CME: TIA Ix and Mx in the ED

Here is Jim’s great talk relating to the management of patients presenting with symptoms consistent with a TIA.

Transient ischaemic attack (TIA) investigation and management in the emergency department from SCGH ED CME

Additional Resources:

• Australian Stroke Foundation: Clinical Guidelines for Stroke and TIA Management 2010 – written as a guide for GP’s
• UK NICE Clinical Pathway: TIA: assessment, early management and imaging
• US TIA Guidleines (?2006) – with reasonable hospital admission criteria
• ABCD2 Score Calculator from MDCalc

Some take home points from the discussion:

Diagnosis:

• There are differential diagnoses that need to be considered and potentially excluded (based on a thorough assessment – Hx/Ex/appropriate Ix’s)
• Acute MR imaging would be very useful in making the diagnosis of ?significant TIA’s
• CT (Non-contrast) useful to:
  • exclude haemorrhage / tumour
  • confirm previous silent ischaemia (useful in risk assessment and providing further evidence for diagnosis of CVA)

Risk Assessment:

• History:
  • recurrent episodes / fluctuating course
• ABCD2 score (see above)
  • designed for primary care (?score <4 suggests consider early, <48/24, outpatient f/u)
  • ?opinion of neurologists at SCGH is that it is not that sensitive in the ED setting
• Vascular anatomy
  • if significant (stenosis > 70%) is an indication for admission and urgent (<48hr) carotid endarterectomy (?stenting)
  • Ix options:
    • Carotid Doppler (?best use of money when available  – when anterior circulation symptoms)
    • CTA (?probably most accessible)
    • MRA
• Cardiac disease
  • atrial fibrillation
    • Ix options:
      • single ECG
      • monitoring (IP/OP)
  • Structural heart disease
    • Echocardiogram (less time critical than carotid doppler)

Treatment:

• antiplatelets
  • aspirin comparable to clopidogrel (clopidogrel may be slightly better)
  • aspirin should be given early
  • combination antiplatelet therapy may be of some added benefit (awaiting the result of trials)
• anitcoagulation
  • in those with AF – warfarin / NOAC’s (probably rivoroxiban the most useful – as daily dosing, ?some reversibility)
  • consider heparin in those with known cardiac mural thrombus or intra-aterial thrombus
• cholesterol control – long term
• blood pressure control – long term

So who needs inpatient or outpatient investigation and management. There seems to be debate about this within the neurology department and wider community. This may depend on what risk assessment information can be established in the emergency department setting (i.e. availability of carotid dopplers, acute MR etc…).

Currently I think it is appropriate that all patients presenting with symptoms suggestive of a TIA be discussed with neurology team and the following investigations be ordered within the ED to assist in the patients risk assessment:

• Routine bloods: FBP, U&E’s, Glucose
• ECG
• non-contrast CT imaging of the brain (or ?MRI)
• carotid doppler (if in hours and anterior circulation symptoms – ??to be considered by members of the ED ultrasound group after hours in the future if it is thought to alter patient disposition)

Thoughts for the future:

• documented guidance from the neurology department on admission criteria for patients presenting with symptoms of TIA to ensure timely booking of appropriate bed (Neurology or EDU awaiting urgent investigation)
• consideration for establishing a TIA investigation outpatient clinic
• making acute MR imaging more available
• formulation of an ED protocol for TIA management after d/w neurology department