1. The Management of ED TIA Patients:
WBH Emergency Medicine Residency Grand Rounds May 31, 2007
Michael A. Ross MD FACEP
Associate Professor Emergency Medicine
Department of Emergency Medicine
William Beaumont Hospital
Wayne State University School of Medicine

2. Case presentation
A 58 year old female presents to the emergency department after developing dysarthria, diploplia, numbness, and pronounced weakness of the right face and hand that lasted roughly 12 minutes. The patient feels completely normal and only came in at her families insistence.
Review of systems - mild headache with event. No palpitations, chest pain, or SOB.
Past medical history - Positive for hypertension and hyperlipidemia. No prior stroke or TIA.
Family history positive for premature coronary disease.
Meds - Beta-blocker for HTN. Not on aspirin.
Social - She does not smoke.

3. Case presentation Phyisical Exam:
On examination the patient was normotensive, and comfortable.
HEENT exam showed no facial or oral asymmetry or numbness. No scalp tenderness.
CHEST exam showed no murmurs and a regular rhythm,
ABDOMINAL and EXTREMITY exam was normal,
NEUROLOGICAL exam showed normal mentation, CN II-XII normal as tested, motor / sensory exam normal, symmetrical normal reflexes, and normal cerebellar exam.

4. Case presentation ED course:
ECG showed a normal sinus rhythm with mild LVH.
Non-contrast head CT scan was normal.
Blood-work (CBC with differential, electrolytes, BUN/Cr, and glucose) was normal. ESR was normal.
Monitor showed no dysrhythmias
Normal subsequent neurological symptoms.
The patient feels fine and is wondering if she can go home.
What do you think?

5. Background 300,000 TIAs occur annually - Johnstons’ data
Within 90 days:
10.5% will suffer a stroke
21% will be fatal
64% will be disabling
Half of these will occur within days of ED visit
2.6% will die
2.6% will suffer adverse cardiovascular events
12.7% will have additional TIAs

6. Stroke Risk After TIA Year N Stroke Risk
Johnston, et al (Kaiser ED) % /90d
Eliasew, et al (NASCET) % /90d
Lovett, et al (Oxfordshire) % /30d
Gladstone, et al (Toronto) % /30d
Daffertshofer, et al (Grmy) % /180d
Hill, et al (Alberta) % /90d
Lisabeth, et al (Texas) % /90d
Kleindorfer, et al (Cinc) % /90d
Whitehead, et al (Scotland) % /30d
Correia, et al (Portugal) % /7d
Tsivgoulis, et al (Greece) % /30d
AVERAGE ~12% stroke risk in 90 days after TIA
5% in first 2 days

7. Stroke Risk After Stroke
IST 3.3 %/ 3m
CAST 1.6%/ 3m
TOAST 5.7%/ 3m
NASCET 2.3%/3m
AVERAGE ~4% stroke risk in 90 days after stroke

8. Pathophysiology Short-term risk of stroke: Possible explanation
After TIA (11%) > after stroke (4%)
Possible explanation
Tissue still at risk: unstable situation
More thrombo-embolic events
Johnston, NEJM 2002; 347:1687

9. Candidate Blood Markers???
Unstable plaque with intense staining for PAPP-A within spindle shaped smooth muscle cells and in extracellular matrix of eroded plaque
Stable plaque with absence of PAPP-A staining
Unstable plaque ; Lp-PLA2
Candidate Blood Markers???
Unstable Plaque:
Lp-PLA2, PAPP-A, MMP-9, CRP, S-TF
Coagulation Activation:
D-dimer, F 1.2, TAT
Cardioembolism:
BNP (CHF), D-dimer

10. TIA: Differential Diagnosis “Mimics”
Cervical disc disease
Carpal tunnel syndrome
Metabolic derangement (ex, hypoglycemia)
Inner ear disease/BPV
Transient global amnesia
Cranial arteritis
Epilepsy
Complicated migraine
Subdural hematoma
Mass lesions, AVMs
Arterial dissection
Oxfordshire Community Stroke Project found that 62% of patients referred by GP with a diagnosis of TIA were found to have some other explanation for symptoms
(Dennis M, Stroke 1989)

11. Is a “TIA” a TIA?
Little agreement, even among neurologists (kappa )
Generally, neurologists are not the ones making the diagnosis
May even be less reproducibility
Risk factors for stroke may identify true TIAs
Johnston et al, Neurology 2003; 60:280

12. Utility of the H/P? TIA risk stratification Johnston criteria
Rothwell criteria - “ABCD”
Combination of the above = “ABCD2”

13. Risk factors were additive
TIA risk stratification - California Model Johnston et al. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284:
Independent risk factors for stroke:
Age > 60yr (OR = 1.8)
Diabetes (OR = 2.0)
TIA > 10 min. (OR = 2.3)
Weakness with TIA (OR = 1.9)
Speech impairment (OR = 1.5)
Risk factors were additive

14. Our patient’s Johnston score?
Independent risk factors for stroke:
Age > 60yr
Diabetes
TIA > 10 min
Weakness with TIA
Speech impairment 1
stroke risk score of 3:
~5% at one week
~8% at 3 months

15. TIA risk stratification - British model. Rothwell,et al
TIA risk stratification - British model? Rothwell,et al. Lancet 2005; 366: 29–36
A = Age >60 years = 1pt
B = BP: SBP >140 or DBP >90 = 1pt
C = Clinical:
Unilateral weakness = 2pt
Speech disturbance = 1pt
D = Duration
>60 min = 2pt
10 – 59 min = 1pt
<10 min = 0pt

17. Our patients ABCD score?
A = Age >60 years = 0
B = BP: SBP >140 or DBP >90 = 0
C = Clinical:
Unilateral weakness = 2pt
Speech disturbance = 1pt
D = Duration
>60 min = 0
10 – 59 min = 1pt
<10 min = 0
TOTAL SCORE = 4 (5% risk of stroke at one week)

18. ABCD2 Score

19. ABCD2 Score Score points for each of the following: Final Score 0-7
Age >60 (1)
Blood pressure >140/90 on initial evaluation (1)
Clinical:
Focal weakness (2)
Speech impairment without weakness (1)
Duration
>60 min (2)
10-59 min (1)
Diabetes (1)
Final Score 0-7

20. ABCD2 Score Validation: Meta-analysis

21. ABCD2 Score and Stroke Risks

22. Prognosis Conclusions
The ABCD2 Score stratifies short-term risk of stroke after TIA
2-day risks
Low Risk (34%): Score 0-3  1%
Moderate Risk (45%): Score 4-5  4%
Very High Risk (21%): Score 6-7  8%
“This rule is ready for clinical use”
C. Johnston

23. What is our patients’ ABCD2 score?
Age > = 0
Blood pressure >140/90 (initial) (1) = 0
Clinical:
Focal weakness (2) = 2
Speech impairment without weakness (1) = 0
Duration
>60 min (2) = 0
10-59 min (1) = 1
Diabetes (1) = 0
Total = 3
Stroke at 2 days = 1%
Stroke at 7 days = 2% (?!)

24. Limitations of Prediction Rules
Discriminatory value sub-optimal
What about the patient with 90% carotid stenosis and a low score???
Generalizability seems poor (though exact reasons for this unclear)
Are these rules really just selecting patients with “real” TIAs?

25. 2. HCT, ECG HCT - tumor, SDH, NPH, etc
Minor stroke and TIA associated with a 10% incidence of stroke on MRI.

26. Infarction in TIA
Approximately 50% of those with TIA have DWI changes on MRI
Kidwell et al Stroke 1999

27. TIA Stroke Reversible ischemia Infarction Minor stroke DWI+ TIA
Reversible ischemic neurologic deficit (RIND)
Stroke
Cerebral infarction with transient signs

28. 2. HCT, ECG ECG – ATRIAL FIBRILLATION!!!
Stroke risk – cardio-embolic risk
4.6% at 1 month
11.9% at 3 months
61% reduction in annual risk of stroke (both ischemic or hemorrhagic) with coumadin

29. 3. Carotid Dopplers Stroke risk depends on where the disease is:
7day 90day
CE = Cardio-Embolic: 2.5% 12%
LAA = Large arteries 4.0% 19%
Und = Undetermined 2.3% 9%
SVS = Small Vessels 0% 3%

30. Outpatient carotid dopplers?
Office management of TIA??? Goldstein et al. New transient ischemic attack and stroke: outpatient management by primary care physicians. Arch Intern Med. 2000;160:
Design:
Retrospective study of 95 TIA and 81 stroke patients seen in office
Diagnostic testing within 30 days:
23% had head CT done
40% had carotid dopplers done
18% had ECG done
19% had echo done
31% had no other evaluation

31. 5. Medical management Antiplatelet Therapy
Useful in non-cardioembolic causes
Aspirin mg/day
Clopidogrel or ticlopidine
Aspirin plus dipyridamole
Latter two if ASA intolerant or if TIA while on ASA
Routine anticoagulation not recommended

32. 5. Medical management Risk Factor Management
HTN: BP below 140/90
DM: fasting glucose < 126 mg/dl
Hyperlipidemia: LDL < 100 mg/dl
Stop smoking!
Exercise min, 3x/week
Avoid excessive alcohol use
Weight loss: < 120% of ideal weight

33. Hospital Admission for TIA
Medical management to minimize risk of recurrent ischemia
Expedite evaluation and treatment of specific mechanisms – CEA for carotid stenosis, anticoagulation for atrial fibrillation
Observation for further events, with potential expedited thrombolysis
Avoid the lawyers

34. Management of TIA: Areas of Certainty:
Need for ED visit, ECG, labs, Head CT
Areas of less certainty
The timing of the carotid dopplers
Areas of Uncertainty - Johnston SC. N Engl J Med. 2002;347:
“The benefit of hospitalization is unknown. . . Observation units within the ED may provide a more cost-effective option.”

35. An Emergency Department Diagnostic Protocol For Patients With Transient Ischemic Attack: A Randomized Controlled Trial
To determine if emergency department TIA patients managed using an accelerated diagnostic protocol (ADP) in an observation unit (EDOU) will experience:
shorter length of stays
lower costs
comparable clinical outcomes
. . . relative to traditional inpatient admission.

36. Patient population: ED evaluation:
Presented to the ED with symptoms of TIA
ED evaluation:
History and physical
ECG, monitor, HCT
Appropriate labs
Diagnosis of TIA established
Decision to admit or observe
SCREENING AND RANDOMIZATION

37. Methods: ADP Interventions
Four components:
Serial neuro exams
Unit staff, physician, and a neurology consult
Cardiac monitoring
Carotid dopplers
2-D echo
BOTH study groups had orders for the same four components

38. Methods: ADP Disposition criteria
Home
No recurrent deficits, negative workup
Appropriate antiplatelet therapy and follow-up
Inpatient admission from EDOU
Recurrent symptoms or neuro deficit
Surgical carotid stenosis (ie >50%)
Embolic source requiring treatment
Unable to safely discharge patient

39. Results: Performance of clinical testing

40. Results: Length of Stay
Median
Inpatient = 61.2 hr
ADP = 25.6 hr
Difference = 29.8 hr
(Hodges-Lehmann)
(p<0.001)
ADP sub-groups:
ADP - home = 24.2 hr
ADP - admit = hr

41. Results: 90-Day Clinical Outcomes

42. Results: 90 - day Costs Median Inpatient = $1548 ADP = $890
Difference = $540
(Hodges-Lehmann)
(p<0.001)
ADP sub-groups:
ADP - home = $844
ADP - admit = $2,737

43. Study conclusion:
Compared to inpatient admission, the ED TIA diagnostic protocol was:
More efficient
Less costly
With comparable clinical outcomes

44. Implications National feasibility of ADP: 18% of EDs have an EDOU
220 JCAHO stroke centers
National health care costs
Potential savings if 18% used ADP:
$29.1 million dollars
Medicare observation APC
Impact of shorter LOS
Patients – satisfaction, missed Dx . . .
Hospitals – bed availability

45. CLINICAL CASE - OUTCOME
The patient was started on aspirin and admitted to the ED observation unit.
While in the unit she had a 2-D echo with bubble contrast, that was normal. She had no arrhythmia detected on cardiac monitoring and no subsequent neurological deficits.
However, carotid dopplers were abnormal. She showed 30-50% stenosis of the right internal carotid artery, and a severe flow limiting >70% stenosis of the left carotid artery at the origin of the internal carotid artery.
She was admitted to the hospital for endarterectomy. Five days following ED arrival, and following inpatient pre-operative clearance, she underwent successful endarterectomy.
On one month follow-up she was asymptomatic and her carotids were doing well.

46. Who do you send home from the ED???
C. Johnston:
“TIA risk score does not identify a “zero” risk group”
But it is a good start. . .
Possibly:
Negative ED work-up (ECG, exam, CT), low TIA score, negative carotid dopplers within 6 months, safe home support for return in next 48 hours if needed?
Appropriate medications.

47. Who do you send home from the ED???
Ron Krome:
“It doesn’t matter what you do, as long as you are right”
If you are not sure, better play it safe. . .
Admit or observe

48. Conclusions TIAs are ominous
Justifies acute interventions, including hospitalization
Opportunity to prevent injury but trials are needed
Recovery rather than complete resolution is likely the important distinguishing characteristic and may identify an unstable pathophysiology
“TIAs” are heterogeneous
Management should be individualized
Prognostic scores may help
Secondary prevention is critical
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