factor: 17.367
Authors: F Bala; N Singh; F Moreau; T S Field; M Goyal; M D Hill; S B Coutts; M Almekhlafi Journal: AJNR Am J Neuroradiol Date: 2022-02-17 Impact factor: 3.825
Authors: Amy Y X Yu; Michael D Hill; Negar Asdaghi; Jean-Martin Boulanger; Marie-Christine Camden; Bruce C V Campbell; Andrew M Demchuk; Thalia S Field; Mayank Goyal; Martin Krause; Jennifer Mandzia; Bijoy K Menon; Robert Mikulik; Francois Moreau; Andrew M Penn; Richard H Swartz; Shelagh B Coutts Journal: Neurology Date: 2020-11-12 Impact factor: 9.910
Authors: Jeffrey J Perry; Marco L A Sivilotti; Marcel Émond; Ian G Stiell; Grant Stotts; Jacques Lee; Andrew Worster; Judy Morris; Ka Wai Cheung; Albert Y Jin; Wieslaw J Oczkowski; Demetrios J Sahlas; Heather E Murray; Ariane Mackey; Steve Verreault; Marie-Christine Camden; Samuel Yip; Philip Teal; David J Gladstone; Mark I Boulos; Nicolas Chagnon; Elizabeth Shouldice; Clare Atzema; Tarik Slaoui; Jeanne Teitlebaum; Kasim Abdulaziz; Marie-Joe Nemnom; George A Wells; Mukul Sharma Journal: BMJ Date: 2021-02-04
Authors: Alia Stanciu; Mihai Banciu; Alireza Sadighi; Kyle A Marshall; Neil R Holland; Vida Abedi; Ramin Zand Journal: BMC Med Inform Decis Mak Date: 2020-06-18 Impact factor: 2.796
Authors: Amie W Hsia; Marie L Luby; Richard Leigh; John K Lynch; Zurab Nadareishvili; Richard T Benson; Chandni Kalaria; Shannon P Burton; Larry Latour Journal: Neurology Date: 2021-01-20 Impact factor: 9.910
Authors: Irene L Katzan; Andrew Schuster; Lynn Daboul; Christine Doherty; Sidra Speaker; Ken Uchino; Brittany Lapin Journal: JAMA Netw Open Date: 2021-07-01