Clinically low-risk presentations did not reliably exclude DWI-positive lesions in suspected TIA, supporting MRI-based evaluation, while clinical and cardiovascular features may help estimate DWI positivity likelihood but require prospective validation for MRI prioritization.
Acute DWI-positive lesions were found in 28.2% of patients presenting with suspected TIA who received early standardized MRI.
Motor symptoms, NIHSS 1-5, and acute symptom onset were independently associated with higher odds of DWI positivity in the clinical-neurological analysis.
Cardiovascular risk factors showed the strongest association with DWI positivity in the extended analysis.
Subacute onset, non-specific accompanying symptoms, NIHSS 0, and dizziness were associated with lower odds of DWI positivity.
DWI-positive lesions remained present in a non-negligible proportion of patients with multiple low-risk clinical features.
Clinically low-risk presentations did not reliably exclude DWI-positive lesions, supporting MRI-based evaluation.
This study looked back at 418 patients who came to hospital with symptoms suggesting a transient ischemic attack (TIA, or 'mini-stroke') and had a specialized brain MRI within 6 hours. About 28% had a fresh lesion on the diffusion-weighted scan, meaning that what looked like a TIA was actually a small stroke with visible tissue damage. Patients with weakness or motor symptoms, mild but present stroke-scale deficits, sudden onset, or cardiovascular risk factors were more likely to have such lesions. Patients with dizziness, vague accompanying symptoms, gradual onset, or no measurable deficits were less likely. However, even among patients with two or more of these lower-risk features, nearly 10% had a lesion, and about 4% did with three or more. This research suggests that a reassuring clinical picture does not rule out a small stroke on MRI. Clinical features may help estimate the likelihood of a lesion, but whether they can be used to decide who gets MRI first when scanners are limited needs to be tested in future prospective studies. As a retrospective single-group analysis, its findings are exploratory.
Mann L, Ern K, Stahn S, Hildner M, Hattingen E, Keil F. (2026). Clinically low-risk features do not exclude diffusion-weighted imaging-positive lesions in suspected transient ischemic attack.. Frontiers in neurology. https://doi.org/10.3389/fneur.2026.1964862