Prognostic value of the ABCD2 clinical prediction rule: a systematic review and meta-analysis

Objective. The purpose of this systematic review with meta-analysis is to determine the predictive value of the ABCD2 at 7 and 90 days across three strata of risk.Background. The risk of stroke after transient ischaemic attack (TIA) is significant. The ABCD2 clinical prediction rule is designed to predict early risk of stroke after TIA. A number of independent validation studies have been conducted since the rule was derived.Methods. A systematic literature search was conducted to identify studies that validated the ABCD2. The derived rule was used as a predictive model and applied to subsequent validation studies. Comparisons were made between observed and predicted number of strokes stratified by risk group: low (0–3 points), moderate (4–5 points) and high (6–7 points). Pooled results are presented as risk ratios (RRs) with 95% confidence intervals (CIs), in terms of over-prediction (RR > 1) or under-prediction (RR < 1) of stroke at 7 and 90 days.Results. We include 16 validation studies. Fourteen studies report 7-day stroke risk (n = 6282, 388 strokes). The ABCD2 rule correctly predicts occurrence of stroke at 7 days across all three risk strata: low [RR 0.86, 95% CI (0.47–1.58), I2 = 16%], moderate [RR 0.99, 95% CI (0.67–1.47), I2 = 68%] and high [RR 0.84, 95% CI (0.6–1.19), I2 = 46%]. Eleven studies report 90-day stroke risk (n = 6304). There is a non-significant trend towards over-prediction of stroke in all risk categories at 90 days. There are 426 strokes observed in contrast to a predicted 626 strokes. As the trichotomized ABCD2 score increases, the risk of stroke increases (P < 0.01). There is no evidence of publication bias in these studies (P > 0.05).Conclusion. The ABCD2 is a useful CPR, particularly in relation to 7-day risk of stroke

Emergency Management of Ischemic Stroke in Children

OPINION STATEMENT Children who present with acute neurological symptoms suggestive of a stroke need immediate clinical assessment and urgent neuroimaging to confirm diagnosis. Magnetic resonance imaging (MRI) is the investigation of first choice due to limited sensitivity of computed tomography (CT) for detection of ischaemia. Acute monitoring should include monitoring of blood pressure and body temperature, and neurological observations. Surveillance in a paediatric high dependency or intensive care unit and neurosurgical consultation are mandatory in children with large infarcts at risk of developing malignant oedema or haemorrhagic transformation. Thrombolysis and/or endovascular treatment, whilst not currently approved for use in children, may be considered when stroke diagnosis is confirmed within 4.5 to 6 h, provided there are no contraindications on standard adult criteria. Standard treatment consists of aspirin, but anticoagulation therapy is frequently prescribed in stroke due to cardiac disease and extracranial dissection. Steroids and immunosuppression have a definite place in children with proven vasculitis, but their role in focal arteriopathies is less clear. Decompressive craniotomy should be considered in children with deteriorating consciousness or signs of raised intracranial pressure