ABCD(2) risk score does not predict the presence of cerebral microemboli in patients with hyper-acute symptomatic critical carotid artery stenosis

INTRODUCTION: ABCD(2) risk score and cerebral microemboli detected by transcranial Doppler (TCD) have been separately shown to the predict risk of recurrent acute stroke. We studied whether ABCD(2) risk score predicts cerebral microemboli in patients with hyper-acute symptomatic carotid artery stenosis. PARTICIPANTS AND METHODS: We studied 206 patients presenting within 2 weeks of transient ischaemic attack or minor stroke and found to have critical carotid artery stenosis (≥50%). 86 patients (age 70±1 (SEM: years), 58 men, 83 Caucasian) had evidence of microemboli; 72 (84%) of these underwent carotid endarterectomy (CEA). 120 patients (age 72±1 years, 91 men, 113 Caucasian) did not have microemboli detected; 102 (85%) of these underwent CEA. Data were analysed using X (2) and Mann–Whitney U tests and receiver operating characteristic (ROC) curves. RESULTS: 140/206 (68%: 95% CI 61.63 to 74.37) patients with hyper-acute symptomatic critical carotid stenosis had an ABCD(2) risk score ≥4. There was no significant difference in the NICE red flag criterion for early assessment (ABCD(2) risk score ≥4) for patients with cerebral microemboli versus those without microemboli (59/86 vs 81/120 patients: OR 1.05 ABCD(2) risk score ≥4 (95% CI 0.58 to 1.90, p=0.867)). The ABCD(2) risk score was <4 in 27 of 86 (31%: 95% CI 21 to 41) embolising patients and in 39 of 120 (31%: 95% CI 23 to 39) without cerebral microemboli. After adjusting for pre-neurological event antiplatelet treatment (APT), area under the curve (AUC) of ROC for ABCD(2) risk score showed no prediction of cerebral microemboli (no pre-event APT, n=57: AUC 0.45 (95% CI 0.29 to 0.60, p=0.531); pre-event APT, n=147: AUC 0.51 (95% CI 0.42 to 0.60, p=0.804)). CONCLUSIONS: The ABCD(2) score did not predict the presence of cerebral microemboli or carotid disease in over one-quarter of patients with symptomatic critical carotid artery stenosis. On the basis of NICE guidelines (refer early if ABCD(2) ≥4), assessment of high stroke risk based on ABCD(2) scoring may lead to inappropriate delay in urgent treatment in many patients.