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ABCD3-I Scores in the Risk-Assessment of TIA Patients and the Management of Risk factors for
Cerebrovascular Disease

Introduction:_______________________________________________________________________

The patient interviewed was a 70 year old man. He presented in early 2010 to his local emergency

department following acute vomiting, faecal incontinence, aphasia, and right sided hemiparesis. The

patient was diagnosed with an ischaemic stroke following CT and MRI scans. He has since been left

with multiple disabilities, including difficulty swallowing, and an inability to walk due to paralysis of

the right leg. The patient experienced a previous transient ischaemic attack (TIA) in 2008, but following

diagnosis no management or prevention plan was put in place.

Strokes are a common occurrence in the UK, occurring in roughly 152,000 people per year [1]. They

are therefore of major concern to clinicians due to the large amount of treatment and rehabilitation

each patient requires.

In light of this, efforts have been made to identify risk factors associated with stroke in order to

intervene socially, medically, or politically to lower the incidence of stroke in the population. This

paper will assess the current evidence on stroke epidemiology to answer the following questions:

1. How effective is the ABCD3-I risk assessment score at predicting strokes in patients with

previous TIAs compared to the current California and ABCD2 scores?

2. How does the management of the known risk factors for stroke change the incidence of

cerebrovascular disease?

California, ABCD2, and ABCD3-I Scores for Risk Assessment in TIA Patients:______________________

The patient discussed suffered a previous TIA two years before his stroke. Sources state that TIAs are

often a preceding sign of a stroke, with anywhere from 4-25% risk of having a stroke within 90 days of

a TIA [2]. Because of this, tools to assess patients for their stroke risk in the days and weeks following

a TIA are useful for continued management.

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Currently there are two scores used for assessment of stroke risk after TIA, the California and ABCD2

scores. Both scores take into account various patient demographic information including age, blood-

pressure, clinical features, and symptom duration to assess patients for their overall risk of having an

ischaemic stroke. Table 1 (Appendix) describes the scoring for each of these tests. Following scoring

patients are broken down into low, medium, or high risk for stroke. Theoretically it is from these risk

brackets that patients are placed down the correct management pathways. The study indicated that

increased California and ABCD2 score positively correlate with a higher risk of ischaemic stroke

following TIA, making them useful tools to guide the management of patients. This was corroborated

by the second half of the study carried out in the United States and by Tsivgoulis et al [4], using a Greek

cohort rather than an English one.

The major drawback of these scores however is that they are only considered accurate at risk-

assessment within 90 days of TIA, which is not useful for a patient who has a stroke years after a TIA.

It is this dilemma that has led to the development of the ABCD3-I score. This score incorporates the

demographic information of the ABCD2 score, but also incorporates points for a dual TIA (two TIAs

within 7 days), diffusion weighted imaging for intracerebral abnormalities, and imaging of the carotid

arteries to find stenosis.

A study of 3886 patients in Ireland showed that addition of these two criteria improved risk-

categorisation of TIA patients by 39.4% compared to the classic ABCD2 score [5]. These results have

been validated in various cohorts in multiple countries. However these larger studies still only assess

the value of the ABCD3-1 score at 90 days maximum [6][7]. To date only one study has been conducted

to assess if the ABCD3-I score is effective at assessing and categorising patients into risk-brackets and

directing their management. The study looked at 693 patients with a TIA admission in Fukuoka, Japan

and followed them for three years [8]. The patients were assessed for risk using the ABCD2 and ABCD3-

I scores. Over the three year period the overall incidence of stroke in the cohort was 21.6%, of which

11.2% occurred after the first 90 days. AUROC analysis of both scores showed significant improvement
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in the risk assessment of patients using ABCD3-1 vs ABCD2 at 7 days (c-statistic = 0.66 vs 0.54) and a

less pronounced improvement at 90 days and 3 years, both of which did not meet the threshold for

statistical significance in the entire cohort. Unfortunately this indicates that although the ABCD3-I

score may improve upon the previous scores for a 90 day period, it would have been inapplicable to

our patient. It is therefore necessary to consider risk-factors for stroke and their management to

improve long-term outcomes.

Risk Factors and Their Management:____________________________________________________

The risk factors for stroke fall into two categories, changeable and non-changeable. Changeable risk

factors, such as hypertension, hyperlipidaemia, and obesity, are targets for therapeutic intervention.

The risk factor of hypertension and hyperlipidaemia will be discussed below due to their relation to

our patient. Non-changeable risk factors such as age, ethnicity, and family history, will not be

discussed because of an inability to intervene with them.

Hypertension:

Hypertension has long been thought a risk-factor for cardiovascular events, particularly stroke. In a

recent audit by the Royal College of Physicians, it was found that hypertension was a comorbidity in

54% (n=10173) of stroke patients in England, Wales and Northern Ireland assessed between October

2013 and 2014 [5]. This number is much higher than the overall prevalence of hypertension in the UK

population, estimated at 13.8% [9]. Although the true prevalence of hypertension is possibly higher

due to a large number of underdiagnoses for what is a largely asymptomatic disease.

A meta-analysis of 61 prospective observational studies followed a total of 1m adults aged 40-69,

looked at the number of stroke deaths occurring in the population, and related those deaths to each

individuals blood pressure. The analysis found a twofold increase in stroke deaths for each 20mmHg

systolic or 10mmHg diastolic blood-pressure rise from a baseline of 115/75mmHg [10].

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Somewhat counterintuitively however, antihypertensive treatment does not produce a clear-cut

reduction in incidence of stroke. Current evidence shows that reduction in blood pressure in patients

with stage 1 hypertension (140/90-160/100) and either a history of hypertension related end-organ

damage or diabetes mellitus lowers stroke incidence and improves general outcome. In patients with

stage 1 hypertension and no symptoms, there is little difference in total morbidity and mortality when

treated with antihypertensives vs placebo after 5 years [11]. However, this analysis is much smaller

than other studies (n=8912), and only lasted 5 years. Therefore a larger study may be necessary to

ensure validity.

Hyperlipidaemia and Statin Therapy:

The relationship between hyperlipidaemia and cerebrovascular events have been found somewhat

inconsistent. A meta-analysis of 45 observational studies, which included a total of 450,000 patients

showed that there was little relationship between hyperlipidaemia and fatal stroke risk [12] A larger

study of 1 million corroborated these findings, but only for patients over 70 years old, while

hyperlipidaemia was associated with increased risk of fatal stroke under 70 years [13].

To conclusively say that there is no relationship is difficult however as there are multiple reasons why

these studies show inconclusive results. Both of these studies have excluded non-fatal strokes, which

account for roughly 80% of all stroke cases. Furthermore, there is no attempt to separate the types of

stroke into their district subtypes. Strokes may be haemorrhagic or ischaemic, with the latter being

further divided into atherothrombotic, or cardioembolic. These subtypes have different pathogenesis,

and therefore risk for some subtypes may be increased by hyperlipidaemia, while others may not. This

was demonstrated in a study that showed overall strokes were not associated with hyperlipidaemia,

but divided into their subtypes atherothrombotic strokes were correlated with high LDL while

cardioembolic strokes were not.

A second body of evidence that supports the relationship between stoke and hyperlipidaemia is the

use of statin therapy in prevention. The main function of statins is the decrease of cholesterol
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production in the liver, and decrease in LDL serum levels. Studies have shown that the use of statins

in people with a high risk of cerebrovascular disease decreases stroke risk by 25% [14].

Management of the Patient:___________________________________________________________

Due to the fact that our patient suffered an ischaemic stroke two years after a TIA, it is unlikely that

use of the California ABCD2 or ABCD3-I scores would have helped in determining the long term

outcome. With this in mind the best long term management for this patient would have been

management of risk factors including blood pressure and hyperlipidaemia, with the aim of preventing

further deterioration. The patient was not placed on any drug therapy following the TIA, but was put

on statins and antihypertensives following stroke. If these drugs were started earlier such a severe

outcome may have been avoided and quality of life may preserved.