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Editors’ Note: Commenting on “ABCD2 score and secondary stroke prevention: Meta-analysis and effect per 1,000 patients triaged,” Lima Filho et al. suggest that TIA clinics may be the best option for managing patients with TIA. Authors Wardlaw et al. agree and recommend admission to a stroke service when rapid access to outpatient stroke expertise is not available. Sethi et al. recently published a Teaching NeuroImage on a patient with migraine associated with red forehead dot syndrome and eyelid ecchymosis. The Teaching NeuroImage helped Monaghan and Smyth recognize the same syndrome in a patient. The latter provided photographic evidence (figure, A and B) since the ecchymosis resolved by the time the patient visited the doctor. —Chafic Karam, MD, and Robert C. Griggs, MD


Jonas B. Lima Filho, Igor de Lima Teixeira, Gustavo Jose Luvizutto, Gabriel Pereira Braga, Rodrigo Bazan, Botucatu, Brazil: We read with interest the systematic review and meta-analysis by Wardlaw et al.1 concerning the ability of the age, blood pressure, clinical features, duration of TIA, and presence of diabetes (ABCD2) score to predict the risk of stroke in TIA patients and to stratify by known risk factors. Patients with TIA are at high risk of developing a stroke. Studies show that 4%–20% will have a stroke within 90 days after TIA, half within the first 2 days.2 Prognostic scores for early risk of stroke are important, but should not be valued more than the individualized assessment of each patient. There is no perfect scale, as this meta-analysis concluded, with the ABCD2 failing to identify patients with carotid stenosis or atrial fibrillation (conditions related to high risk of stroke). TIA clinics appear to be the safest and most costeffective option.3,4 Treatment at these clinics helps patients avoid full hospitalization in most cases as stroke specialists perform TIA workup (e.g., brain, arterial, and cardiac imaging) in an outpatient environment. A feasible solution might be to adjust stroke

units to receive TIA patients for 24-hour hospitalization and risk stratification in a real-world setting. Author Response: Joanna M. Wardlaw, Edinburgh; Miriam Brazzelli, Aberdeen; Francesca Chappell, Martin S. Dennis, Peter A.G. Sandercock, Edinburgh, UK: We thank Lima Filho et al. for their comments on our article concerning the ABCD2 score to triage patients for secondary stroke prevention.1 We agree that rapid clinical assessment by stroke specialists followed by rapid investigation to differentiate ischemic from hemorrhagic events and mimics is necessary. In addition, the identification of specific treatable risk factors and rapid implementation of appropriate secondary prevention based on the findings is essential to prevent most strokes. Where rapid access to stroke expertise is not available for outpatients, admission to a specialist stroke service for rapid assessment and secondary prevention is an alternative. Stroke services should consider the option that best suits their available facilities and expertise so as to ensure rapid access for all patients. © 2016 American Academy of Neurology 1.




Wardlaw JM, Brazzelli M, Chappell FM, et al. ABCD2 score and secondary stroke prevention: meta-analysis and effect per 1,000 patients triaged. Neurology 2015;85:373– 380. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369:283–292. Martinez-Martinez MM, Martinez-Sanchez P, Fuentes B, et al. Transient ischaemic attacks clinics provide equivalent and more efficient care than early in-hospital assessment. Eur J Neurol 2013;20:338–343. Lavallee P, Amarenco P. TIA clinic: a major advance in management of transient ischemic attacks. Front Neurol Neurosci 2014;33:30–40.


Bernadette M. Monaghan, Shane Smyth, Dublin: We were perplexed by a recent patient with migraine who reported spontaneous bruising around her left eye until we read the report by Sethi et al.1 Our patient, a 44-year-old woman with a 20-year history Neurology 86

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ª 2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.


of migraine, had developed periocular bruising 2 days after onset of headache. It had resolved by the time of evaluation, but the patient provided photographic evidence (figure, A and B). Having read the report by Sethi et al., we found similar—albeit rare—reports of such phenomena. DeBroff and Spierings2 described 2 cases of migraine associated with periorbital ecchymosis and Dafer and Jay3 described chronic headache with recurrent facial ecchymosis primarily affecting the periorbital and epicanthal regions. Attanasio et al.4 also described periorbital ecchymosis in the setting of a trigeminal autonomic cephalgia. We thank Sethi et al. for again bringing this phenomenon to light. We would also assume that it reflects the complex neurovascular changes of migraine, specifically vasodilation of intracranial and extracerebral blood vessels through release of vasoactive substances.5

well-recognized. We reported the red forehead dot syndrome in 2007 and again in our recent article.1,8 We thank Drs. Monaghan and Smyth for their letter, and for reporting another case of this fascinating clinical phenomenon and its temporal association with migraine and trigeminal autonomic cephalgia. © 2016 American Academy of Neurology 1.

2. 3.



Author Response: Nitin K. Sethi, New York; Prahlad K. Sethi, New Delhi; Josh Torgovnick, New York: In 1994, Dr. James W. Lance6 reported the red ear syndrome. Following a plea to colleagues to “lend me your ear,” Dr. Lance7 subsequently reported on additional, similar cases in neurology. Now, the association of red ear syndrome with migraine is

6. 7. 8.

Sethi PK, Sethi NK, Torgovnick J. Teaching NeuroImages: red forehead dot syndrome and migraine revisited. Neurology 2015;85;e28. DeBroff B, Spierings EL. Migraine associated with periorbital ecchymosis. Headache 1990;30:260–263. Dafer R, Jay WM. Atypical chronic headache and recurrent facial ecchymosis: a case report. Neuro Ophthalmol 2011; 35:76–77. Attanasio A, D’Amico D, Frediani F, et al. Trigeminal autonomic cephalgia with periorbital ecchymosis, ocular hemorrhage, hypertension and behavioral alterations. Pain 2000; 88:109–112. Aggarwal M, Puri V, Puri S. Serotonin and CGRP in migraine. Ann Neurosci 2012;19:88–94. Lance JW. The mystery of one red ear. Clin Exp Neurol 1994;31:13–18. Lance JW. The red ear syndrome. Neurology 1996;47:617– 620. Sethi PK, Sethi NK, Torgovnick J. Red forehead dot syndrome and migraine. J Headache Pain 2007;8: 135–136.

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Teaching NeuroImages: Red forehead dot syndrome and migraine revisited Bernadette M. Monaghan, Nitin K. Sethi, Shane Smyth, et al. Neurology 2016;86;697-698 DOI 10.1212/01.wnl.0000481056.72967.7a This information is current as of February 15, 2016 Updated Information & Services

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Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2016 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.

Teaching NeuroImages: Red forehead dot syndrome and migraine revisited.

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