1. Andrew W. Asimos, MD, FACEP Transient Ischemic Attack Patient Update: The Optimal Management of Emergency Department Patients With Suspected Cerebral Ischemia

2. Andrew W. Asimos, MD, FACEP Acute Neuroimaging and Risk Stratification for Suspected TIA Patients in the Emergency Department

3. Andrew W. Asimos, MD, FACEP Andrew Asimos, MD Director of Emergency Stroke Care Department of Emergency Medicine Carolinas Medical Center, Charlotte, NC Adjunct Associate Professor, Department of Emergency Medicine University of North Carolina School of Medicine at Chapel Hill

4. Andrew W. Asimos, MD, FACEP Attending Physician Emergency Medicine Carolinas Medical Center Department of Emergency Medicine Charlotte, NC

5. Andrew W. Asimos, MD, FACEP

6. CME Disclosure Statement Emergency Medicine Advisory Board –Boehringer Ingelheim Pharmaceuticals Research support from the Foundation for Education and Research in Neurologic Emergencies (FERNE) and Emergency Medicine Foundation (EMF) Research support from Boehringer Ingelheim Pharmaceuticals

7. Andrew W. Asimos, MD, FACEP Session Objectives What is the short term ischemic stroke risk for ED patients with suspected cerebral ischemia who are diagnosed with a TIA? What TIA features or syndromes impart greater stroke risk, and can these patients be identified clinically or with TIA risk stratification tools? What is the role of MRI in TIA patient risk stratification? Can and should ED TIA patients be safely dispositioned home with outpatient follow-up and still have an optimal outcome, given the short-term ischemic stroke risk?

8. Andrew W. Asimos, MD, FACEP TIA Conceptual Change TIA is a process, not an event Can we reliably predict who is at risk of suffering a completed stroke within the first hours, days, or weeks of a presumed TIA? Can we acutely intervene in the TIA process and prevent a completed stroke from occurring?

9. Andrew W. Asimos, MD, FACEP Early Risk First Emphasized in 1973

10. Andrew W. Asimos, MD, FACEP Early Risk First Emphasized in 1973

11. Andrew W. Asimos, MD, FACEP 27 Years Later

12. Andrew W. Asimos, MD, FACEP

13. 90-Day Prognosis after ED Diagnosis of TIA 10.5% will suffer a stroke –21% will be fatal –64% will be disabling –Half of these will occur within 1 - 2 days of ED visit 2.6% will die 2.6% will suffer adverse cardiovascular events 12.7% will have additional TIAs Johnston SC et al. JAMA 2000;284:2901-2906.

14. Andrew W. Asimos, MD, FACEP Stroke Risk after TIA Giles MF et al. Lancet Neurology 2007;6:1063–1072. 18 independent cohorts 10,126 patients Pooled stroke risk 3.1% (95%CI 2.0-4.1) at 2 days 5.2% (95% CI 3.9-6.5) at 7 days

15. Andrew W. Asimos, MD, FACEP Which TIA Patients are at Highest Risk? A risk stratification score could help allocate expensive evaluation and treatment to the highest risk patients High risk patients might benefit more from hospital admission –If expedited ED evaluation not an option Outpatient evaluation for low risk patients

16. Andrew W. Asimos, MD, FACEP

17. ABCD 2 Score VariableScore Age ≥ 60 years1 First BP ≥ 140/90 mmHg1 Clinical: Unilateral Weakness2 Speech Impairment without weakness1 Duration: 10-59 mins1 ≥ 60 mins2 Diabetes Mellitus1 Johnston SC et al. Lancet 2007;369:283-92.

18. Andrew W. Asimos, MD, FACEP ABCD 2 Score and Short-term Stroke Risk Johnston SC et al. Lancet 2007;369:283-92. Stroke Risk (%) ABCD 2 score 2-Day Risk Low Risk: Score 0-3 → 1% Moderate Risk: Score 4-5→ 4% High Risk: Score 6-7 → 8%

19. Andrew W. Asimos, MD, FACEP North Carolina Collaborative TIA Risk Validation Study

20. Andrew W. Asimos, MD, FACEP

21. Benign Recurrent TIAs Johnston SC et al. Neurology 2003;60:280-285.

22. Andrew W. Asimos, MD, FACEP MRI versus CT DWI imaging on MRI can detect ischemic lesions within minutes of the event

23. Andrew W. Asimos, MD, FACEP 2006 NSA TIA Evaluation Consensus Guidelines

24. Andrew W. Asimos, MD, FACEP 2008 European TIA Evaluation Consensus Guidelines

25. Andrew W. Asimos, MD, FACEP Frequency of Positive Diffusion MRI: 5 Reported Series of TIAs Ovbiagele B et al. Stroke 2003;34(4):919-24.

26. Andrew W. Asimos, MD, FACEP Do hyperacute DWI abnormalities in TIA patients signify irreversible ischemic infarction? 21 consecutive TIA patients with DWI with 6 hours –Half DWI positive Follow-up MRI at 2-9 days –All initially positive DWI patients with abnormalities on T2/FLAIR images Inatomi Y et al. Cerebrovasc Dis 2005;19:362-368.

27. Andrew W. Asimos, MD, FACEP DWI Negative TIA Patients at Risk of Recurrent Transient Events 85 TIA patients with DWI MRI within 24 hours DWI negative patients –4.6 times (27% versus 6%) more likely to have subsequent TIA (i.e. not a stroke) –4.3 times (2% versus 9%) less likely to have a stroke within one year Boulanger J et al. Stroke 2007;38:2367-69.

28. Andrew W. Asimos, MD, FACEP MRI as a Tool for Risk Stratifcation 90-day new stroke rate –4.3% No DWI lesion –11%DWI lesion and no vessel occlusion –33%DWI lesion and vessel occlusion 60% of DWI+ patients “high-risk” compared with 9% of DWI- patients –OR 15.8 (95% CI 3.7-67.5) Coutts SB et al. Ann Neurol 2005;57:848-854. Cucchiara BL et al. Stroke 2006;37:1710-1714.

29. Andrew W. Asimos, MD, FACEP Association Between Positive DWI Imaging and Clinical Predictors of Early Stroke Redgrave J et al. Stroke 2007;38:1482-1488. Variable# studiesOR (95% CI) Duration ≥ 60 mins131.5 (1.16-1.96) Dysphasia92.3 (1.57-3.22) Dysarthria81.7 (1.11-2.68) Motor Weakness92.2 (1.56-3.10) Atrial Fibrillation92.8 (1.78-4.25) Ipsilateral ≥ 50 carotid stenosis 101.9 (1.34-2.76)

30. Andrew W. Asimos, MD, FACEP Stroke Risk After TIA Giles MF et al. Lancet Neurology 2007;6:1063–1072. Urgent Evaluation Associated with Lower Risk

31. Andrew W. Asimos, MD, FACEP Questions? www.ferne.org aasimos@carolinas.org www.ferne.org ferne_clindec_2008_tia_asimos_image_risk_brief_062508_final