Field-testing the explicit diagnostic criteria for transient ischemic attack: a diagnostic accuracy study

Explicit diagnostic criteria for transient ischemic attack (TIA) (EDCT) have been recently proposed based on the assumption, that a migraine aura-like symptom is not typical for a TIA. However, migraine-like symptoms have been unexpectedly frequent in patients with confirmed ischemic stroke. This cross-sectional study aimed to field-test the EDCT to distinguish transient neurological symptoms caused by cerebral infarction from those caused by migraine aura.

The sensitivity, specificity, positive and negative predictive values of the EDCT score were calculated in samples of patients with (i) transient symptoms caused by cerebral infarction confirmed by imaging and (ii) patients with migraine with aura diagnosed according to the International Classification of Headache Disorders 3rd edition. Sensitivity, specificity, positive and negative predictive values of the original and modified EDCT were calculated, as well as area under the curve adjusted for age and sex using the logistic regression method.

The study population included 59 patients with cerebral infarction and 324 patients with migraine with aura. The median age of the stroke group was 72 (IQR 61–81) and of the migraine group 39 (IQR 29–53). There were 36 (61%) men in the stroke group and 221 (68%) women in the migraine group. For the detection of TIA with imaging-proven cerebral infarction, the original EDCT had a sensitivity of 90% (95%CI 79–96), a specificity 77% (95%CI 72–82), a positive predictive value of 42% (95%CI 33–51), and the negative predictive value 98% (95% CI 95–99). For the modified EDCT, the sensitivity was 81% (95%CI 69–90), the specificity 97% (95%CI 94–98), the positive predictive value 81% (95%CI 69–90), and the negative predictive value 97% (95%CI 94–98).

The original and modified EDCT criteria miss up to 1 of 10 and 1 of 5 patients, respectively, with transient symptoms due to cerebral infarction. However, the modified EDCT criteria are more specific but less sensitive in detection of ischemic events. The optimal combination of clinical markers to reliably distinguish TIA from migraine aura remains to be found.