Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK.
Neurology. 2012 Sep 25;79(13):1356-62. doi: 10.1212/WNL.0b013e31826c1af8. Epub 2012 Sep 12.
Many guidelines recommend emergency assessment for patients with ≥2 TIAs within 7 days, perhaps in recognition of the capsular warning syndrome. However, it is unclear whether all patients with multiple TIAs are at high early risk of stroke and whether treatable underlying pathologies are more prevalent in this group.
We studied clinical characteristics, Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and risk of stroke in 1,000 consecutive patients with incident and recurrent TIAs in a prospective, population-based study (Oxford Vascular Study).
Of 1,000 patients with TIAs, 170 had a further TIA within 7 days (105 within 24 hours). Multiple TIAs were not associated with carotid stenosis or atrial fibrillation, and much of the 10.6 (95% confidence interval [CI] 6.5-15.9) risk of stroke during the 7 days after the first TIA was due to patients with small-vessel disease (SVD) etiology (10 of 24 vs 8 of 146, odds ratio [OR] = 12.3, 95% CI 3.7-41.9, p < 0.0001), particularly those with motor weakness (i.e., capsular warning syndrome) compared with hemisensory events (9 of 15 [60%], 95% CI 35.3-84.7 vs 1 of 9 [11.1%], 95% CI 0-31.7, p = 0.03). The 7-day risk of stroke after a recurrent TIA was similar to the risk after a single TIA in patients with non-SVD TIA (8 of 146 [5.5%] vs 76 of 830 [9.2%], OR = 0.58, 95% CI 0.25-1.3, p = 0.20). Of the 9 patients with stroke after a capsular warning syndrome, all had the recurrent TIA within 24 hours after the first TIA, and the subsequent stroke occurred within 72 hours of the second TIA in 8. The ABCD2 scores of all preceding TIAs were ≥4 in all 9 patients with capsular warning syndrome before stroke.
Capsular warning syndrome is rare (1.5% of TIA presentations) but has a poor prognosis (7-day stroke risk of 60%). Otherwise, recurrent TIA within 7 days is not associated with a greater stroke risk than that after a single TIA.
许多指南建议对 7 天内出现≥2 次 TIA 的患者进行紧急评估，这可能是为了识别出壳核警告综合征。然而，目前尚不清楚是否所有多次 TIA 的患者都存在早期高卒中风险，以及此类患者中是否更常见可治疗的潜在病理。
我们对前瞻性、基于人群的牛津血管研究（Oxford Vascular Study）中 1000 例首发和复发 TIA 连续患者的临床特征、TOAST 分类和卒中风险进行了研究。
1000 例 TIA 患者中，170 例在 7 天内再次发生 TIA（105 例在 24 小时内）。多次 TIA 与颈动脉狭窄或心房颤动无关，首次 TIA 后 7 天内 10.6%（95%置信区间[CI]6.5-15.9）的卒中风险主要归因于小血管疾病（SVD）病因患者（24 例中有 10 例，146 例中有 8 例，比值比[OR]为 12.3，95%CI 3.7-41.9，p<0.0001），尤其是伴运动无力（即壳核警告综合征）的患者与单纯感觉障碍事件相比（9 例中有 15 例[60%]，95%CI 35.3-84.7 比 1 例中有 9 例[11.1%]，95%CI 0-31.7，p=0.03）。复发 TIA 后 7 天内的卒中风险与非 SVD TIA 患者单次 TIA 后的风险相似（146 例中有 8 例[5.5%]，830 例中有 76 例[9.2%]，OR=0.58，95%CI 0.25-1.3，p=0.20）。在出现壳核警告综合征的 9 例卒中患者中，所有患者的复发 TIA 均发生在首次 TIA 后 24 小时内，且 8 例患者的第二次 TIA 后 72 小时内发生了后续卒中。在出现壳核警告综合征的 9 例患者中，所有患者之前的 TIA 的 ABCD2 评分均≥4。
壳核警告综合征罕见（TIA 发作的 1.5%），但预后不良（7 天内卒中风险为 60%）。否则，7 天内的复发性 TIA 与单次 TIA 后相比，卒中风险无显著增加。
