Management of E.D. Patients who Present with a Transient Ischemic Attack or. Can We Safely Send TIA Patients Home From the E.D. ??. Edward P. Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL.
64 year old presents to ED
Trouble using L hand
“Couldn’t grasp cup of coffee or key”
Symptoms lasted for about 30 minutes
Spontaneous resolution, now no sx
Hx DM, smoker
No recent illness
75 year old presents to ED
Slurred speech and dim vision
No motor symptoms
Symptoms lasted for 45-60 minutes
Paramedics called by family
Speech slow, but resolving now
Hx “heart trouble”, “bad blood vessels”
Neurological sx common, variable
TIA: Sx due to cerebral ischemia
Some TIA pts have infarcts
A minimal work-up is required
Therapies must be provided
CVAs will occur following TIAs
In-hospital CVAs allow tPA use
How do TIA patients present?
How is CNS ischemia assessed?
How are cerebral infarcts Dx’d?
What work-up must be done?
What therapies must be provided?
How often will CVAs occur?
How do we assess admit benefits?
Motor, sensory or speech problems
Specific cerebrovascular distribution
Loss of function
Loss of vision
Not wavy lines, as in a migraine
All sx occur & resolve at same time
Loss in global cerebral function
Transient global amnesia
Positive symptoms (ringing in ears)
Sx that come and go differently
Glucose, Hb, hydration, medications
Migraine or temporal arteritis
Akinetic seizure or partial lobe epilepsy
CNS space-occupying lesions
ENT, ophthomologic pathology
Carotid artery disease
Brain large or small artery disease
Careful history and physical
Labs to rule out metabolic causes
CT to rule out mass lesions
Resolution of symptoms
TIAs: most last < 30-60 minutes
TIA: < 24 hrs not clinically useful
Cerebral infarcts are present in TIA pts AT THE TIME OF THE INITIAL ED EVALUATION
CT: 15-20% cerebral infarction rate
MRI: ~50% have ischemic injury
MRI: ~25% have cerebral infarction
Transient Sx presentation does not mean the absence of a CVA
Cerebral infarction will have occurred in some TIA pts by the time the symptoms have resolved
Subsequent CVA isn’t the issue
The key is to diagnose “cerebral infarction with transient signs”
Resolution of chest pain does not mean a myocardial infarction has not occurred: get an EKG!
Resolution of TIA sx does not mean a cerebral infarction has not occurred: get a CT or MRI!
Cardiac ischemia: PCI, medical Rx
CNS Ischemia: fewer interventions
Intervention need can be assessed in the Emergency Department
Once non-CNS causes excluded, there is the possibility to send the patient home for outpatient Rx
Careful history and physical
Can the distribution be determined?
Is the pt neurologically intact?
CT or MRI
Is there a mass lesion?
Is there a cerebral infarct?
Carotid artery imaging
To rule out carotid artery stenosis
Doppler US, MRA or CT angiography
83-86% sensitive for a 70% + lesion
Is there atrial fibrillation?
Is echocardiography useful??
Risk factor management
Useful in cardioembolic causes
Long-term oral warfarin in afib
Short-term heparin in afib??
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
Anticoagulation not recommended
Useful in good surgical candidates
Lesions of 70% + stenosis
TIA within past two years
50-69% lesion, consider risk
Patient surgical risk, stroke risk
Timing of surgery not clarified
HTN: BP below 140/90
DM: fasting glucose < 126 mg/dl
Hyperlipidemia: LDL < 100 mg/dl
Exercise 30-60 min, 3x/week
Avoid excessive alcohol use
Weight loss: < 120% of ideal weight
25% have already had an infarct!
They most likely will be the patients who go on to develop a symptomatic stroke with persistent & worsening Sx
Risk stratify and find these pts!!
How many will develop persistent cerebral infarction symptoms?
1707 TIA CA patients
10.5% stroke rate at 90 days
50% within 48 hours after ED visit
Johnston SC et al, JAMA, Dec 13, 2000. 284:2901-2906
Acute stroke risk is correlated with 5 risk factors
Age > 60, DM, Sx > 10min
Weakness and speech Sx
Low risk pts: less stroke risk
Lower risk acutely and over time
Early stroke risk predicted by RF Ischemic Attack
Lifestyle risk factors
Sx duration: longer is worse
Sx type: non-retinal Sx worse
Complete evaluation likely
Risk factor management easier
Lifestyle modification possible
Patient education more extensive
Rapid assessment if CVA occurs
Patient ease and comfort
Hospital infection risk
Outcome has not been addressed
Ease with which work-up can be completed from E.D.
Observation unit availability
“Why not do an out-pt work-up, there’s nothing we can do in the hospital anyways!”
If persistent recurrent Sx occur, tPA can be given within minutes
This is an important issue
It does not, however, drive the standard of care
You had a small stroke
You will likely have another stroke in the future, possibly very soon
You must take an aspirin daily
You must have further tests done
You must see your MD tomorrow
You must return if these Sx recur!
The exact Sx and their resolution
A detailed neurological exam
Normal speech, vision, and gait
Normal labs, CT (MRI), EKG, and carotid doppler (MRA)
Comprehension of pt instructions
New meds, clear follow-up plan
Assessment of risk
Rational for disposition
If outpatient disposition, state clearly that the patient is at low risk for subsequent CVA
It is possible to send home low risk TIA patients for outpatient observation, further assessment, and continued therapies
Doing so does not fall below a reasonable standard of care
Outpatient approach is work
E.D. throughput delayed
Poorly connected pts may suffer
Patients need to stop and think
Admission costs may be justified
If RF and lifestyle changes enhanced
If subsequent stroke risk reduced
Does subsequent stroke risk change based on disposition?
This must be studied prospectively
E.D. observation unit evaluation?
A surgical approach to a medical problem: EM physicians can get the job done quickly
Many TIA pts have cerebral infarcts
Acute Dx and Rx reqs are limited
Risk stratification can take place
An outpatient approach is possible
It is a reasonable standard of care
Prospective evaluation of optimal approach is needed
Do a comprehensive E.D. work-up
Identify pts with a cerebral infarct
Admit those at highest risk
Disposition others based on consideration of all factors
Assess best practice via an observation unit study