Edward P. Sloan, MD, MPH, FACEP EMRA /FERNE Case Conference: The ED Management of TIA, AIS and ICH Patients

Edward P. Sloan, MD, MPH, FACEP

EMRA /FERNE EMRA /FERNE Case Conference:Case Conference:

The ED Management of The ED Management of TIA, AIS and ICH PatientsTIA, AIS and ICH Patients

Edward P. Sloan, MD, MPH, FACEP

ACEPACEPScientific AssemblyScientific Assembly

New Orleans, LANew Orleans, LAOctober 15-18, 2006October 15-18, 2006

FERNE/EMRA

Can We Risk StratifyCan We Risk StratifyTIA Patients in the ED?TIA Patients in the ED?

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Andrew Asimos, MD, FACEP

Adjunct Associate Professor

Department of Emergency MedicineUniversity of North Carolina School of

Medicine at Chapel HillChapel Hill, NC

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Attending PhysicianEmergency Medicine

Director of Emergency Stroke CareCarolinas Medical Center

Department of Emergency Medicine

Charlotte, NC

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Stroke Risk after TIAStroke Risk after TIA

Johnston SC et al. JAMA 2000;284:2901-2906.Kleindorfer K et al. Stroke 2005;26:720-724.Lovett JK et al. Stroke 2003 34(8):138-40.Coull AJ et al. BMJ 2004 328(7435):326.Gladstone DJ et al. CMAJ 2004 170(7):1099-1104.Hill MD et al. Neurology 2004 62(11):2015-20.

Kaiser

2000

(n=1,707)

Oxford CP

2003

(n=209)

Oxford VS

2004

(n=87)

Alberta

2004

(n=2,285)

Ontario

2004

(n=265)

GCNK

2005

(n=927)

2 Days 5% 3% 4%

7 Days 9% 8% 4% 7%

1 Month 12% 12% 5% 11%

3 Months 11% 17% 10% 6% 15%

6 Months 17%

1 Year 15%

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JAMA, December 13, 2000JAMA, December 13, 2000

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Independent Risk Factors for Independent Risk Factors for Stroke within 90 DaysStroke within 90 Days

Odds RatioOdds Ratio

(95% CI)(95% CI)

P ValueP Value

Age >60Age >60 1.8 (1.1-2.7)1.8 (1.1-2.7) 0.010.01

Diabetes MellitusDiabetes Mellitus 2.0 (1.4-2.9)2.0 (1.4-2.9) <0.001<0.001

> 10 min Duration> 10 min Duration 2.3 (1.3-4.2)2.3 (1.3-4.2) 0.0050.005

WeaknessWeakness 1.9 (1.4-2.6)1.9 (1.4-2.6) <0.001<0.001

Speech ImpairmentSpeech Impairment 1.5 (1.1-2.1)1.5 (1.1-2.1) 0.010.01

Johnston SC et al. JAMA 2000;284:2901-2906.

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90-Day Stroke Risk by Number 90-Day Stroke Risk by Number of Risk Factorsof Risk Factors

# (%)# (%)

# Risk # Risk FactorsFactors

PatientsPatients Stroke within Stroke within 90 days90 days

00 22 (1)22 (1) 0 (0)0 (0)

11 179 (10)179 (10) 5 (3)5 (3)

22 509 (30)509 (30) 36 (7)36 (7)

33 584 (34)584 (34) 63 (11)63 (11)

44 337 (20)337 (20) 51 (15)51 (15)

55 76 (4)76 (4) 26 (34)26 (34)

Johnston SC et al. JAMA 2000;284:2901-2906.

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ABCD ScoreABCD Score

Risk FactorRisk Factor ScoreScore

Age Age ≥60≥60 11

SBP >140 mm Hg and /or DBP SBP >140 mm Hg and /or DBP ≥90 mm Hg≥90 mm Hg 11

Unilateral weaknessUnilateral weakness 22

Speech disturbance without weaknessSpeech disturbance without weakness 11

Symptom duration Symptom duration ≥60 minutes≥60 minutes 22

Symptom duration 10-59 minutesSymptom duration 10-59 minutes 11

Symptom duration <10 minutesSymptom duration <10 minutes 00

Rothwell et al. Lancet 2005;366:29-36.

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7-Day Stroke Risk Stratified by ABCD Score:7-Day Stroke Risk Stratified by ABCD Score:OXVASC Validation CohortOXVASC Validation Cohort

Rothwell et al. Lancet 2005;366:29-36.

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Is the ABCD Score Useful for Risk Is the ABCD Score Useful for Risk

Stratification of Patients With Acute TIA?Stratification of Patients With Acute TIA?

• Prospective study of 117 TIA Prospective study of 117 TIA patients over 3 yearspatients over 3 years• Diagnosed by a neurologistDiagnosed by a neurologist, using the , using the

classic <24-hour definitionclassic <24-hour definition• Hospitalized within 48 hours of Hospitalized within 48 hours of

symptom onsetsymptom onset

Cucchiara BL et al. Stroke 2006; 37(7):1710-1714.

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Is the ABCD Score Useful for Risk Is the ABCD Score Useful for Risk Stratification of Patients With Acute TIA?Stratification of Patients With Acute TIA?

• Primary Outcome Measure wasPrimary Outcome Measure was• Dichotomization of subjects into high-Dichotomization of subjects into high-

risk and low-risk categoriesrisk and low-risk categories• High-risk groupHigh-risk group

–Stroke or death within 90 daysStroke or death within 90 days–≥≥50% stenosis in a vessel referable 50% stenosis in a vessel referable

to symptomsto symptoms–Cardioembolic source warranting Cardioembolic source warranting

anticoagulationanticoagulation


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ResultsResults

• 26 patients (22%) classified as high 26 patients (22%) classified as high riskrisk• Clinical events occurred in 4 patientsClinical events occurred in 4 patients

• 2 strokes, 2 deaths2 strokes, 2 deaths• A A ≥≥50% stenosis in a vessel referable to 50% stenosis in a vessel referable to

the patient’s symptoms was found in 15 the patient’s symptoms was found in 15 patients (14%)patients (14%)

• A cardioembolic source warranting A cardioembolic source warranting anticoagulation was found in 10 anticoagulation was found in 10 patients (9%)patients (9%)


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ResultsResults• Increasing ABCD scores marginally Increasing ABCD scores marginally

associated with increasing riskassociated with increasing risk• ABCD scores in the 2 patients with stroke were 3 ABCD scores in the 2 patients with stroke were 3

and 6and 6• Strokes occurred 26 hours and 39 hours after TIA Strokes occurred 26 hours and 39 hours after TIA

onsetonset• Both patients who died had an ABCD score Both patients who died had an ABCD score

of 5of 5• Patients without weakness or speech Patients without weakness or speech

disturbance still had significant probability disturbance still had significant probability of being high risk (15%) or DWI+ (8%)of being high risk (15%) or DWI+ (8%)


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Is the ABCD Score Useful for Risk Is the ABCD Score Useful for Risk Stratification of Patients With Acute TIA?Stratification of Patients With Acute TIA?

• Discriminatory ability of ABCD score not Discriminatory ability of ABCD score not optimaloptimal

• Patients with a score of 0 to 3 still had a Patients with a score of 0 to 3 still had a clinically significant probability of having clinically significant probability of having stroke within 90 days, or a high-risk cause of stroke within 90 days, or a high-risk cause of cerebral ischemia warranting specific cerebral ischemia warranting specific interventionintervention

• Roughly in the 10% to 20% rangeRoughly in the 10% to 20% range

• Similar percentage had evidence of Similar percentage had evidence of ischemia on early MRIischemia on early MRI


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ConclusionsConclusions• Prediction rules require prospective

validation• Isolated visual or sensory

symptoms suggest low short term risk for stroke

• Role of DWI MRI in short term stroke risk stratification needs further investigation

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Questions?Questions?

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Edward P. Sloan, MD, MPH, FACEP EMRA /FERNE Case Conference: The ED Management of TIA, AIS and ICH Patients