Clinically low-risk features do not exclude diffusion-weighted imaging-positive lesions in suspected transient ischemic attack

Q: What are the key findings of this study?

Cardiovascular risk factors strongly predicted DWI-positive lesions in suspected TIA (aOR 3.959, p<0.001), while ≥2 low-risk features still had a 9.8% lesion rate.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Suspected transient ischemic attack (TIA) (n=418). Intervention: Cardiovascular risk factors (composite of arterial hypertension, diabetes mellitus, dyslipidemia, smoking, obesity, or coronary artery disease) and clinical/low-risk features vs. Absence of cardiovascular risk factors or respective clinical features. Primary outcome: Acute DWI-positive ischemic lesion on MRI (defined as hyperintensity on DWI with corresponding apparent diffusion coefficient reduction) (OR 3.959, 95% CI 2.110-7.429, p=<0.001).

Q: What does this research mean for the field?

Clinically low-risk features do not reliably exclude diffusion-weighted imaging (DWI)-positive ischemic lesions in patients presenting with suspected transient ischemic attack. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To investigate clinical features associated with diffusion-weighted imaging (DWI)-positive lesions in suspected transient ischemic attack and evaluate whether clinically low-risk presentations can reliably exclude acute lesions.

Leonhard Mann; Kayvan Ern; Simon Stahn; Marcel Hildner; Elke Hattingen; Fee Christiane Keil

doi:10.3389/fneur.2026.1964862

October 14, 2026Frontiers in NeurologyOpen Access

Clinically low-risk features do not exclude diffusion-weighted imaging-positive lesions in suspected transient ischemic attack

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Key result

Cardiovascular risk factors are linked to ~4-fold higher odds of DWI-positive lesions in suspected TIA.

OR 3.959
95% CI 2.110-7.429
P<0.001
n=418

Why the study?

While features associated with diffusion-weighted imaging positivity in suspected TIA are well established, it remained uncertain whether clinically low-risk presentations identify patients with a sufficiently low probability of DWI-positive lesions when MRI capacity is limited.

Do clinically low-risk constellations reliably exclude acute DWI-positive ischemic lesions on MRI, and which clinical and cardiovascular features are associated with DWI positivity in patients presenting with suspected TIA?

Key Points

To investigate clinical features associated with diffusion-weighted imaging (DWI)-positive lesions in suspected transient ischemic attack and evaluate whether clinically low-risk presentations can reliably exclude acute lesions.
Retrospectively analyzed 418 patients presenting with suspected transient ischemic attack who received a standardized MRI protocol within 6 h of admission.
Identified acute DWI-positive lesions based on DWI hyperintensity with corresponding apparent diffusion coefficient reduction.
Conducted univariate analyses and exploratory multivariable logistic regression to assess clinical-neurological and cardiovascular predictors of lesion presence.
Acute DWI-positive lesions occurred in 118/418 patients (28.2%), with motor symptoms (aOR 2.683, p < 0.001), NIHSS 1–5 (aOR 1.940, p = 0.007), acute symptom onset (aOR 1.999, p = 0.025), and cardiovascular risk factors (aOR 3.959, p < 0.001) showing positive associations.
DWI-positive lesions remained present in 13/133 patients (9.8%) presenting with ≥2 low-risk features and 2/48 patients (4.2%) presenting with ≥3 low-risk features (subacute onset, non-specific accompanying symptoms, NIHSS 0, and dizziness).

Study Design

Type

Cohort (n=418)

Blinding

Unblinded (routine clinical neuroradiology reports with access to clinical information)

Multicenter

No

Structured PICO

Do clinically low-risk constellations reliably exclude acute DWI-positive ischemic lesions on MRI, and which clinical and cardiovascular features are associated with DWI positivity in patients presenting with suspected TIA?

P

Population

418 adults presenting with suspected TIA (53.3% >65 years, 69.1% with cardiovascular risk factors) who underwent a standardized cranial MRI protocol within 6 hours of admission at a single center in Germany.

E

Exposure

Clinical, neurological, and cardiovascular risk profiles (including motor symptoms, NIHSS 1–5, acute symptom onset, composite cardiovascular risk factors [hypertension, diabetes, dyslipidemia, smoking, obesity, CAD], cardiac comorbidity [atrial fibrillation, PFO], and low-risk constellations [subacute onset, accompanying non-specific symptoms, NIHSS 0, dizziness]) assessed via standardized cranial MRI within 6 hours of admission.

C

Comparator

Absence of respective high-risk or low-risk clinical and cardiovascular features.

O

Outcome

Presence of an acute diffusion-weighted imaging (DWI)-positive ischemic lesion on cranial MRI, defined as DWI hyperintensity with corresponding apparent diffusion coefficient (ADC) reduction, within 6 hours of admission.surrogate

Main Result

Odds Ratio: 3.959 (95% CI 2.11–7.429)

Absolute Event Rate: 36% vs 10.9%

p-value: p=<0.001

Clinically low-risk presentations (such as NIHSS 0, dizziness, subacute onset, or non-specific symptoms) do not reliably rule out acute DWI-positive minor stroke in suspected TIA, supporting routine MRI evaluation rather than clinical exclusion alone.

Limitations

Retrospective, single-center observational design susceptible to documentation and selection bias and lacking a screening log.
Symptoms were assessed dichotomously without weighting by severity or duration, and complete symptom resolution at presentation was not recorded separately.
Heterogeneous symptom-onset-to-MRI intervals (and missing exact timing data in 139 patients).
Cardiovascular risk factors and cardiac comorbidities were analyzed as composite variables rather than individual components.
DWI status was based on routine clinical neuroradiology reports across both 1.5 T and 3 T scanners rather than blinded independent adjudication, and low-risk criteria were evaluated post hoc without external validation.
Retrospective, single-center observational study susceptible to documentation and selection bias, with no screening log of excluded patients.
Dichotomous assessment of symptoms without weighting for severity or duration, and lack of separate coding for complete symptom resolution at presentation.
Heterogeneous symptom-to-MRI time intervals and missing exact onset-to-MRI timing in 139/418 patients.
Cardiovascular risk factors and cardiac comorbidities were analyzed only as composite variables.
Post hoc selection and evaluation of low-risk features in the same cohort without internal or external validation, and reliance on routine clinical MRI reports across 1.5 T and 3 T scanners without blinded adjudication.

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Low-risk TIA features may not exclude DWI lesions; leaves open prospective validation of MRI strategies.

Abstract

Introduction Diffusion-weighted imaging (DWI) is essential for distinguishing tissue-negative transient ischemic attack (TIA) from MRI-defined minor stroke. When MRI capacity is limited, clinical features could help estimate DWI lesion yield. While features associated with DWI positivity are well established, it remains uncertain whether clinically low-risk presentations identify patients with a sufficiently low probability of DWI-positive lesions. We investigated clinical features associated with DWI-positive lesions in patients presenting with suspected TIA and assessed whether clinically low-risk constellations reliably excluded DWI-positive lesions. Methods We retrospectively analyzed 418 patients presenting with suspected TIA who underwent a standardized MRI protocol within 6 h of admission. The study endpoint was an acute DWI-positive lesion, defined by DWI hyperintensity with corresponding apparent diffusion coefficient reduction. Univariate analyses and exploratory multivariable logistic regression analyses were used to examine clinical, neurological, and cardiovascular features associated with DWI positivity, with particular emphasis on clinically low-risk presentations. Results DWI-positive lesions were detected in 118/418 patients (28.2%). Motor symptoms (adjusted odds ratio [aOR] 2.683, p < 0.001), NIHSS 1–5 (aOR 1.940, p = 0.007), and acute symptom onset (aOR 1.999, p = 0.025) were associated with DWI positivity in the clinical-neurological analysis, while cardiovascular risk factors showed the strongest association in the extended analysis (aOR 3.959, p < 0.001). Conversely, subacute onset, non-specific accompanying symptoms, NIHSS 0, and dizziness were associated with lower odds of DWI positivity. Importantly, DWI-positive lesions remained present in 13/133 patients (9.8%) with ≥2 and 2/48 (4.2%) with ≥3 low-risk features. Discussion Clinically low-risk presentations did not reliably exclude DWI-positive lesions, supporting MRI-based evaluation. Clinical and cardiovascular features may help estimate the likelihood of DWI positivity; whether they can inform MRI prioritization requires prospective validation.

Discussion

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Cite This Study

Mann et al. (2026) conducted a cohort in Suspected transient ischemic attack (TIA) (n=418). Cardiovascular risk factors (composite of arterial hypertension, diabetes mellitus, dyslipidemia, smoking, obesity, or coronary artery disease) and clinical/low-risk features vs. Absence of cardiovascular risk factors or respective clinical features was evaluated on Acute DWI-positive ischemic lesion on MRI (defined as hyperintensity on DWI with corresponding apparent diffusion coefficient reduction) (OR 3.959, 95% CI 2.110-7.429, p=<0.001). Cardiovascular risk factors strongly predicted DWI-positive lesions in suspected TIA (aOR 3.959, p<0.001), while ≥2 low-risk features still had a 9.8% lesion rate.

synapsesocial.com/papers/6aee6b6871a7594806220962 https://doi.org/10.3389/fneur.2026.1964862

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Clinically low-risk features do not exclude diffusion-weighted imaging-positive lesions in suspected transient ischemic attack

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Clinically low-risk features do not exclude diffusion-weighted imaging-positive lesions in suspected transient ischemic attack

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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