{"product_id":"why-early-treatment-after-a-tia-or-minor-stroke-prevents-more-strokes","title":"Why Early Treatment After a TIA or Minor Stroke Prevents More Strokes","description":"\u003cp\u003eThis clinical update argues that the risk of a second stroke after a transient ischemic attack (TIA, a temporary stroke-like episode) or minor stroke is far higher. This risk is far higher than doctors traditionally believed. This risk is especially high in the first 7 days. Data from large international trials show that carotid endarterectomy (CEA, surgery to clear the narrowed neck artery) prevents far more strokes when performed within 2 weeks of symptoms. CEA prevents far fewer strokes when delayed beyond 12 weeks. The author concludes that patients with a TIA or minor stroke should be treated as emergencies, and that \"intervene early to prevent more strokes\" is the simplest and best message.\u003c\/p\u003e\n\n\u003ch1\u003eWhy Early Treatment After a TIA or Minor Stroke Prevents More Strokes\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#background\"\u003eBackground: What Is Occam's Razor and Why Does It Matter Here?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#problem\"\u003eThe Problem: Why Most Patients Are Not Treated Quickly\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#early-risk\"\u003eThe Early Risk of Stroke After a TIA Is Much Higher Than Taught\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#delay\"\u003eHow Delay to Surgery Reduces the Benefit of Carotid Endarterectomy\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#gender\"\u003eImportant Differences Between Men and Women\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#strategy\"\u003eThe UK National Stroke Strategy and the ABCD2 Score\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#minor-stroke\"\u003eDoes the Same Advice Apply to Minor Stroke?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#procedural-risk\"\u003eDoes Urgent Surgery Increase Procedural Risks?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#stenting\"\u003eWhat About Carotid Stenting?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#implications\"\u003eClinical Implications: What This Means for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eLimitations of the Evidence\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recommendations\"\u003eRecommendations for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eCarotid endarterectomy prevents far more strokes when performed within 2 weeks of symptoms than when delayed beyond 12 weeks.\u003c\/li\u003e\n\u003cli\u003eIn the trial data, women lost the benefit of carotid endarterectomy sooner than men, especially with moderate stenosis.\u003c\/li\u003e\n\u003cli\u003eThe ABCD2 score can help identify which patients need urgent assessment; a score of 4 or more with 50% to 99% stenosis requires admission.\u003c\/li\u003e\n\u003cli\u003ePatients who recover quickly after a minor stroke may still be at risk of early deterioration and need urgent assessment.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"background\"\u003eBackground: What Is Occam's Razor and Why Does It Matter Here?\u003c\/h2\u003e\n\u003cp\u003eWilliam of Occam lived from AD 1285 to 1349. He is credited with the \"Law of Parsimony,\" which states that \"the simplest explanation is usually the best.\" The word \"razor\" in Occam's razor symbolizes cutting away unnecessary assumptions from a debate.\u003c\/p\u003e\n\u003cp\u003eDespite its great age, this principle is highly relevant to the current debate about the best timing of treatment. This debate concerns patients who suffer a transient ischemic attack (TIA) or a minor stroke. A TIA is a temporary episode of stroke-like symptoms that resolves. A minor stroke causes only mild and often reversible neurological problems.\u003c\/p\u003e\n\u003cp\u003eMost guidelines recommend that carotid endarterectomy (CEA) is performed \"promptly\" after symptoms begin. CEA is an operation that removes fatty plaque from the carotid artery in the neck. This plaque narrows the artery and can send clots to the brain. However, there is evidence that prompt surgery does not happen for most symptomatic patients.\u003c\/p\u003e\n\n\u003ch2 id=\"problem\"\u003eThe Problem: Why Most Patients Are Not Treated Quickly\u003c\/h2\u003e\n\u003cp\u003eThe reasons for delay are multifactorial, meaning many different factors combine to cause the problem. The author lists eleven specific reasons.\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eA lower political priority for treating patients with cerebrovascular disease (disease of the blood vessels in the brain) compared with cancer or heart disease.\u003c\/li\u003e\n  \u003cli\u003eA perception that once the neurological deficit from a TIA or minor stroke has resolved, the early risk of recurrent stroke is relatively low.\u003c\/li\u003e\n  \u003cli\u003eAn inability or unwillingness of health systems to regard TIA and minor stroke as emergencies, similar to unstable angina or myocardial infarction (heart attack).\u003c\/li\u003e\n  \u003cli\u003eLogistical problems with access to duplex ultrasound, magnetic resonance angiography (MRA), or computed tomographic angiography (CTA) within hours of a TIA.\u003c\/li\u003e\n  \u003cli\u003eInadequate patient and physician education about the symptoms of TIA and minor stroke.\u003c\/li\u003e\n  \u003cli\u003eA reluctance to leave elective operating lists \"unfilled\" so that urgent procedures can be added at short notice.\u003c\/li\u003e\n  \u003cli\u003eA tendency to believe that CEA is acceptable as long as it is performed within 6 months, because this complies with the findings of the international trials.\u003c\/li\u003e\n  \u003cli\u003eA tendency to allocate disproportionately more effort toward treating asymptomatic individuals (people with narrowed arteries but no symptoms).\u003c\/li\u003e\n  \u003cli\u003eA lack of awareness, or simply ignoring, published data that document the benefits of intervening early in symptomatic patients.\u003c\/li\u003e\n  \u003cli\u003eA professional or financial reluctance to work up a patient for CEA and then hand that patient to a colleague who can operate sooner.\u003c\/li\u003e\n  \u003cli\u003eA perception that early interventions are more likely to be associated with increased procedural risks, which could lead to medico-legal or professional censure.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThe author notes that it is easy to blame \"inadequacies in the system\" for failures to treat TIA patients more quickly. However, he argues that factors 7 through 11 have also influenced surgical practice more than many surgeons might wish to admit.\u003c\/p\u003e\n\n\u003ch2 id=\"early-risk\"\u003eThe Early Risk of Stroke After a TIA Is Much Higher Than Taught\u003c\/h2\u003e\n\u003cp\u003eTraditional teaching holds that the 7-day risk of stroke after a TIA is 1% to 2%, rising to 2% to 4% at 30 days. At these low levels of risk, most surgeons and providers saw little need to change practice. As a result, 6 months remained the accepted threshold for treating the \"recently symptomatic\" patient.\u003c\/p\u003e\n\u003cp\u003eHowever, the author explains that these \"natural history\" data were intrinsically flawed. The constituent studies recruited patients well after the index event. Strokes that occurred in the interim, or on the day of the TIA itself, were excluded. Significant bias was also introduced by methodological issues. These issues included whether patients were recruited as outpatients, in the emergency room, or from the general population, and the method of follow-up.\u003c\/p\u003e\n\u003cp\u003eTwo recent meta-analyses (studies that combine data from many studies) reviewed the early risk of stroke after TIA. Overall, the 2-day risk of stroke was 3.1%. This increased to 5.2% at 7 days and 8.0% at 30 days. This represents a doubling of risk compared with traditional teaching.\u003c\/p\u003e\n\u003cp\u003eEven these figures are still misleading, according to the author, because of the different ways patients were recruited and followed up. The table below summarizes the early risk of stroke after TIA in different types of studies.\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTraditional teaching:\u003c\/strong\u003e 2-day risk not stated; 7-day risk 1% to 2%; 30-day risk 2% to 4%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMeta-analyses (overall):\u003c\/strong\u003e 2-day risk 3.1%; 7-day risk 5.2%; 30-day risk 8.0%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e\"Passive\" ascertainment:\u003c\/strong\u003e 2-day risk 3.1%; 30-day risk 6.4%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e\"Face to face\" follow-up:\u003c\/strong\u003e 2-day risk 6.7%; 7-day risk 10.4%; 30-day risk 13.4%.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eIn studies that used \"passive\" follow-up, researchers searched computerized hospital databases to identify patients who suffered a stroke, rather than speaking to the patient directly. In this type of study, some patients would not be identified. These include patients who suffered a stroke and were not hospitalized, who attended a different hospital, or who suffered their stroke on the day of the TIA. Not surprisingly, the observed 30-day risk in this type of study (6.4%) was lower than that observed in the meta-analysis overall (8.0%).\u003c\/p\u003e\n\u003cp\u003eBy contrast, TIA patients recruited into population-based studies with \"face to face\" follow-up, and with no urgent interventions, had the worst prognosis. Their 2-day stroke risk was 6.7%, increasing to 10.4% at 7 days and 13.4% at 30 days. In effect, this 30-day risk is four to six times greater than is traditionally taught. The highest risk period is the first 7 days.\u003c\/p\u003e\n\u003cp\u003eThis finding was corroborated in a pooled cohort of 549 patients whose stroke was preceded by a TIA. Among these patients, 43% of the index TIAs occurred within 7 days of the stroke, and 17% actually happened on the same day as the stroke.\u003c\/p\u003e\n\n\u003ch2 id=\"delay\"\u003eHow Delay to Surgery Reduces the Benefit of Carotid Endarterectomy\u003c\/h2\u003e\n\u003cp\u003eHaving established that the early prognosis after a TIA had been underestimated, a second challenge to practice arose from a reanalysis of data from the international randomized trials. The European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) were published in 1991. For the next 15 years, a 6-month threshold for intervention assumed a \"one size fits all\" role.\u003c\/p\u003e\n\u003cp\u003eIn reality, this assumption meant that operating on a patient with an 80% stenosis (narrowing) 5 months and 29 days after their TIA conferred exactly the same benefit for late stroke prevention. That benefit was the same as operating within 3 days of symptoms. More importantly, many surgeons viewed a little delay within the system as potentially beneficial, provided it was within the 6-month threshold. This view was based on the general belief that urgent CEA was associated with increased procedural risks.\u003c\/p\u003e\n\u003cp\u003eThe Carotid Endarterectomy Trialists Collaboration (CETC) combined data from 6000 patients recruited into the ECST, NASCET, and VA trials. All pre-randomization angiograms (X-ray images of the arteries) were remeasured using the NASCET method. These data provided vital information about the effect of delay upon outcome and patient benefit.\u003c\/p\u003e\n\u003cp\u003eThe CETC data detail the absolute risk reduction (ARR) conferred by CEA. The CETC data also detail the number needed to treat to prevent one stroke at 5 years (NNT), and the number of ipsilateral strokes prevented at 5 years per 1000 CEAs. An ipsilateral stroke is a stroke on the same side as the narrowed artery. These figures are stratified for degree of stenosis (50% to 69% versus 70% to 99%) and for gender. The term \"delay\" means the time from symptom onset to randomization. In ECST and NASCET, the mean delay from randomization to surgery was 7 days.\u003c\/p\u003e\n\u003cp\u003eThe data clearly show that the magnitude of benefit conferred by CEA was highest in patients with 70% to 99% stenosis compared with 50% to 69% stenosis. The benefit was also highest in patients in whom delays were least.\u003c\/p\u003e\n\u003cp\u003eFor patients with 50% to 69% stenosis, the reduction in benefit as delays increased was most apparent. After 12 weeks, CEA appeared to confer no benefit at all. The specific numbers for all patients were as follows:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay of 2 weeks or less:\u003c\/strong\u003e ARR 14.8%; NNT 7; 148 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay of 2 to 4 weeks:\u003c\/strong\u003e ARR 3.3%; NNT 30; 33 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay of 4 to 12 weeks:\u003c\/strong\u003e ARR 4.0%; NNT 25; 40 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay of more than 12 weeks:\u003c\/strong\u003e ARR minus 2.9% (no benefit); NNT not applicable; no benefit conferred.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eFor patients with 70% to 99% stenosis, the numbers for all patients were as follows:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay of 2 weeks or less:\u003c\/strong\u003e ARR 23.0%; NNT 4; 230 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay of 2 to 4 weeks:\u003c\/strong\u003e ARR 15.9%; NNT 6; 159 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay of 4 to 12 weeks:\u003c\/strong\u003e ARR 7.9%; NNT 13; 79 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay of more than 12 weeks:\u003c\/strong\u003e ARR 7.4%; NNT 14; 74 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003ePatients with 70% to 99% stenosis gained consistently greater benefit from CEA. However, the magnitude of stroke prevention still fell by 66% in patients in whom more than 12 weeks had elapsed.\u003c\/p\u003e\n\n\u003ch2 id=\"gender\"\u003eImportant Differences Between Men and Women\u003c\/h2\u003e\n\u003cp\u003eMore disturbing were the data that emerged when the CETC stratified for gender. Symptomatic males with 50% to 69% stenosis gained diminishing benefit with time. The benefit conferred in male patients with 70% to 99% stenosis was largely preserved.\u003c\/p\u003e\n\u003cp\u003eIn male patients with 70% to 99% stenosis, approximately 200 ipsilateral strokes were prevented at 5 years by performing 1000 CEAs. This was true whether delays were 2 weeks or less or more than 12 weeks. The specific numbers for men were as follows:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003e50% to 69% stenosis, delay 2 weeks or less:\u003c\/strong\u003e ARR 15.2%; NNT 7; 152 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e50% to 69% stenosis, delay 2 to 4 weeks:\u003c\/strong\u003e ARR 6.8%; NNT 15; 68 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e50% to 69% stenosis, delay 4 to 12 weeks:\u003c\/strong\u003e ARR 5.0%; NNT 20; 50 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e50% to 69% stenosis, delay more than 12 weeks:\u003c\/strong\u003e ARR 6.3%; NNT 16; 63 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e70% to 99% stenosis, delay 2 weeks or less:\u003c\/strong\u003e ARR 23.3%; NNT 4; 233 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e70% to 99% stenosis, delay 2 to 4 weeks:\u003c\/strong\u003e ARR 23.8%; NNT 4; 238 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e70% to 99% stenosis, delay 4 to 12 weeks:\u003c\/strong\u003e ARR 18.3%; NNT 5; 183 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e70% to 99% stenosis, delay more than 12 weeks:\u003c\/strong\u003e ARR 20.4%; NNT 5; 204 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eHowever, the findings were totally different in women. The author states that these findings really do question whether existing practices actually confer any real benefit at all for women.\u003c\/p\u003e\n\u003cp\u003eSymptomatic females with moderate (50% to 69%) stenosis only gained benefit from CEA if the delay was 2 weeks or less. Thereafter, CEA may have been associated with harm. A similar trend was evident in symptomatic female patients with 70% to 99% stenosis. Here, considerable benefit was apparent provided the delay from onset of symptoms to randomization was 4 weeks or less. Thereafter, CEA did not appear to confer any significant benefit at all.\u003c\/p\u003e\n\u003cp\u003eThe specific numbers for women were as follows:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003e50% to 69% stenosis, delay 2 weeks or less:\u003c\/strong\u003e ARR 13.8%; NNT 7; 138 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e50% to 69% stenosis, delay 2 to 4 weeks:\u003c\/strong\u003e ARR minus 5.7% (no benefit); NNT not applicable; no benefit conferred.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e50% to 69% stenosis, delay 4 to 12 weeks:\u003c\/strong\u003e ARR minus 2.2% (no benefit); NNT not applicable; no benefit conferred.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e50% to 69% stenosis, delay more than 12 weeks:\u003c\/strong\u003e ARR minus 21.7% (no benefit); NNT not applicable; no benefit conferred.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e70% to 99% stenosis, delay 2 weeks or less:\u003c\/strong\u003e ARR 41.7%; NNT 2; 417 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e70% to 99% stenosis, delay 2 to 4 weeks:\u003c\/strong\u003e ARR 6.6%; NNT 15; 66 strokes prevented per 1000 CEAs.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e70% to 99% stenosis, delay 4 to 12 weeks:\u003c\/strong\u003e ARR minus 2.2% (no benefit); NNT not applicable; no benefit conferred.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e70% to 99% stenosis, delay more than 12 weeks:\u003c\/strong\u003e ARR minus 2.4% (no benefit); NNT not applicable; no benefit conferred.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThe author explains how these data should be interpreted. Unfortunately, the trials did not document the time from onset of symptoms to CEA. Accordingly, 7 days should be added to each \"delay grouping\" to correct for this. This limitation should not detract from the fundamental message.\u003c\/p\u003e\n\u003cp\u003eThe data have shown that future guidelines cannot uncritically support a practice that does not recognize that delays to intervention mean rapidly diminishing benefit to the patient. This applies whether the intervention is CEA or carotid angioplasty with stenting (CAS), and especially for females.\u003c\/p\u003e\n\u003cp\u003eFor example, it has become conventional, especially in North America and mainland Europe, to undertake CEA in most symptomatic patients with NASCET 50% to 99% stenosis. The CETC data suggest that if CEA is performed within 2 weeks, 185 ipsilateral strokes will be prevented at 5 years per 1000 CEAs, which is highly effective. If, however, CEA is delayed by more than 12 weeks, the number of strokes prevented falls to eight. This means 992 unnecessary interventions.\u003c\/p\u003e\n\u003cp\u003eMany readers will claim that this type of delay is not representative of their practice. However, the author states that the published evidence suggests this not to be the case.\u003c\/p\u003e\n\n\u003ch2 id=\"strategy\"\u003eThe UK National Stroke Strategy and the ABCD2 Score\u003c\/h2\u003e\n\u003cp\u003eThere was compelling evidence that the natural history risk of stroke after TIA had been grossly underestimated. There was also compelling evidence that delays to surgery diminished the overall benefit conferred to the patient even further. Faced with this evidence, the UK Government recently published a National Stroke Strategy. The aim was to raise public and professional awareness of TIA and stroke, as well as to make radical changes to existing practices for investigating and treating patients.\u003c\/p\u003e\n\u003cp\u003eThis strategy has been well received, but it does have major implications for service provision and clinical practice. It has also highlighted several important issues affecting providers and surgeons.\u003c\/p\u003e\n\u003cp\u003eThe first issue relates to the logistics of how to provide such a service. Is it possible to identify \"high risk\" subgroups within cohorts of patients presenting with a TIA? The second issue relates to concerns by surgeons that expedited surgery will inevitably lead to increased procedural risks. These increased risks could either negate any long-term benefit to the patient or render the surgeon liable to medico-legal or professional censure. There is also the important issue of whether such a strategy will apply to practitioners of carotid angioplasty with stenting (CAS). None of the randomized trials comparing CEA with CAS in symptomatic patients have stratified their outcomes to correct for delay from onset of symptoms to intervention.\u003c\/p\u003e\n\u003cp\u003eThere have been a number of attempts to develop clinically useful scoring systems for identifying high risk patients in the first 7 days after TIA onset. The ABCD and Californian Scoring systems have been extensively evaluated and combined within two derivation and four validation cohorts. These cohorts comprised 4799 TIA patients, and the combined system was renamed the ABCD2 score.\u003c\/p\u003e\n\u003cp\u003eThe ABCD2 score uses the following criteria:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eA — Age:\u003c\/strong\u003e 60 years or older scores 1 point.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eB — Blood pressure:\u003c\/strong\u003e systolic 140 mm Hg or higher, or diastolic 90 mm Hg or higher, scores 1 point.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eC — Clinical features:\u003c\/strong\u003e unilateral weakness scores 2 points; speech impairment without weakness scores 1 point.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eD — Duration of TIA:\u003c\/strong\u003e 60 minutes or longer scores 2 points; 10 to 59 minutes scores 1 point.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eD — Diabetes:\u003c\/strong\u003e diabetes scores 1 point.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThe maximum score is 7. The risk of stroke stratified for the ABCD2 score was as follows:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eScore 0 to 3 (1628 patients):\u003c\/strong\u003e 2-day risk 1.0%; 7-day risk 1.2%; 90-day risk 3.1%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eScore 4 to 5 (2169 patients):\u003c\/strong\u003e 2-day risk 4.1%; 7-day risk 5.9%; 90-day risk 9.8%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eScore 6 to 7 (1012 patients):\u003c\/strong\u003e 2-day risk 8.1%; 7-day risk 11.7%; 90-day risk 17.8%.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eNote that patients with a score of 3 or less have a very low stroke risk (1% at 2 days, 1.2% at 7 days, and 3.1% at 90 days). Early stroke risk increased in patients scoring 4 or more, with the greatest risk seen in patients scoring 6 to 7 (2-day risk of stroke 8.1%, 7-day risk of stroke 11.7%).\u003c\/p\u003e\n\u003cp\u003eThe UK National Stroke Strategy recommends that any patient with an ABCD2 score of 3 or less should be assessed within 7 days of onset of symptoms. This means such a patient should not be treated as an acute emergency. However, those scoring 4 or more need to be assessed and investigated with MRI, CT, or duplex ultrasound by a stroke specialist within 24 hours of onset of symptoms.\u003c\/p\u003e\n\u003cp\u003ePatients with an ABCD2 score of 4 or more and a 50% to 99% ipsilateral carotid stenosis should be admitted to hospital. Carotid endarterectomy should be performed within 48 hours unless contra-indicated. The obvious caveat is the patient who presents some time after the index event. That patient would qualify for being seen within the 7-day non-urgent threshold.\u003c\/p\u003e\n\u003cp\u003eThis strategy will clearly require a major reorganization of the way vascular technologists, surgeons, and hospital services work. It will also have to include access to cerebral vascular clinics on a daily basis, including weekends.\u003c\/p\u003e\n\n\u003ch2 id=\"minor-stroke\"\u003eDoes the Same Advice Apply to Minor Stroke?\u003c\/h2\u003e\n\u003cp\u003eIn the current era of league tables, increasing accountability, and litigation, any recommendation is going to arouse concerns. This applies to a recommendation to undertake the majority of CEAs within 1 to 2 weeks of a TIA or minor stroke. The first concern is whether the prognosis in patients presenting with a minor stroke is similar to that cited for TIA patients.\u003c\/p\u003e\n\u003cp\u003eIf the answer is yes, the second issue is how the advice to intervene early can be reconciled with traditional teaching. Traditional teaching recommends deferring surgery for 6 to 8 weeks in patients who have suffered a stroke. The third issue is that most surgeons will intuitively believe that expedited or urgent surgery is associated with increased procedural risks. If that is the case, won't these increased risks negate any long-term benefit? Moreover, how can the surgeon be reassured that an increase in procedural risk will not make him or her liable to uncritical professional censure?\u003c\/p\u003e\n\u003cp\u003eThe first question is surprisingly difficult to answer, especially using population-based data. Although there have been a number of conflicting studies, Coull showed that patients presenting with a minor stroke faced an equivalent or slightly worse early prognosis than their TIA counterparts. This was the finding if anything. The stroke risk was 11.5% at 7 days and 15% at 30 days.\u003c\/p\u003e\n\u003cp\u003eAccordingly, if surgeons continue to defer surgery for up to 6 weeks, the majority of vulnerable patients will have suffered their stroke before having any chance of undergoing CEA or CAS. There is also evidence that patients who recover neurological function early after a minor stroke may be at increased risk of suffering early secondary neurological deterioration.\u003c\/p\u003e\n\u003cp\u003eFor these reasons, the UK National Stroke Strategy recommendations for treating TIA and minor stroke patients expeditiously are the same.\u003c\/p\u003e\n\u003cp\u003eThis recommendation is, however, at odds with \"traditional\" teaching, which states that CEA should be deferred for 6 weeks in stroke patients. This recommendation followed poor outcomes in the 1960s, especially hemorrhagic transformation of an ischemic infarct (bleeding into an area of brain damage caused by reduced blood flow). At that time, patients suffering an acute thrombotic stroke were subjected to emergency surgery. Many of these patients, however, presented with acute carotid thromboses, had dense neurological deficits, or were neurologically obtunded (reduced level of consciousness).\u003c\/p\u003e\n\u003cp\u003eSince then, most surgeons would never consider this genre of patient as being appropriate for emergency intervention. Over the last 40 years, the quality of anesthesia, blood pressure control, and intensive care therapy has improved dramatically. Despite this, the \"6-week rule\" has endured, even in patients who make a rapid neurological recovery.\u003c\/p\u003e\n\u003cp\u003eIn a subgroup analysis, NASCET was one of the first to challenge this doctrine. NASCET showed that patients presenting with a minor stroke in whom CEA was deferred for 30 days or more were more likely to have an abnormal CT scan. However, there was no difference in the perioperative risk. The perioperative risk was 4.8% when CEA was performed within 30 days and 5.2% when CEA was performed after 30 days. Nor was the operative risk increased in patients with an infarct on CT scan: 0.0% when CEA was performed within 30 days and 5.4% when CEA was performed after 30 days.\u003c\/p\u003e\n\u003cp\u003eA number of studies have reported similar findings. A meta-analysis has shown no evidence of a significant increase in risk if CEA is performed early. Unfortunately, NASCET used 4 weeks for the definition of early versus late, while the meta-analysis used up to 6 weeks.\u003c\/p\u003e\n\u003cp\u003eThe table below summarizes the few published series where CEA was performed within a median of 14 days since onset of symptoms. As can be seen, most patients presented with a stroke.\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eRicco (2000), 72 patients, stroke, median 5.5 days to CEA:\u003c\/strong\u003e 30-day death\/stroke rate 2.8%; intracranial hemorrhage 0.0%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003ePaty (2004), 72 patients, stroke, within 7 days, \"nondisabling\":\u003c\/strong\u003e 30-day death\/stroke rate 2.8%; intracranial hemorrhage not stated.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003ePaty (2004), 131 patients, stroke, within 14 days, \"nondisabling\":\u003c\/strong\u003e 30-day death\/stroke rate 3.1%; intracranial hemorrhage not stated.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDorigo (2007), 70 patients, stroke or TIA, median 2.0 days, \"nondisabling\":\u003c\/strong\u003e 30-day death\/stroke rate 5.4%; intracranial hemorrhage not stated.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAleksic (2006), 50 patients, stroke or TIA, median 4.5 days, Rankin 4 or less:\u003c\/strong\u003e 30-day death\/stroke rate 6.0%; intracranial hemorrhage 4.0%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eKarkos (2007), 42 patients, TIA, median 3.0 days, Rankin 4 or less:\u003c\/strong\u003e 30-day death\/stroke rate 7.0%; intracranial hemorrhage 0.0%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eSbarigia (2006), 96 patients, stroke, median 1.5 days, NIHSS 22 or less:\u003c\/strong\u003e 30-day death\/stroke rate 7.3%; intracranial hemorrhage 0.0%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eRantner (2006), 226 patients, stroke, median 12 days, 66% Rankin 2 or less:\u003c\/strong\u003e 30-day death\/stroke rate 8.4%; intracranial hemorrhage 0.4%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eHuber (2003), 67 patients, stroke or TIA, median 2.0 days, 48% Rankin 3 to 5:\u003c\/strong\u003e 30-day death\/stroke rate 16.4%; intracranial hemorrhage 1.5%.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eHuber's series was unique in that it included patients with completed strokes, crescendo TIAs (repeated TIAs that increase in frequency or severity), and severe neurological deficits (Rankin 3 to 5). Huber's series also included some patients with acute carotid occlusion (complete blockage of the artery). Not surprisingly, the procedural risk in Huber's series was 16.4%, much higher than the others.\u003c\/p\u003e\n\u003cp\u003eAccordingly, the concept of \"picking winners\" will remain crucial. The type of minor stroke patient liable to be selected for urgent CEA will have made a relatively rapid recovery from their deficit or will have a neurological plateau. These patients will not have carotid occlusion. They will be Rankin 0 to 2 in terms of disability. The area of infarction should not exceed one third of the middle cerebral artery territory. There should be no intracranial hemorrhage, and patients should be lucid and able to give informed consent.\u003c\/p\u003e\n\u003cp\u003eAll other patients, meaning those with more severe deficits, should have CEA deferred on the grounds that the benefits of early intervention are still outweighed by the risks.\u003c\/p\u003e\n\u003cp\u003eGiven these caveats, Rantner's series of 226 patients is probably the most relevant study. This series was much larger than the others and was derived from a collaboration of three prospective databases. Two-thirds of patients presented with a minor stroke. Overall, 226 patients underwent CEA within a median of 48 hours after onset of symptoms, incurring a 30-day death or stroke rate of 8.4%. Some might view this risk as being excessive and as further evidence that CEA should have been deferred. However, the author hopes the next section will suggest this not to be the case.\u003c\/p\u003e\n\n\u003ch2 id=\"procedural-risk\"\u003eDoes Urgent Surgery Increase Procedural Risks?\u003c\/h2\u003e\n\u003cp\u003eThe third issue facing the surgeon or interventionist is whether urgent CEA or CAS should become standard practice, and whether this will be associated with increased procedural risks. One of the catalysts for this debate was the publication of outcomes following more than 1000 CEAs in symptomatic patients, which included stratification for delay from presentation to surgery.\u003c\/p\u003e\n\u003cp\u003ePatients undergoing CEA within 4 weeks of symptom onset faced a threefold increase in the procedural risk compared with patients in whom surgery was deferred for more than 4 weeks. The risk was 5.1% versus 1.6%. The author's clear message was that patients would benefit from deferred surgery in order to minimize the procedural risk.\u003c\/p\u003e\n\u003cp\u003eBazan reviewed outcomes following 764 CEAs performed for \"urgent\" indications in all acute, nonfederal Connecticut hospitals between 1992 and 2002. They did not state the delay to surgery, although by implication CEA must have been performed soon after admission. Outcomes were stratified according to the All Patient Refined Diagnosis Related Groups (APR-DRG) risk mortality variable.\u003c\/p\u003e\n\u003cp\u003ePatients were classed as low comorbidity if they were grade 1 (minor) or 2 (moderate). They were classed as high comorbidity if they were grade 3 (major) or 4 (extreme severity). Overall, patients undergoing \"urgent\" CEA with a low comorbidity score had similar 30-day risks to patients undergoing elective CEA during the same time period. By contrast, \"urgent\" CEA patients with high comorbidity suffered significantly higher mortality rates than their \"urgent\" but low comorbidity counterparts.\u003c\/p\u003e\n\n\u003ch2 id=\"stenting\"\u003eWhat About Carotid Stenting?\u003c\/h2\u003e\n\u003cp\u003eInterestingly, a similar debate is emerging in the CAS literature. The CAPTURE Registry observed a significantly higher risk of suffering a procedural stroke in a group of patients. This group presented with a TIA or minor stroke and underwent protected CAS within 14 days of symptom onset. The odds ratio was 2.52, with a 95% confidence interval of 1.33 to 4.78. After 14 days had elapsed, this excess risk disappeared.\u003c\/p\u003e\n\u003cp\u003eTwo other CAS studies are worthy of note. In a relatively small series of 77 patients, Topakian noted a significantly higher 30-day death or stroke rate in one group. This group presented with TIA or stroke and underwent protected CAS within 14 days of symptom onset, compared with patients undergoing deferred CAS. The rate was 26.1% versus 1.9%.\u003c\/p\u003e\n\u003cp\u003eIn response to this, Groschel reviewed their own experience of 320 patients. Groschel noted no difference in 30-day death or stroke relative to whether CAS was performed within 14 days (7.0%) or after 14 days (9.6%).\u003c\/p\u003e\n\u003cp\u003eThe author states that this is clearly a very important issue. It may be one of the reasons why the EVA-3S study encountered a 9.6% 30-day death-stroke rate in its CAS patients. Ignored by many of the critics of EVA-3S was data showing that 20% of patients underwent CAS within 14 days of onset of symptoms. Another 25% underwent CAS between 14 to 28 days after symptom onset. Overall, 45% of CAS patients underwent intervention within 28 days of presentation.\u003c\/p\u003e\n\u003cp\u003eThe author hopes that the principle randomized trials comparing CEA with CAS will combine their data and specifically look at the effect of delay to intervention on procedural risk.\u003c\/p\u003e\n\u003cp\u003eOn balance, the available evidence does suggest that the early risk of stroke after a TIA or minor stroke is significantly higher than previously thought. In most health systems, this unfortunately means that many vulnerable patients will have suffered their stroke before having had any chance of being considered for CEA or CAS.\u003c\/p\u003e\n\u003cp\u003eThe problem is then compounded by institutional delays in finally undertaking CEA or CAS, which leads to even greater diminishing benefit to the patient. The international trials used a 6-month threshold for inclusion. It remains an unpalatable fact that if CEA or CAS is delayed beyond 12 weeks in symptomatic patients with NASCET 50% to 99% stenosis, the patient is exposed to all of the risks of intervening. The patient gains little in the way of long-term stroke prevention.\u003c\/p\u003e\n\u003cp\u003eThe take-home message is, therefore, very simple: \"intervene early to prevent more strokes.\" Occam's razor has never been sharper.\u003c\/p\u003e\n\n\u003ch2 id=\"implications\"\u003eClinical Implications: What This Means for Patients\u003c\/h2\u003e\n\u003cp\u003eThis article has several important implications for patients who experience a TIA or minor stroke.\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eThe risk of a second stroke in the days after a TIA is much higher than doctors traditionally believed. The highest risk period is the first 7 days.\u003c\/li\u003e\n  \u003cli\u003eCarotid endarterectomy prevents far more strokes when performed within 2 weeks of symptoms than when delayed beyond 12 weeks.\u003c\/li\u003e\n  \u003cli\u003eFor patients with 50% to 69% stenosis, CEA appears to confer no benefit at all if delayed beyond 12 weeks.\u003c\/li\u003e\n  \u003cli\u003eFor patients with 70% to 99% stenosis, the benefit of CEA falls by 66% when more than 12 weeks have elapsed.\u003c\/li\u003e\n  \u003cli\u003eWomen appear to lose the benefit of CEA more quickly than men. Symptomatic women with moderate stenosis only gained benefit if CEA was performed within 2 weeks.\u003c\/li\u003e\n  \u003cli\u003eThe ABCD2 score can help identify which patients are at highest risk and need urgent assessment.\u003c\/li\u003e\n  \u003cli\u003ePatients with an ABCD2 score of 4 or more and a 50% to 99% ipsilateral carotid stenosis should be admitted to hospital and have CEA performed within 48 hours unless contra-indicated.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThe author emphasizes that patients who recover neurological function early after a minor stroke may be at increased risk of early secondary neurological deterioration. This means that even patients who feel better quickly still need urgent assessment.\u003c\/p\u003e\n\n\u003ch2 id=\"limitations\"\u003eLimitations of the Evidence\u003c\/h2\u003e\n\u003cp\u003eThe author identifies several limitations in the available evidence.\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eThe international trials did not document the time from onset of symptoms to CEA. The author suggests that 7 days should be added to each delay grouping to correct for this.\u003c\/li\u003e\n  \u003cli\u003eTraditional \"natural history\" data were intrinsically flawed because the constituent studies recruited patients well after the index event. Strokes occurring in the interim or on the day of the TIA were excluded.\u003c\/li\u003e\n  \u003cli\u003eSignificant bias was introduced by methodological issues, such as outpatient versus emergency room versus population-based recruitment, and by the method of follow-up.\u003c\/li\u003e\n  \u003cli\u003eNone of the randomized trials comparing CEA with CAS in symptomatic patients have stratified their outcomes to correct for delay from onset of symptoms to intervention.\u003c\/li\u003e\n  \u003cli\u003eNASCET used 4 weeks for the definition of early versus late, while the meta-analysis used up to 6 weeks.\u003c\/li\u003e\n  \u003cli\u003eHuber's series included patients with completed strokes, crescendo TIAs, severe neurological deficits, and some with acute carotid occlusion, which likely explains the higher procedural risk in that series.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThe author notes that the first question is surprisingly difficult to answer. The first question is whether the prognosis in patients presenting with a minor stroke is similar to that cited for TIA patients. This is especially difficult using population-based data.\u003c\/p\u003e\n\n\u003ch2 id=\"recommendations\"\u003eRecommendations for Patients\u003c\/h2\u003e\n\u003cp\u003eBased on this article, patients and their families should be aware of the following recommendations.\u003c\/p\u003e\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTreat TIA and minor stroke as emergencies.\u003c\/strong\u003e Do not wait to see if symptoms resolve on their own. Seek urgent medical attention.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eKnow the symptoms of TIA and minor stroke.\u003c\/strong\u003e These include sudden weakness on one side of the body, speech impairment, and other neurological symptoms that may resolve quickly.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAsk about the ABCD2 score.\u003c\/strong\u003e If you or a family member has a TIA, ask your doctor about the ABCD2 score and what it means for urgency of assessment.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIf you have an ABCD2 score of 4 or more and a 50% to 99% carotid stenosis, you should be admitted to hospital.\u003c\/strong\u003e Carotid endarterectomy should be performed within 48 hours unless contra-indicated.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eUnderstand that delay reduces benefit.\u003c\/strong\u003e If CEA is delayed beyond 12 weeks, the patient is exposed to all of the risks of intervening but gains little in the way of long-term stroke prevention.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eWomen should be especially aware of the importance of early intervention.\u003c\/strong\u003e The data suggest that women lose the benefit of CEA more quickly than men.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAsk about access to urgent imaging.\u003c\/strong\u003e Duplex ultrasound, magnetic resonance angiography (MRA), or computed tomographic angiography (CTA) should be available within hours of a TIA.\u003c\/li\u003e\n\u003c\/ol\u003e\n\u003cp\u003eThe author concludes with a simple message: \"intervene early to prevent more strokes.\" Occam's razor has never been sharper.\u003c\/p\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eHow high is my risk of a second stroke after a TIA or minor stroke?\u003c\/h3\u003e\n\u003cp\u003eTraditional teaching put the 7-day risk at 1% to 2%, but two recent meta-analyses found a 2-day risk of 3.1%, rising to 5.2% at 7 days and 8.0% at 30 days. In population-based studies with face-to-face follow-up, the 30-day risk reached 13.4%. The highest risk period is the first 7 days.\u003c\/p\u003e\n\u003ch3\u003eDo women lose the benefit of carotid endarterectomy sooner than men?\u003c\/h3\u003e\n\u003cp\u003eYes. In the trial data, symptomatic women with 50% to 69% stenosis only gained benefit if surgery was within 2 weeks; after that it may have caused harm. Women with 70% to 99% stenosis gained considerable benefit only if surgery was within 4 weeks. Men with 70% to 99% stenosis largely kept their benefit despite delay.\u003c\/p\u003e\n\u003ch3\u003eWhat is the ABCD2 score and what do the numbers mean?\u003c\/h3\u003e\n\u003cp\u003eThe ABCD2 score uses age, blood pressure, clinical features, duration of TIA and diabetes, up to 7 points. In 4799 TIA patients, a score of 0 to 3 carried a 2-day stroke risk of 1.0%, while a score of 6 to 7 carried a 2-day risk of 8.1% and a 7-day risk of 11.7%.\u003c\/p\u003e\n\u003ch3\u003eDoes urgent carotid surgery increase the risks of the operation?\u003c\/h3\u003e\n\u003cp\u003eOne report of more than 1000 operations found a threefold higher procedural risk when surgery was within 4 weeks (5.1% versus 1.6%). However, a review of 764 urgent operations found that patients with low comorbidity had 30-day risks similar to elective surgery; those with high comorbidity had significantly higher mortality.\u003c\/p\u003e\n\u003ch3\u003eIf I feel better quickly after a minor stroke, do I still need urgent assessment?\u003c\/h3\u003e\n\u003cp\u003eYes. Patients presenting with a minor stroke faced a stroke risk of 11.5% at 7 days and 15% at 30 days in one study. There is also evidence that patients who recover neurological function early after a minor stroke may be at increased risk of early secondary neurological deterioration, so rapid recovery does not remove the need for urgent assessment.\u003c\/p\u003e\n\u003ch3\u003eWhat should I do if I or a family member has symptoms of a TIA or minor stroke?\u003c\/h3\u003e\n\u003cp\u003eTreat it as an emergency and seek urgent medical attention rather than waiting to see if symptoms resolve. Symptoms include sudden weakness on one side of the body and speech impairment. Ask your doctor about the ABCD2 score, and about access to duplex ultrasound, MRA or CTA, which should be available within hours.\u003c\/p\u003e\n\u003ch3\u003eShould I get a second opinion if I had a TIA or minor stroke and surgery is being delayed?\u003c\/h3\u003e\n\u003cp\u003eThe risk of a second stroke is highest in the first 7 days after a TIA or minor stroke, and carotid endarterectomy prevents far more strokes when performed within 2 weeks of symptoms than when delayed beyond 12 weeks. If surgery is being scheduled weeks or months out, or if you are a woman with moderate narrowing, a second opinion can help confirm the urgency and whether earlier intervention is appropriate. Diagnostic Detectives Network provides independent expert second opinions.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\u003cp\u003e\u003cstrong\u003eOriginal article title:\u003c\/strong\u003e Occam’s razor- Intervene early to prevent more strokes!\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePublication:\u003c\/strong\u003e Journal of Vascular Surgery, 2008;48:1053-9.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eDOI:\u003c\/strong\u003e 10.1016\/j.jvs.2008.06.044\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eCopyright:\u003c\/strong\u003e Copyright 2008 by The Society for Vascular Surgery.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompetition of interest:\u003c\/strong\u003e None.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eReprint requests:\u003c\/strong\u003e A. Ross Naylor, MD, FRCS, Professor of Vascular Surgery, Department of Vascular Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Robert Kilpatrick Building, PO Box 65, Leicester LE2 7LX, United Kingdom.\u003c\/p\u003e\n\u003cp\u003e\u003cem\u003eThis patient-friendly article is based on peer-reviewed research.\u003c\/em\u003e\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47807399755932,"sku":null,"price":0.0,"currency_code":"KRW","in_stock":true}],"url":"https:\/\/diagnosticdetectives.kr\/products\/why-early-treatment-after-a-tia-or-minor-stroke-prevents-more-strokes","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}