michael ross, md, facep the management of ed tia patients: michael a. ross md facep associate...

Michael Ross, MD, FACEP

The Management of ED TIA Patients: The Management of ED TIA Patients:

Michael A. Ross MD FACEPAssociate Professor Emergency Medicine

Department of Emergency Medicine

William Beaumont Hospital

Wayne State University School of Medicine


Case presentationCase 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.


Case presentationCase 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.


Case presentationCase 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?


BackgroundBackground• 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 1 - 2 days of ED visit

• 2.6% will die• 2.6% will suffer adverse cardiovascular events• 12.7% will have additional TIAs


Stroke Risk After TIAStroke Risk After TIAYear N Stroke Risk

Johnston, et al (Kaiser ED) 2000 1707 10.5% /90dEliasew, et al (NASCET) 2004 603 20.1% /90dLovett, et al (Oxfordshire) 2004 209 12% /30dGladstone, et al (Toronto) 2004 371 5% /30dDaffertshofer, et al (Grmy) 2004 1150 13% /180dHill, et al (Alberta) 2004 2285 9.5% /90dLisabeth, et al (Texas) 2004 612 4.0% /90dKleindorfer, et al (Cinc) 2005 927 14.6% /90dWhitehead, et al (Scotland)2005 205 7% /30dCorreia, et al (Portugal) 2006 141 13% /7dTsivgoulis, et al (Greece) 2006 226 9.7% /30d

AVERAGE ~12% stroke risk in 90 days after TIA 5% in first 2 days


Stroke Risk After StrokeStroke 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


PathophysiologyPathophysiology

• Short-term risk of stroke:– After TIA (11%) > after stroke (4%)

• Possible explanation– Tissue still at risk: unstable situation

• More thrombo-embolic events

Johnston, NEJM 2002; 347:1687


Possible Explanation: InstabilityPossible Explanation: Instability


Outside the “head”: Outside the “head”: Cardio-embolic Cardio-embolic

sourcessources


BackgroundBackground• Stroke is preceded by TIA in 15% of pts

• Stroke is the THIRD leading cause of death

– National cost of stroke = $51 billion annually!

– Many consider stroke to be worse than death.


TIA

ST

RO

KE


Topics to be coveredTopics to be covered

1. Appropriate history, physical, and labs

2. ECG, monitor, HCT

3. Carotid dopplers - why, when, how?

4. Further clinical testing

5. Therapy – starting with aspirin


TIA DefinitionTIA Definition

• Traditional– Neurological deficit lasting less than 24 hours due to focal

ischemia in the brain or retina.

• Newly Proposed– A brief episode of neurologic dysfunction– caused by focal brain or retinal ischemia,– with clinical symptoms typically lasting less than 1hr, – and without evidence of acute infarction”.

• If TIA symptoms last >1hr, then >85% have a stroke– NINDs tPA study data - Albers et al.


1. History and physical:1. History and physical:The HistoryThe History

• Duration - <10min, 10-60min, >60 min• Evidence to suggest non-vascular cause?

– Focal vs. non-focal symptoms– Abrupt vs. gradual symptom onset

• Vascular risk factors?– DM, prior “CVA-TIA-MI-PVD”

• Symptoms to suggest potential causes? – Neck pain - dissection– Palpitations - atrial fibrillation


Evaluation:Evaluation: Physical examinationPhysical examination

• Neurologic deficits?• Carotid bruits (note limitations)?• Cardiac abnormalities?

– Arrhythmia– Murmur– Signs of heart failure

• Symptoms reproducible with provocative maneuvers?– Cervical stretch test– Carpal tunnel positioning tests


Neurological ExamNeurological Exam• Six major areas

– MS, CN II-IX, Motor, Sensory, Reflex, Coordination

• NIH stroke score– Structured neurological exam– Validated tool for detection of significant deficits– Value as an educational tool– Thrombolytic screening tool

– Google - “NIHSS training”: http://asa.trainingcampus.net/uas/modules/trees/windex.aspx

– Google - “FERNE” website:http://www.ferne.org/


Evaluation:Evaluation: Laboratory testingLaboratory testing

• Complete blood count – anemia, polycythemia,

thrombocytosis/thrombocytopenia• Chemistry panel

– hypoglycemia, diabetes, renal failure• Sedimentation rate

– temporal arteritis, endocarditis• EKG

– prior MI, atrial fibrillation


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


TIA: Differential DiagnosisTIA: Differential Diagnosis“Mimics”“Mimics”

• Epilepsy• Complicated migraine• Subdural hematoma• Mass lesions, AVMs• Arterial dissection

• Cervical disc disease• Carpal tunnel syndrome• Metabolic derangement (ex,

hypoglycemia)• Inner ear disease/BPV• Transient global amnesia• Cranial arteritis

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)


Is a “TIA” a TIA?Is a “TIA” a TIA?

• Little agreement, even among neurologists (kappa 0.25-0.65)

• 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


Utility of the H/P?Utility of the H/P?

• TIA risk stratification– Johnston criteria– Rothwell criteria - “ABCD”– Combination of the above = “ABCD2”


TIA risk stratification - California ModelTIA risk stratification - California ModelJohnston et al. Short-term prognosis after emergency department diagnosis of TIA. Johnston et al. Short-term prognosis after emergency department diagnosis of TIA.

JAMA.JAMA. 2000;284:2901-6. 2000;284:2901-6.

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


Our patient’s Johnston score?Our patient’s Johnston score?

Independent risk factors for stroke:• Age > 60yr 0• Diabetes 0• TIA > 10 min. 1• Weakness with TIA 1• Speech impairment 1

stroke risk score of 3:~5% at one week~8% at 3 months


TIA risk stratification - British model?TIA risk stratification - British model?Rothwell,et al. 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


Our patients ABCD score?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)


ABCDABCD22 Score Score


ABCDABCD22 Score Score

Score points for each of the following:– 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


ABCDABCD22 Score Validation: Meta-analysis Score Validation: Meta-analysis

Variable

Age >60 years 3690 (76.7) 1.4 (1.0 -2.1) 1.4 (1.0 -2.0) 1.5 (1.2 -2.0)

Diabetes mellitus 797 (16.6) 1.6 (1.1 -2.2) 1.4 (1.1 -1.9) 1.7 (1.3 -2.1)

SBP >140 mmHg or DBP >90 mmHg 3420 (71.2) 2.1 (1.4 -3.1) 1.9 (1.4 -2.6) 1.6 (1.2 -2.0)

Duration 10-59 min vs. <10 min 993 (20.7) 2.0 (1.0 -3.7) 1.9 (1.1 -3.3) 1.7 (1.1 -2.5)

Duration >60 min vs. <10 min. 2973 (61.9) 2.3 (1.3 -4.0) 2.6 (1.6 -4.3) 2.1 (1.5 -3.0)

Speech impairment without focal weakness 899 (18.7) 1.4 (0.8 -2.3) 1.5 (1.0 -2.4) 1.7 (1.2 -2.3)

Focal weakness 1979 (41.2) 2.9 (2.0 -4.3) 3.5 (2.5 -4.8) 3.2 (2.5 -4.1)

*All listed independent predictors were included in logistic regression analysis.

Odds Ratio (95% CI)

No (%)

Odds Ratio (95% CI)

Odds Ratio (95% CI)

2-Day Risk 7-Day Risk 90-Day Risk


ABCDABCD22 Score and Stroke Risks Score and Stroke Risks

0%

5%

10%

15%

20%

25%

0 1 2 3 4 5 6 7

ABCD2 Score

Str

ok

e R

isk 2-Day Risk

7-Day Risk

30-Day Risk

90-Day Risk


Prognosis ConclusionsPrognosis 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


What is our patients’ ABCD2 score?What is our patients’ ABCD2 score?– Age >60 = 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% (?!)


Limitations of Prediction RulesLimitations 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?


2. HCT, ECG2. HCT, ECG

• HCT - tumor, SDH, NPH, etc– Minor stroke and TIA

associated with a 10% incidence of stroke on MRI.


Infarction in TIAInfarction in TIA

• Approximately 50% of those with TIA have DWI changes on MRI

Kidwell et al Stroke 1999


When is a “TIA” a TIA?When is a “TIA” a TIA?• What about when a clinically silent acute infarct is

present?– New infarct on CT as a predictor of stroke:

• 38% with new infarct had a stroke within 90 days vs. 10% without (p=0.008).

• OR 4.1 after adjustment for clinical factors.

– Recently, new infarct on MRI also shown to be a predictor.

• 5-fold increase in risk with new lesion on baseline MRI• Also, greater risk of in-hospital stroke in a second cohort.

VC Douglas et al, Stroke 2003; 34:2894SB Coutts et al, Neurology 2005; 65:513H Ay et al, Ann Neurol 2005; 57:679


Time

Neurologic Deficit

Recovery

Stroke

TIAStroke?


90-day risk of stroke in patients with 90-day risk of stroke in patients with a small stroke vs TIA?a small stroke vs TIA?

Lancet Neurol 2006; 5: 323–31


TIA Stroke

Minor stroke

Reversible ischemic neurologic deficit

(RIND)

Cerebral infarction with transient signs

Reversible ischemia

Infarction

DWI+ TIA


2. HCT, ECG2. 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


3. Carotid Dopplers3. 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%


3. Carotid dopplers3. Carotid dopplersThe BIG question - WHEN???The BIG question - WHEN???

• Carotid surgery if >70% stenosis lesions is “time sensitive”.

• Stroke risk reduction if done within:– 0-2 weeks

• 75% stenosis = 30.2%– 2-4 weeks

• 75% stenosis = 17.6%– 4-12 weeks

• 75% stenosis = 11.4%– +12 weeks

• 75% stenosis = 8.9%

• Similar for 50-70% lesions


Outpatient carotid dopplers?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;160:2941-6.

• 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


4. Further Clinical testing?4. Further Clinical testing?• Serial neurological

exams?– 10.5% stroke within 3

months• Half within 2 days• Most within 1 day

• Monitoring for AF?• 2-D echo?

Johnston et al, JAMA 284:2901

4. Further clinical testing

Pro

babili

ty o

f S

urv

ival

Days after TIA0 7 30 60 90

.6

.7

.8

.9

1

No. of Patients

At Risk For:

St roke 1001 1577 1527 1480 1451 Adverse Events 1001 1462 1361 1293 1248

Strokes

Adverse Events


5. Medical management5. Medical managementAntiplatelet Therapy

• Useful in non-cardioembolic causes–Aspirin 50-325 mg/day

–Clopidogrel or ticlopidine

–Aspirin plus dipyridamole•Latter two if ASA intolerant or if TIA while on ASA

• Routine anticoagulation not recommended


5. Medical management5. Medical managementRisk Factor Management

• HTN: BP below 140/90

• DM: fasting glucose < 126 mg/dl

• Hyperlipidemia: LDL < 100 mg/dl

• Stop smoking!

• Exercise 30-60 min, 3x/week

• Avoid excessive alcohol use

• Weight loss: < 120% of ideal weight


Hospital Admission for TIAHospital 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


Management of TIA: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;347:1687-92.

– “The benefit of hospitalization is unknown. . . Observation units within the ED. . . may provide a more cost-effective option.”


An Emergency Department Diagnostic Protocol An Emergency Department Diagnostic Protocol For Patients With Transient Ischemic Attack: For Patients With Transient Ischemic Attack:

A Randomized Controlled TrialA 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.


Patient populationPatient population::

• 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


Methods:Methods:ADP Exclusion criteriaADP Exclusion criteria

• Persistent acute neurological deficits • Crescendo TIAs • Positive HCT• Known embolic source (including a. fib)• Known carotid stenosis (>50%)• Non-focal symptoms• Hypertensive encephalopathy / emergency

• Prior stroke with large remaining deficit• Severe dementia or nursing home patient• Social issues making ED discharge / follow up unlikely• History of IV drug use


• 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

Methods:Methods:ADP InterventionsADP Interventions


Methods:Methods:ADP Disposition criteriaADP 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


ResultsResults


Results:Results:PatientPatient CharacteristicsCharacteristics

InpatientTotaln=74

TIA-ADPTotaln=75

Mean Age (sd)67.7yr(15.4)

68.4yr(15.3)

Male n (%)34

(46%)31

(41%)

TIA Stroke Risk Factors - mean (sd) *2.7

(1.4)2.4

(1.1)

Median (IQR) Initial ED Length of Stay6.2 hrs

(5.0-6.2)5.7 hrs

(4.5-5.5)* Johnston - JJAAMMAA.. 22000000;;228844::22990011--66..


Results:Results:Performance of clinical testingPerformance of clinical testing

Inpatient

(n=74)TIA-ADP(n=75)

Carotid imaging

Number completed (n, %)67

(90.5%)73

(97.3%)

Time to completion25.2 hr

(17.3 – 37.1)13.0 hr

(8.4 – 18.0)Echocardiography

Number completed (n, %)54

(73%)73

(97.3%)

Time to completion43.0 hr

(23.8 – 63.8)19.1 hr

(16.7 – 22.5)

Results:Results:Length of StayLength of Stay

MedianInpatient = 61.2 hrADP = 25.6 hr

Difference = 29.8 hr(Hodges-Lehmann)

(p<0.001)

ADP sub-groups:ADP - home = 24.2 hrADP - admit = 100.5 hr


Results:Results:90-Day Clinical Outcomes90-Day Clinical Outcomes

90 Day Outcomes

InpatientTotaln=74

TIA-ADPTotaln=75

Related return visits 9 (12%) 9 (12%)Clinical Outcomes

Index visit CVA 5 7Subsequent CVA (90 day) 2 3

Total 90 day CVA7

(9%)10

(13%)Related Major event or MACE 4 4

Results:Results:90 - day Costs90 - day Costs

MedianInpatient = $1548ADP = $890

Difference = $540(Hodges-Lehmann)

(p<0.001)

ADP sub-groups:ADP - home = $844ADP - admit = $2,737


Study conclusion:Study conclusion:

Compared to inpatient admission, the ED TIA diagnostic protocol was:

• More efficient

• Less costly

• With comparable clinical outcomes


ImplicationsImplications• 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


CLINICAL CASE - OUTCOMECLINICAL 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.


Who do you send home Who do you send home from the ED???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.


• 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

Who do you send home Who do you send home from the ED???from the ED???


ConclusionsConclusions• 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

michael ross, md, facep the management of ed tia patients: michael a. ross md facep associate...

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