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Volume 44 Issue 4
Apr.  2019
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Article Navigation >  Journal of Bengbu Medical College  > 2019,  44 > 4: (459-462)  

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Value of ABCD score in predicting early risk of cerebral ischemic stroke after transient ischemic attack

  • 1.

    Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu 221002, China

  • 2.

    Department of Medical Statistics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu 221002, China

  • 3.

    Department of Rheumatology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu 221002, China

  • Corresponding author: ZHANG Ting, zt_0925@126.com
  • Received Date: 2018-03-23
    Accepted Date: 2018-07-10
  • ObjectiveTo investigate the clinical value of three kinds of ABCD score in predicting the risk of new cerebral ischemic stroke within 7 days after transient ischemic attack(TIA)in Chinese.MethodsThe scores in 150 patients with TIA were evaluated using ABCD2, ABCD3 and ABCD3-Ⅰ score within 48 h of admission, and the patients were divided into the low, medium and high risk groups according to the score.According to the onset of new ischemic stroke within 7 days after TIA, 150 patients were divided into the new ischemic stroke group(50 patients) and non-new ischemic stroke(100 patients).Three kinds of scores between two groups were compared.The number of patients with secondary cerebral infarction in the low, medium and high risk groups within 7 days after TIA was recorded.ResultsCompared with the non-new ischemic stroke group, the scores of three kinds of ABCD score significantly increased in new ischemic stroke group, and the difference of which was statistically significant(P < 0.05 to P < 0.01).Except the score of ABCD2, with the increasing of the scores of ABCD3 and ABCD3-Ⅰ, the incidence rate of secondary cerebral infarction increased continuously within 7 days after TIA(P < 0.01).The area under the ROC curve showed that the predictive AUC value of three kinds of ABCD score was 0.67, 0.84 and 0.91 within 7 days after TIA, respectively, and the differences of those were statistically significant(P < 0.01).The degrees of accuracy of ABCD3-Ⅰ and ABCD3 score in predicting the secondary cerebral infarction within 7 days after TIA were better than those of ABCD3 and ABCD2 score, respectively(P < 0.01).ConclusionsABCD2, ABCD3 and ABCD3-Ⅰ score can predict the secondary cerebral infarction within 7 days after TIA, and the higher the score, the higher the secondary cerebral infarction risk within 7 days after TIA is.The prediction accuracy of ABCD3-Ⅰ score is the highest.
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  • [1] EASTON JD, SAVER JL, ALBERS GW, et al.Definition and evaluation of transient ischemic attack:a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease.The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists[J].Stroke, 2009, 40(6):2276. doi: 10.1161/STROKEAHA.108.192218
    [2] WU CM, MCLAUGHLIN K, LORENZETTI DL, et al.Early risk of stroke after transient ischemic attack:a systematic review and meta-analysis[J].Arch Intern Med, 2007, 167(22):2417. doi: 10.1001/archinte.167.22.2417
    [3] KERNAN WN, OVBIAGELE B, BLACK HR, et al.Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack:a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J].Stroke, 2014, 45(7):2160. doi: 10.1161/STR.0000000000000024
    [4] 中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组.中国急性缺血性脑卒中诊治指南2014[J].中华神经科杂志, 2015, 48(4):246. doi: 10.3760/cma.j.issn.1006-7876.2015.04.002
    [5] 中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组.中国缺血性卒中和短暂性脑缺血发作二级预防指南2014[J].中华神经科杂志, 2015, 48(4):258. doi: 10.3760/cma.j.issn.1006-7876.2015.04.003
    [6] ROTHWELL PM, GILES MF, FLOSSMANN E, et al.A simple score(ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack[J].Lancet, 2005, 366(9479):29. doi: 10.1016/S0140-6736(05)66702-5
    [7] KELLY PJ, ALBERS GW, CHATZIKONSTANTINOU A, et al.Validation and comparison of imaging-based scores for prediction of early stroke risk after transient ischaemic attack:a pooled analysis of individual-patient data from cohort studies[J].Lancet Neurol, 2016, 15(12):1238. doi: 10.1016/S1474-4422(16)30236-8
    [8] ZHAO M, WANG S, ZHANG D, et al.Comparison of stroke prediction accuracy of ABCD2 and ABCD3-Ⅰ in patients with transient ischemic attack:A meta-analysis[J].J Stroke Cerebrovasc Dis, 2017, 26(10):2387. doi: 10.1016/j.jstrokecerebrovasdis.2017.05.030
    [9] WARDLAW JM, BRAZZELLI M, CHAPPELL FM, et al.ABCD2 score and secondary stroke prevention:meta-analysis and effect per 1, 000 patients triaged[J].Neurology, 2015, 85(4):373. doi: 10.1212/WNL.0000000000001780
    [10] ISHIDA K, RASER-SCHRAMM JM, WILSON CA, et al.Convergent validity and interrater reliability of estimating the ABCD2 score from medical records[J].Stroke, 2013, 44(3):803. doi: 10.1161/STROKEAHA.112.675611
    [11] KNOFLACH M, LANG W, SEYFANG L, et al.Predictive value of ABCD2 and ABCD3-Ⅰ scores in TIA and minor stroke in the stroke unit setting[J].Neurology, 2016, 87(9):861. doi: 10.1212/WNL.0000000000003033
    [12] MIYAGI T, VEHARAT, KIMURA K, et al.Examination timing and lesion patterns in diffision-weighted magnetic resonance imaging of patients with classically defined transient ischemic attack[J].Stroke Cerebrovase Dis, 2013, 22(8):e310. doi: 10.1016/j.jstrokecerebrovasdis.2012.12.007
    [13] KELLY PJ, ALBERS GW, CHATZIKONSTANTINOU A, et al.Validation and comparison of imaging-based scores for prediction of early stroke risk after transient ischaemic attack:a pooled analysis of individual-patient data from cohort studies[J].Lancet Neurol, 2016, 15(12):1238. doi: 10.1016/S1474-4422(16)30236-8
    [14] DIENER HC, FRANK B.Stroke:Stroke prevention-time to say goodbye to the ABCD2 score?[J].Nat Rev Neurol, 2015, 11(10):552. doi: 10.1038/nrneurol.2015.156
    [15] LAVALLEE PC, MESEGUER E, ABBOUD H, et al.A transient ischaemic attack clinic with round-the-clock access (SOS-TIA):feasibility and effects[J].Lancet Neurol, 2007, 6(11):953. doi: 10.1016/S1474-4422(07)70248-X
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Value of ABCD score in predicting early risk of cerebral ischemic stroke after transient ischemic attack

    Corresponding author: ZHANG Ting, zt_0925@126.com
  • 1. Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu 221002, China
  • 2. Department of Medical Statistics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu 221002, China
  • 3. Department of Rheumatology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu 221002, China
  • Received Date: 2018-03-23
  • Accepted Date: 2018-07-10
  • Available Online: 2019-04-15

Abstract: ObjectiveTo investigate the clinical value of three kinds of ABCD score in predicting the risk of new cerebral ischemic stroke within 7 days after transient ischemic attack(TIA)in Chinese.MethodsThe scores in 150 patients with TIA were evaluated using ABCD2, ABCD3 and ABCD3-Ⅰ score within 48 h of admission, and the patients were divided into the low, medium and high risk groups according to the score.According to the onset of new ischemic stroke within 7 days after TIA, 150 patients were divided into the new ischemic stroke group(50 patients) and non-new ischemic stroke(100 patients).Three kinds of scores between two groups were compared.The number of patients with secondary cerebral infarction in the low, medium and high risk groups within 7 days after TIA was recorded.ResultsCompared with the non-new ischemic stroke group, the scores of three kinds of ABCD score significantly increased in new ischemic stroke group, and the difference of which was statistically significant(P < 0.05 to P < 0.01).Except the score of ABCD2, with the increasing of the scores of ABCD3 and ABCD3-Ⅰ, the incidence rate of secondary cerebral infarction increased continuously within 7 days after TIA(P < 0.01).The area under the ROC curve showed that the predictive AUC value of three kinds of ABCD score was 0.67, 0.84 and 0.91 within 7 days after TIA, respectively, and the differences of those were statistically significant(P < 0.01).The degrees of accuracy of ABCD3-Ⅰ and ABCD3 score in predicting the secondary cerebral infarction within 7 days after TIA were better than those of ABCD3 and ABCD2 score, respectively(P < 0.01).ConclusionsABCD2, ABCD3 and ABCD3-Ⅰ score can predict the secondary cerebral infarction within 7 days after TIA, and the higher the score, the higher the secondary cerebral infarction risk within 7 days after TIA is.The prediction accuracy of ABCD3-Ⅰ score is the highest.

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  • 短暂性脑缺血发作(transient ischemic attack，TIA)是由脑、脊髓或视网膜缺血所引起的短暂性神经功能障碍，不伴有急性梗死[1]。TIA是急性缺血性脑血管病的高危因素，TIA病人发作后发生缺血性卒中的风险显著增高，4%~20%的TIA病人会在90 d内发生脑卒中，其中大约有一半的卒中发生在TIA后2 d内[2]。规范化的危险分层及早期临床评估，有益于降低早期卒中复发高风险。因此，亟待需要评价TIA病人发作后早期卒中风险预测的量表作为评价体系。目前，以ABCD评分系统应用最为广泛，ABCD评分系统常用的有ABCD2、ABCD3、ABCD3-Ⅰ等3种评分方法。本研究拟采用上述3种评价方式对TIA病人进行评估，同时记录TIA病人发作后7 d内发生新发脑梗死的比例，并分析这些评分对TIA后7 d内继发脑梗死风险的预测价值。

1.   资料和方法

    1.1.   一般资料

  • 选择2016年1-12月我院神经内科住院的150例TIA病人为研究对象，男性111例，女性39例，年龄22~87岁。TIA或脑梗死的诊断标准均符合2014年《美国AHA/ASA卒中和TIA二级预防指南》[3]、2015年发表的《中国急性缺血性脑卒中诊治指南2014》[4]和《中国缺血性卒中和短暂性脑缺血发作二级预防指南2014》[5]。TIA的诊断标准：由脑、脊髓或视网膜缺血所引起的短暂性神经功能障碍，并且在影像学上没有急性缺血性脑卒中的证据[1]。急性缺血性脑卒中的诊断标准：急性起病；局灶神经功能缺损(一侧面部或肢体无力或麻木，语言障碍等)，少数为全面神经功能缺损；症状或体征持续时间不限(当影像学显示有责任缺血性病灶时)，或持续24 h以上(当缺乏影像学责任病灶时)；排除非血管性病因；脑CT/MRI排除脑出血。本研究经过我院伦理委员会批准。

    • 1.2.   方法

    1.2.1.   脑血管危险因素的评估

  • 包括身高、体质量、体质量指数(BMI)、高血压、糖尿病、冠心病、高脂血症、脑卒中、吸烟史、饮酒史、肥胖等，以及入院后监测的空腹血糖、血脂(如胆固醇、低密度脂蛋白)、血压、同型半胱氨酸、糖化血红蛋白、尿酸等指标。

    • 1.2.2.   ABCD评价系统

  • 入院48 h内分别完成ABCD2、ABCD3、ABCD3-Ⅰ评分，并分为低危组、中危组及高危组。ABCD2评分法：总分为7分，0~3分为低危组, 4~5分为中危组, 6~7分为高危组。ABCD3评分：总分为9分，0~3分为低危组, 4~5分为中危组, 6~9分为高危组。ABCD3-Ⅰ评分：总分为13分，0~3分为低危组, 4~7分为中危组, 8~13分为高危组。

    • 1.2.3.   TIA发作7 d进行随访

  • 对TIA病人进行ABCD评分系统评估后，以TIA发作的第7天为终点事件，记录其发作后7 d内是否有新发的缺血性脑卒中事件，并比较不同ABCD评分系统评价病人脑梗死的发生率。根据病人TIA后7 d内是否存在新发的脑梗死，可将TIA病人分为新发脑梗死组和非脑梗死组。比较脑梗死组和非脑梗死组TIA病人的3种评分情况，记录3种评分的低、中、高危组TIA后7 d内继发脑梗死病人例数。

    • 1.3.   统计学方法

  • 采用t(或t′)检验、χ2检验和χ2趋势检验。

2.   结果

    2.1.   一般临床资料

  • 研究发现，150例TIA病人一周内新发脑梗死的发生率为33.3%(50/150)。2组研究对象在性别、年龄、BMI上差异均无统计学意义(P>0.05)；在高血压、糖尿病、冠心病、高脂血症史、脑血管病、糖化血红蛋白和低密度脂蛋白等脑血管病危险因素方面差异均无统计学意义(P>0.05)，而在吸烟和饮酒史方面脑梗死组均高于非脑梗死组(P＜0.05)(见表 1)。

    分组 n 年龄/岁 男 女 BMI/
    (kg/m2)    		 高血压 糖尿病 冠心病 高脂
    血症    		 脑血
    管病    		 吸烟 饮酒 糖化血红
    蛋白/%    		 同型半胱
    氨酸/(μmol/L)    		 尿酸/
    (μmol/L)    		 低密度脂
    蛋白/(mmol/L)
    新发脑梗死组 50 59.6±12.9 35 15 23.7±3.0 34 16 2 44 9 32 19 6.4±1.7 20.1±12.2 318.8±87.0 2.69±0.8
    非脑梗死组 100 60.7±13.2 78 22 22.9±3.5 63 25 12 77 16 43 20 6.2±1.2 16.7±9.7 342.0±89.4 2.7±0.8
    χ2 — -0.48* 1.15 -1.80* 0.37 0.82 1.66 2.59 0.1 5.88 5.61 0.74△ 1.85* 1.51* 0.07*
    P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 ＜0.05 ＜0.05 >0.05 >0.05 >0.05 >0.05
    *示t值; △示t′值

    • 2.2.   2组TIA病人3种评分系统评分的比较

  • 与非脑梗死组比较，新发脑梗死组的3种不同的ABCD系统的评分结果均升高(P＜0.05~P＜0.01)(见表 2)。

    分组 n ABCD2 ABCD3 ABCD3-Ⅰ
    新发脑梗死组 50 3.7±1.3 5.0±1.7 7.2±1.9
    非脑梗死组 100 3.2±1.5 4.2±1.8 4.3±1.9
    t — 2.01 2.61 8.81
    P — ＜0.05 ＜0.01 ＜0.01

    • 2.3.   ABCD评分与7 d内继发脑梗死相关性

  • 除ABCD2评分外，随着ABCD3、ABCD3-Ⅰ评分分值的升高，7 d内继发脑梗死率不断增加(P＜0.01)(见表 3)。

    分组 ABCD2 ABCD3 ABCD3-Ⅰ
    低危 中危 高危 低危 中危 高危 低危 中危 高危
    新发脑梗死组 22(28.6) 25(39.1) 3(33.3) 9(20.0) 19(30.6) 22(51.2) 2(6.1) 24(28.9) 24(80.0)
    非脑梗死组 55(71.4) 39(60.9) 6(66.7) 36(80.0) 43(69.4) 21(48.8) 31(93.9) 59(71.1) 6(20.0)
    χ2 1.73 9.49 31.16
    P >0.05 ＜0.01 ＜0.01

    • 2.4.   ABCD评分系统预测TIA病人发生新发脑梗死之间的比较

  • ROC曲线分析发现，3种ABCD评分系统对7 d内继发脑梗死的预测AUC分别为0.67、0.84和0.91，均大于基准线面积的0.5，差异有统计学意义(P＜0.01)。ABCD3-Ⅰ预测7 d内继发脑梗死准确度优于ABCD3，ABCD3优于ABCD2，差异具有统计学意义(P＜0.01)(见表 4)。

    评分系统 AUC(95% CI) P
    ABCD2 0.67(0.58~0.74) ＜0.01
    ABCD3 0.84(0.71~0.90) ＜0.01
    ABCD3-Ⅰ 0.91(0.82~0.94) ＜0.01
3.   讨论

  • 目前，关于TIA的诊断标准和治疗策略，都以ABCD评分系统作为重要的评估工具。早在2005年，英国牛津大学ROTHWELL等[6]设计了一个基于病人年龄、血压、临床特征和症状持续时间的ABCD评分系统(共6分，包括年龄、血压、临床表现及症状持续时间4个组成部分), 并证实了该评分系统对预测TIA后7 d内卒中危险的准确性。ABCD评分法用来预测7 d内发生卒中的风险，评分小于或等于4分，其卒中风险有限；评分5~6分，卒中风险明显增加，多需住院观察，以便发生卒中及时溶栓。此后，发展出了ABCD2(共7分，年龄、血压、临床特征、症状持续时间和糖尿病)、ABCD2-Ⅰ(共10分，增加了颅脑影像)、ABCD3(总分9分，增加了双重TIA)、ABCD3-Ⅰ(共13分，增加了双重TIA、颈动脉影像和颅脑影像)多种类型的工具，其中以ABCD2评分应用最为广泛。最新的研究[7-8]表明，在ABCD2评分基础上增加TIA发作频率与影像学检查(ABCD3和ABCD3-Ⅰ)，能更有效地评估TIA病人的早期卒中风险。建议疑似TIA的病人应早期行ABCD2评估，并尽早进行全面检查与评估。评估的主要目的是判断导致TIA的病因和可能的发病机制。因此，早在2009年TIA定义及评估指南推荐：ABCD2评分大于4分的病人应入院接受专科诊治[1]。

    当然，ABCD2评分也存在一定的局限性，少数研究表明约1/3的假性卒中病人首次的ABCD2评分大于等于4分。研究还显示ABCD2评分量表对于TIA病人是否合并特定卒中危险因素的辨别能力较差。WARDLAW等[9]的meta分析表明ABCD2评分并不能很好地满足最初设计这个评分的目的。如果按照标准4分作为分界点，应用这个评分或许会因此遗漏那些症状性颈动脉狭窄而需要紧急血管内介入治疗或支架治疗的病人，或是遗漏那些合并房颤而需要尽早启动口服抗凝治疗的病人。近年来越来越多的研究[10]表明，ABCD2评分用于TIA后卒中风险的预测存在较多局限性，正是因为ABCD2评分没有从病因学方面进行评估，使其预测价值受到了质疑。

    KNOFLACH等[11]评估ABCD2和ABCD3-Ⅰ评分对TIA和小卒中(定义为NIHSS评分＜4分)病人的早期(发病1~3 d内，平均2 d)及3个月时的卒中再发风险预测价值。研究纳入了5 237例TIA和小卒中病人，在发病24 h之内即入院。结果显示，发病早期(1~3 d)时，应用ABCD2评分的卒中风险为(0%~4.8%)，应用ABCD3-Ⅰ评分的卒中风险(0%~16.7%)；3个月时，ABCD2评分的卒中风险为(0%~8%)，应用ABCD3-Ⅰ评分的卒中风险(0%~23.8%)。研究[12]显示，在评分的项目中，年龄、血压和糖尿病与发病早期及3个月时卒中风险无明显相关性，而临床表现、症状持续时间、颅脑影像学检查和颈部血管检查是整个评分的关键信息。2016年KELLY等[13]的一项汇总分析纳入了16个队列研究的2 176例TIA病人，比较了ABCD2，ABCD2-Ⅰ和ABCD3-Ⅰ3个评分量表对危险分层及发病早期(2 d和7 d内)风险预估。结果显示：ABCD2-Ⅰ评分相较于ABCD2评分对于早期2 d内卒中风险的预测更好，而ABCD3-Ⅰ评分对于早期2 d内卒中风险的预测又比ABCD2-Ⅰ评分和ABCD2评分要好。因此，增加了影像学检查的ABCD2-Ⅰ评分和ABCD3-Ⅰ评分在评估TIA后早期卒中风险方面，预测值均高于ABCD2评分。

    本研究发现，与非脑梗死组比较，新发脑梗死组的3种不同的ABCD系统的评分结果均显著升高；随着ABCD2、ABCD3、ABCD3-Ⅰ评分分值的升高，7 d内继发脑梗死的危险度不断增加；3种ABCD评分系统之间存在组别的差异，两两比较发现，ABCD3-Ⅰ优于ABCD3，ABCD3优于ABCD2。本研究与既往的研究基本一致，ABCD评分标准是临床上预测TIA短期进展为脑梗死的一种比较有效的方法，尤其是ABCD3-Ⅰ评分。

    然而，需要注意的是，目前没有研究表明任何一种危险分层的工具有识别短期卒中风险的能力。因此，对于那些疑似TIA或无法准确识别的TIA病人，与其纠结应用哪种风险高低的评分，不如加强TIA门急诊的流程管理，让所有表现为TIA的病人都立即得到卒中专业人员的评估，从而及时排除假性卒中，并且能够保证让真正的TIA病人得到及时合适的卒中二级预防治疗[14-15]。这些预测量表主要是用于诊断、疗效评价和功能评定的工具，不能替代临床诊断。在众多预测评分系统中，已从最初的基于临床特点的评分工具发展到影像学、实验室检查与临床特点相结合的评分方法，但由于各量表采用的方法、评估因素和侧重点不同，尚未形成被公认和完善的预测评分系统，而这仍需要进一步研究。

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