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TIA – The questions
Jim Fleet
Introduction
• Common encountered diagnosis and
very common differential
• Often initial presentation to A&E
– Or GP usher...
Topics
• Stroke and TIA diagnosis
• Risk assessment
• Service provision and investigation
• Secondary prevention
Case - Mr O
• 37 year old man
• PMH:
– Marfan’s syndrome
– Ulcerative colitis
• Presents with:
– Episode of memory loss 2/...
Mr O
• Normal neurological examination
• Normal cardiovascular exam (BP
128/84)
• ECG – SR
• CTB ....
• What to do??
First question - Is it a stroke/TIA?
• Most important questions across
spectrum on acuity
• What are the common mimics and...
Collapse and TIA
• Consciousness disturbance indicates
pathology of reticular activating system
• Diffuse pathway – requir...
He’s vertiginous – it is a stroke
• Need to distinguish peripheral vs central
– Peripheral usually benign - no A&E
neuroim...
Head thrust test
Confusion
• Receptive dysphasia
– Can come in under the stroke radar
– Paraphasic errors and neologisms
– Attention key
• ...
Delirium
• Fluctuations in over time
• Attention is the key!
• Can be very difficult differential in a person
with an aged...
Functional
• Examination key here
– Gait
– Hoover’s sign
– Pronator drift
– Distraction & variability
– Give way weakness
...
Migraine
• Headache often occurs after onset of
neurology
• Spotted by
• Gradual spreading of symptoms over
vascular terri...
Vision deficit
• Common presentation
• Transient painless visual loss is a stroke
case
– Most people don’t check if one or...
TIA
• High risk of subsequent stroke
– Likely higher than completed stroke using
traditional definitions
• Witnessed popul...
I think he’s had a TIA – what now?
• Do I need a scan in A&E?
– CT helpful
– Silent ischaemia
– Approx 1% in people will h...
MRI in TIA
• Acute MRI most helpful in clarifying
difficult cases
– 50% of traditional thought of TIA have DWI
abnormality...
Other investigations
• Time critical (EXPRESS, 2007; SOS-TIA, 2007)
– Investigation to identify modifiable risk
factors
– ...
Investigations
• Cardiac work up
– Up to ¼ have indication for anticoagulation
(broadly)
– ECG mandatory (and easy)
– Furt...
In patient vs outpatient management?
• Risk stratification plays a (health
economic) role
• ABCD2
– use your app!
• Often ...
ABCD2
• Developed for 10
care
• External validation inconsistent
• Poorly performing in
– Hospitals (high risk group)
– Vs...
Other risk features
– Known carotid disease
– Multiple/fluctuating course
• Capsular warning syndrome
• Possible artery-ar...
Service provision
• Risk front loaded
– Traditionally 50% of 30 day stroke risk
in 1st 24 hours
• Imaging revealing increa...
Service provision – who to admit?
• Where should rapid diagnostic work up be
done?
– A&E
– Clinic
– Inpatient
– GP
• Who s...
Medical management - Antiplatelets
• Dipyridamole out
– Bd dosing + side effects
• Aspirin
– Largest evidence base (CAST +...
Antiplatelets
• Combination
– In conventional stroke
• Worse outcomes (MATCH trial, 2004; SPS3 2011
CHARISMA, 2006)
– In h...
Antiplatelets
• Future
– Combination therapy in non-asian
populations (POINT)
– Different subgroups
–Large artery atherosc...
Anticoagulation
• Heparin higher risk of death than
aspirin in acute ischaemic stroke (Berge,
2002)
• However – certain su...
Lipids
• Atorvastatin 80mg tested in stroke
group in SPARCL trial
– 1 to 6 months after stroke
– Combined ARR over 5 years...
Blood pressure
• Most important secondary prevention option
• Often transiently elevated in acute stroke
– ? TIA
• However...
Mr O
• Discharged on aspirin
• Urgent OPD MRI
Mr O
• Readmitted, symptoms settled with
aspirin
• Readmitted again 2 months later with
recurrent symptoms
– Anticoagulate...
Thanks!!
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Transient ischaemic attack (TIA) investigation and management in the emergency department

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Transient ischaemic attack (TIA) investigation and management in the emergency department

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Transient ischaemic attack (TIA) investigation and management in the emergency department

  1. 1. TIA – The questions Jim Fleet
  2. 2. Introduction • Common encountered diagnosis and very common differential • Often initial presentation to A&E – Or GP ushered • Fairly rapidly evolving evidence base • Still many unanswered questions • Variable approach to management/service provision
  3. 3. Topics • Stroke and TIA diagnosis • Risk assessment • Service provision and investigation • Secondary prevention
  4. 4. Case - Mr O • 37 year old man • PMH: – Marfan’s syndrome – Ulcerative colitis • Presents with: – Episode of memory loss 2/52 ago • Could recall simple instructions at work – Headache of gradual onset 3/7, more prominent on left, intermittent – 3-4 episodes of right arm weakness and numbness • Lasting 15 minutes – 2 episodes of buttock numbness
  5. 5. Mr O • Normal neurological examination • Normal cardiovascular exam (BP 128/84) • ECG – SR • CTB .... • What to do??
  6. 6. First question - Is it a stroke/TIA? • Most important questions across spectrum on acuity • What are the common mimics and how can you find them? • Sudden onset • Worse within minutes of onset Hand , 2006
  7. 7. Collapse and TIA • Consciousness disturbance indicates pathology of reticular activating system • Diffuse pathway – requires significant vascular insult – Likely to have focal deficits and CT changes within hours if anterior – Unlikely to recover rapidly – “never” a TIA • Diagnosis – Syncope, seizure, hypoglycaemia • Pitfalls – Focal neurology in seizure & hypoglycaemia – Thalamic syndromes and secondary delirium • Still likely to have subtle focal neurology in neurologically robust patients
  8. 8. He’s vertiginous – it is a stroke • Need to distinguish peripheral vs central – Peripheral usually benign - no A&E neuroimaging required – Central - needs admission for MRI • Key is examination if ongoing symptoms – Focal neurology – Nystagmus • Central is multi-directional or up beating • Peripheral is uni-directional and horizontal – Eye ROM including skew test – VOR – the head thrust test – Application of these principles sensitivity similar to MRI (HINTS study, Kattah, 2009) • Other “red flags” - Headache & hearing loss • TIA very tricky!
  9. 9. Head thrust test
  10. 10. Confusion • Receptive dysphasia – Can come in under the stroke radar – Paraphasic errors and neologisms – Attention key • Transient global amnesia – Profound but isolated inability to form new memories – loss of self-awareness and intact higher functions excludes TGA – Prominent perseveration – Lasts less than 24 hours
  11. 11. Delirium • Fluctuations in over time • Attention is the key! • Can be very difficult differential in a person with an aged or demented brain • Stroke diagnosis principles apply as delirium complicates stroke in the aging brain – As above - onset, focal deficits, vascular territory • Other acute medical condition • Consider chronic medical condition prone to delirium e.g. Decompensated cirrhosis
  12. 12. Functional • Examination key here – Gait – Hoover’s sign – Pronator drift – Distraction & variability – Give way weakness • Beware of overlay and resolved transient phenomenon • Difficult to interpret psychological co- morbidity
  13. 13. Migraine • Headache often occurs after onset of neurology • Spotted by • Gradual spreading of symptoms over vascular territories • Positive symptoms – Scintilating scotoma • Flashing lights • Zigzagging • Haze – Strange sensory abnormalities - water flowing down skin, paraesthesia still can be stroke • Hemiplegic migraine rare in onset over
  14. 14. Vision deficit • Common presentation • Transient painless visual loss is a stroke case – Most people don’t check if one or both eyes involved • Ophthalmology review however very useful – Retinal detachment/tear, venous occlusion – Stroke aetiology • Visualising an embolus very helpful • ? Roth spots • Similar stroke work up – Less high risk however
  15. 15. TIA • High risk of subsequent stroke – Likely higher than completed stroke using traditional definitions • Witnessed population based success – Treating TIAs urgently reduces the risk of stroke by 80% (EXPRESS, 2007) • In 2004, one in 10 TIAs led to a stroke within a week in UK • In 2012, about one in 20 TIAs led to a stroke within a week
  16. 16. I think he’s had a TIA – what now? • Do I need a scan in A&E? – CT helpful – Silent ischaemia – Approx 1% in people will have non- ischaemic scan • Convexity SAH, SDH • Tumour • Scan the amaurosis?
  17. 17. MRI in TIA • Acute MRI most helpful in clarifying difficult cases – 50% of traditional thought of TIA have DWI abnormality – Risk stratification significantly improved – More common internationally – Resultant tissue based definition – Future: MRI perfusion
  18. 18. Other investigations • Time critical (EXPRESS, 2007; SOS-TIA, 2007) – Investigation to identify modifiable risk factors – Rapid initiation of stroke secondary prevention • Investigations – Vascular anatomy • Dopplers – Early endarterectomy effective (NNT=6 at 2 years) • CTA/MRA – Dissections esp. young people – Posterior circulation – high risk if stenosis
  19. 19. Investigations • Cardiac work up – Up to ¼ have indication for anticoagulation (broadly) – ECG mandatory (and easy) – Further telemetry/holter helpful – Echocardiogram needed in most patients
  20. 20. In patient vs outpatient management? • Risk stratification plays a (health economic) role • ABCD2 – use your app! • Often quoted that if > 4 should be admitted Score 2 day stroke risk 7 day stroke risk 1-3 (low) 1.0% 1.2% 4-5 (moderate) 4.1% 5.9% 6–7 (high) 8.1% 11.7%
  21. 21. ABCD2 • Developed for 10 care • External validation inconsistent • Poorly performing in – Hospitals (high risk group) – Vs Specialist assessment • Probably very difficult to simplify to simple risk model • Possible mimic exclusion? • Possible role of diagnostics/treatments in hospital
  22. 22. Other risk features – Known carotid disease – Multiple/fluctuating course • Capsular warning syndrome • Possible artery-artery embolism – AF (?) • Traditional thought of as high risk population – DWI hits • Practical relevance • May be even higher than traditional defined stroke – ? Related to sub-type e.g. artery to artery – Needs more work
  23. 23. Service provision • Risk front loaded – Traditionally 50% of 30 day stroke risk in 1st 24 hours • Imaging revealing increasing recognised dynamic process • New stroke or evolution • Collaterals & spontaneous re- canalisation – Is this relevant to clinical practice?
  24. 24. Service provision – who to admit? • Where should rapid diagnostic work up be done? – A&E – Clinic – Inpatient – GP • Who should get admitted for monitoring – Potential deterioration - who? —High risk groups – how to identify? —Hyper-acute treatment – is it cost effective? —Investigations - telemetry —At risk if alone
  25. 25. Medical management - Antiplatelets • Dipyridamole out – Bd dosing + side effects • Aspirin – Largest evidence base (CAST + IST) – Stroke prevention - NNT = 111 in first 2 weeks – Combined cardiovascular outcomes NNT 25- 30 over 2 years – Various doses used (300mg in CAST) • Clopidogrel – Better than aspirin (but NNT=200) (CAPRIE, 1996) – Not tested in TIA or acute stroke monotherapy
  26. 26. Antiplatelets • Combination – In conventional stroke • Worse outcomes (MATCH trial, 2004; SPS3 2011 CHARISMA, 2006) – In high risk TIA or smaller stroke (CHANCE, 2013) • 28 days combination • 90 recurrent stroke 3.5% ARR • Chinese population • A/W subgroups analysis – Non-clinical data supporting (CARESS, 2005; CLAIR, 2010)
  27. 27. Antiplatelets • Future – Combination therapy in non-asian populations (POINT) – Different subgroups –Large artery atherosclerosis – Triple therapy (TARDIS) – More potent anti-platelets
  28. 28. Anticoagulation • Heparin higher risk of death than aspirin in acute ischaemic stroke (Berge, 2002) • However – certain subtypes may be beneficial – Cardiac mural thrombus – Intra-arterial thrombus? • Note aspirin as effective as warfarin (WARSS, 2002) • May not need aspirin in addition if another anticoagulation requirement
  29. 29. Lipids • Atorvastatin 80mg tested in stroke group in SPARCL trial – 1 to 6 months after stroke – Combined ARR over 5 years was 3.5% – Similar RRR whatever baseline LDL- cholesterol • Start low as SE occur • Simvastatin? • Fibrates or ezetimibe? • Targets?
  30. 30. Blood pressure • Most important secondary prevention option • Often transiently elevated in acute stroke – ? TIA • However little acute trial data • Influenced most by PROGRESS trial – Perindopril/indapamide – Similar RRR across very broad BP range • Goal is 130/80 • Start in A&E ?
  31. 31. Mr O • Discharged on aspirin • Urgent OPD MRI
  32. 32. Mr O • Readmitted, symptoms settled with aspirin • Readmitted again 2 months later with recurrent symptoms – Anticoagulated • Due for follow up neuro-imaging in few months
  33. 33. Thanks!!

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