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Updated: Jul 15, 2025
A Thrombotic Stroke Model Based On Transient Cerebral Hypoxia-ischemia
Published on: August 18, 2015
Underlying Causes of TIA and Minor Ischemic Stroke and Risk of Major Vascular Events
Philippa C Lavallée1, Hugo Charles1, Gregory W Albers2
1Department of Neurology and Stroke Center, Bichat Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut National de la Santé et de la Recherche Médicale (INSERM) Laboratory for Vascular Translational Science (LVTS)-U1148, University Paris-Cité, Paris, France.
Insights
The coexistence of multiple underlying causes in patients experiencing transient ischemic attack (TIA) or minor ischemic stroke is common. These underlying causes significantly impact the 5-year risk of major vascular events, necessitating tailored prevention strategies.
Area of Science:
- Neurology
- Cardiology
- Vascular Medicine
Background:
- The coexistence of underlying causes for transient ischemic attack (TIA) and minor ischemic stroke is not well understood.
- Associated 5-year risks for major vascular events in these patients require further investigation.
Purpose of the Study:
- To apply the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other cause, or dissection) grading system.
- To assess the coexistence of underlying causes of TIA and minor ischemic stroke.
- To determine the 5-year risk for major vascular events based on these causes.
Main Methods:
- An international registry cohort study (TIAregistry.org) enrolled 4789 patients with TIA or minor stroke.
- Patients underwent 1- to 5-year follow-up across 61 sites in 21 countries.
- Data from 3847 patients completing 5-year follow-up were analyzed.
Main Results:
- A substantial coexistence of underlying causes (atherosclerosis, small vessel disease, cardiac pathology) was observed in TIA and minor stroke patients.
- Patients with causal atherosclerosis had a 4.86-fold higher 5-year risk of major vascular events.
- Patients with causal cardiac pathology had a 4.01-fold higher 5-year risk, and those with causal lacunar stroke had a 2.57-fold higher risk.
Conclusions:
- The coexistence of underlying causes in TIA and minor ischemic stroke patients is significant.
- The 5-year risk of major vascular events varies considerably based on the specific underlying diseases.
- Secondary prevention strategies should be pathophysiology-based rather than adopting a one-size-fits-all approach.
Importance:
The coexistence of underlying causes in patients with transient ischemic attack (TIA) or minor ischemic stroke as well as their associated 5-year risks are not well known.
Objective:
To apply the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other cause, or dissection) grading system to assess coexistence of underlying causes of TIA and minor ischemic stroke and the 5-year risk for major vascular events.
Design, Setting, And Participants:
This international registry cohort (TIAregistry.org) study enrolled 4789 patients from June 1, 2009, to December 31, 2011, with 1- to 5-year follow-up at 61 sites in 21 countries. Eligible patients had a TIA or minor stroke (with modified Rankin Scale score of 0 or 1) within the last 7 days. Among these, 3847 patients completed the 5-year follow-up by December 31, 2016. Data were analyzed from October 1, 2022, to June 15, 2023.
Exposure:
Five-year follow-up.
Main Outcomes And Measures:
Estimated 5-year risk of the composite outcome of stroke, acute coronary syndrome, or cardiovascular death.
Results:
A total of 3847 patients (mean [SD] age, 66.4 [13.2] years; 2295 men [59.7%]) in 42 sites were enrolled and participated in the 5-year follow-up cohort (median percentage of 5-year follow-up per center was 92.3% [IQR, 83.4%-97.8%]). In 998 patients with probable or possible causal atherosclerotic disease, 489 (49.0%) had some form of small vessel disease (SVD), including 110 (11.0%) in whom a lacunar stroke was also probably or possibly causal, and 504 (50.5%) had no SVD; 275 (27.6%) had some cardiac findings, including 225 (22.6%) in whom cardiac pathology was also probably or possibly causal, and 702 (70.3%) had no cardiac findings. Compared with patients with none of the 5 ASCOD categories of disease (n = 484), the 5-year rate of major vascular events was almost 5 times higher (hazard ratio [HR], 4.86 [95% CI, 3.07-7.72]; P < .001) in patients with causal atherosclerosis, 2.5 times higher (HR, 2.57 [95% CI, 1.58-4.20]; P < .001) in patients with causal lacunar stroke or lacunar syndrome, and 4 times higher (HR, 4.01 [95% CI, 2.50-6.44]; P < .001) in patients with causal cardiac pathology.
Conclusion And Relevance:
The findings of this cohort study suggest that in patients with TIA and minor ischemic stroke, the coexistence of atherosclerosis, SVD, cardiac pathology, dissection, or other causes is substantial, and the 5-year risk of a major vascular event varies considerably across the 5 categories of underlying diseases. These findings further suggest the need for secondary prevention strategies based on pathophysiology rather than a one-size-fits-all approach.
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