D-dimer, magnetic resonance imaging diffusion-weighted imaging, and ABCD2 score for transient ischemic attack risk stratification.

BACKGROUND: We sought to determine whether measurement of D-dimer (DD) would improve risk stratification after transient ischemic attack (TIA). METHODS: We enrolled 167 patients with acute TIA in a prospective observational study. DD was measured using rapid enzyme-linked immunosorbent assay. The primary outcome measure was a composite end point consisting of stroke or death within 90 days or the identification of a high-risk stroke mechanism requiring specific early intervention (defined as > or =50% stenosis in a vessel referable to symptoms or a cardioembolic source warranting anticoagulation). RESULTS: The composite end point occurred in 41 patients (25%). A 50% or greater stenosis was found in 25 patients (15%), a cardioembolic source in 14 (8%), and clinical events in 8 (5 strokes, 3 deaths), 6 of whom also had a high-risk cause of TIA. ABCD(2) score was associated with outcome (P for trend = .017, c-statistic 0.63). DD levels did not differ based on outcome status (geometric mean 0.75 v 0.82 microg fibrinogen equivalent unit/mL, P = .56), and DD had little use for predicting outcome (c-statistic 0.57), even when combined with ABCD(2) score. Of 96 patients with early magnetic resonance imaging (MRI), 23% had diffusion-weighted imaging (DWI) abnormalities, and MRI DWI was predictive of outcome (c-statistic 0.76). The addition of MRI DWI to ABCD(2) improved predictive accuracy (c-statistic 0.83) compared with either alone. CONCLUSIONS: Many patients with TIA have a high-risk mechanism (large vessel stenosis or cardioembolism) or will experience stroke/death within 90 days. Increasing ABCD(2) scores were associated with this composite end point. Measurement of DD did not provide additional prognostic information.

Lipoprotein-associated phospholipase A2 and C-reactive protein for risk-stratification of patients with TIA.

BACKGROUND AND PURPOSE: Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) is a marker of unstable atherosclerotic plaque, and is predictive of both primary and secondary stroke in population-based studies. METHODS: We conducted a prospective study of patients with acute TIA who presented to the ED. Clinical risk scoring using the ABCD(2) score was determined and Lp-PLA(2) mass (LpPLA(2)-M) and activity (LpPLA(2)-A) and high-sensitivity C-reactive protein (CRP) were measured. The primary outcome measure was a composite end point consisting of stroke or death within 90 days or identification of a high-risk stroke mechanism requiring specific early intervention (defined as >or=50% stenosis in a vessel referable to symptoms or a cardioembolic source warranting anticoagulation). RESULTS: The composite outcome end point occurred in 41/167 (25%) patients. LpPLA(2)-M levels were higher in end point-positive compared to -negative patients (mean, 192+/-48 ng/mL versus 175+/-44 ng/mL, P=0.04). LpPLA(2)-A levels showed similar results (geometric mean, 132 nmol/min/mL, 95% CI 119 to 146 versus 114 nmol/min/mL, 95% CI 108 to 121, P=0.01). There was no relationship between CRP and outcome (P=0.82). Subgroup analysis showed that both LpPLA(2)-M (P=0.04) and LpPLA(2)-A (P=0.06) but not CRP (P=0.36) were elevated in patients with >50% stenosis. In multivariate analysis using cut-off points defined by the top quartile of each marker, predictors of outcome included LpPLA(2)-A (OR 3.75, 95% CI 1.58 to 8.86, P=0.003) and ABCD(2) score (OR 1.30 per point, 95% CI 0.97 to 1.75, P=0.08). CONCLUSIONS: Many patients with TIA have a high-risk mechanism (large vessel stenosis or cardioembolism) or will experience stroke/death within 90 days. In contrast to CRP, both Lp-PLA(2) mass and activity were associated with this composite end point, and LpPLA(2)-A appears to provide additional prognostic information beyond the ABCD(2) clinical risk score alone.

Is the ABCD score useful for risk stratification of patients with acute transient ischemic attack?

BACKGROUND AND PURPOSE: A 6-point scoring system (ABCD) was described recently for stratifying risk after transient ischemic attack (TIA). This score incorporates age (A), blood pressure (B), clinical features (C), and duration (D) of TIA. A score <4 reportedly indicates minimal short-term stroke risk. We evaluated this scoring system in an independent population. METHODS: This was a prospective study of TIA patients (diagnosed by a neurologist using the classic <24-hour definition) hospitalized <48 hours from symptom onset. The primary outcome assessment consisted of dichotomization of patients into 2 groups. The high-risk group included patients with stroke or death within 90 days, > or =50% stenosis in a relevant artery, or a cardioembolic source warranting anticoagulation. All others were classified as low risk. Findings on diffusion-weighted MRI (DWI) were also evaluated when performed and patients classified as DWI+ or DWI-. RESULTS: Over 3 years, 117 patients were enrolled. Median time from symptom onset to enrollment was 25.2 hours (interquartile range 19.8 to 30.2). Overall, 26 patients (22%) were classified as high risk, including 2 strokes, 2 deaths, 15 with > or =50% stenosis, and 10 with cardioembolic source. The frequency of high-risk patients increased with ABCD score (0 to 1 13%; 2 8%; 3 17%; 4 27%; 5 26%; 6 30%; P for trend=0.11). ABCD scores in the 2 patients with stroke were 3 and 6. Of those who underwent MRI, 15 of 61 (25%) were DWI+, but this correlated poorly with ABCD score (0 to 1 17%; 2 10%; 3 36%; 4 24%; 5 13%; 6 60%; P for trend=0.24). CONCLUSIONS: Although the ABCD score has some predictive value, patients with a score <4 still have a substantial probability of having a high-risk cause of cerebral ischemia or radiographic evidence of acute infarction despite transient symptoms.

Brachial plexopathy due to malignant peripheral nerve sheath tumor in neurofibromatosis type 1: case report and subject review.

Neurofibromatosis type 1 (NF1) is a common tumor predisposition syndrome affecting approximately 1 in 4,000 persons. It is an autosomal-dominant disorder with half of the cases resulting from spontaneous mutations. This genetic defect leads to the formation of benign tumors or neurofibromas of the peripheral nervous system. Dermal neurofibromas may cause local discomfort and itching but are rarely associated with neurological deficit and do not undergo malignant change. The more extensive plexiform neurofibromas produce neurological complications in 27%-43% of patients with NF1 and may undergo malignant degeneration in 5% of cases. Patients with NF1 who develop pain or new neurological symptoms should have a rapid and thorough assessment for malignancy. In this report, we illustrate this point by presenting a patient who developed acute shoulder pain and weakness due to malignant degeneration of a plexiform neurofibroma involving the left brachial plexus, and review the literature on this subject.

Neurologic assessment and therapy of patients with impaired mobility.

Disorders of mobility are an important determinant of function in older persons. As a risk factor for falls, these disorders also contribute to significant morbidity and mortality in older individuals. Although many causes are neurologic, potentially reversible nonneurologic contributors need to be carefully ruled out. Patients with more advanced mobility impairments may benefit from having their specific problem areas defined, with physical therapists then providing training programs in specific functional domains.