TIA Hotline (ASPIRE
Project) and TIA
Management
Shelagh Coutts BSc, MBChB, MD, FRCP(C)
March 13th, 2009
Telehealth Presentation
Objectives
• What is a TIA and what isn’t?
• How can we differentiate high risk from
low risk TIAs? What are the data?
• How urgently should TIA patients receive
diagnosis, assessment, investigation and
management?
• How to facilitate rapid assessment of
TIA? The ASPIRE Project and the TIA
Hotline.
Patient 1
• Jerome is a 85 year old male with HT,
CHF, hyperlipidemia.
• Complains of three spells in the previous
four days that have been referred as
TIAs
• Spells involve loss of consciousness
• Are these TIAs?
Diagnosing ‘spells’
• Phenomenology: before, during, after the
event
• Was the event witnessed? What did
witnesses observe?
• What is the setting? (vascular risk
factors, elderly, young without risk
factors)
Patient 1
• Upon rising from seated to standing
patient develops a sense of dizziness
and unsteadiness and feels very lightheaded
• Then experiences blurring of the vision
starting peripherally and loses
consciousness
Patient 1
• Upon rising from seated to standing
patient develops a sense of dizziness
and unsteadiness and feels very lightheaded
• Then experiences blurring of the vision
starting peripherally and loses
consciousness
• Syncope
The Definition of
Stroke/ TIA
•
A clinical syndrome
characterized by the sudden
onset of a focal neurological
deficit presumed to be on a
vascular basis.
Conditions Misdiagnosed as TIA:
•Migraine aura
•Syncope, postural hypotension
•Seizure
•Vertigo
•Transient Global Amnesia
•Anxiety/Hyperventilation
•Confusion
•Unexplained fall
•Peripheral nerve palsy etc.
Focal versus non focal symptoms
• Localised cerebral ischemia
causes focal symptoms.
• Non focal symptoms such as
faintness , dizziness or
generalized weakness are
rarely due to focal cerebral
ischemia.
Focal neurological symptoms
•
•
•
•
•
•
Motor: weakness, clumsiness, ataxia*
– one side of body.
Speech/language: difficulty speaking
or expressing, slurred speech*.
Sensory symptoms: abnormal feeling.
Visual: monocular, binocular,
diplopia.*
Vestibular: vertigo.*
*in isolation not usually stroke.
Non focal Neurological symptoms
•Generalized weakness and/or
sensory disturbance.
•Light-headedness
•Faintness
•Blackouts
•Incontinence of urine or feces
•Confusion
•Tinnitus.
Top 6 symptoms likely
to be a TIA-1
Sudden onset, lasting minutes to hours,
resolves
6. Vertigo only if present with brainstem
symtoms
5. Hemibody numbness
4. Double vision, crossed numbness or
weakness, slurred speech, ataxia of gait
Top 6 symptoms likely
to be a TIA - 2
3. Speech disturbance for a defined period
of time (definite dysarthria, muteness or
marked word finding difficulty, paraphasic
speech)
2. Monocular or hemifield visual loss (not
blurring of entire visual field)
1. Hemibody weakness
Top 7 symptoms unlikely to
be a TIA
7. Postural dizziness alone
6. Tingling of all 4 extremities
5. Syncopal events
4. Momentary word finding trouble that is
not new
3. Positional and recurrent numbness of
one limb
2. Scintillating or flashing visual
disturbances
Symptoms unlikely to
be a TIA - 2
1. Almost anything with hyperventilation or
chest pain (but make sure it isn’t cardiac!)
Why are these
patients important?
90 Day Prognosis after ED Dx of TIA
•180 / 1707 (10.5%) patients had stroke
– 91 occurred in first 2 days
– Age > 60, DM, Sx > 10 min, weakness, speech
•428 (25.1%) had some adverse event
– More than half occurred in first 4 days
Johnston SC, JAMA 2000;284:2901-2906
Independent Risk Factors for
Stroke Following TIA
• Independent risk factors for stroke following
suspected TIA include:
–
–
–
–
–
Age >= 60 years
Diabetes mellitus
Motor weakness
Speech impairment
Symptom duration > 10 minutes
Johnston et al. JAMA 2000;284:2901-6.
ABCD2 Score
Derived a 7 point score to stratify the
clinical risk of stroke after TIA:
•A: age > 60 years – 1 point
•B: BP (systolic>140mmHg, diastolic>90
mmHg). Either 1 point. (max 1 point)
•C: clinical – unilateral weakness =2,
speech only = 1,
•D: Duration, >60 minutes =2, 10-59 =1,
<10 =0.
•D: Diabetes mellitus =1
Johnston, SC, Lancet 2007;369:283-292.
ABCD2 Score
Predictive Value of the ABCD2 progostic score
Prognostic scores for screening:
caution advised
Highest
scores
medium
scores
lowest
scores
= recurrent stroke
Most events actually occur in
those of medium risk! So be
careful of too high a cutoff.
1
22
How urgently should high risk
TIA patients be assessed?
Does it make a difference?
Express Study
ASPIRE TIA Triaging
Consensus
• Urgent triage and assessment of TIA should
be province wide
• Access to expertise should not be dependent
on geography.
• TIA Triaging algorithm created at Aug 2008
meeting
• Facilitate urgent access for high risk patients
using a TIA Hotline
• Backing of the APSS and the Educational
Strategy of the APSS
Conclusions
• Either ABCD2 >=4 OR Speech or motor symptoms
can identify high risk symptoms
• They have similar sensitivity (88-100%) and
specificity (31-52%) to identify high risk stroke
patients
• ASPIRE Consensus group choose these cutoffs for
TIA Triaging within Alberta
Hotline process
• North - every TIA hotline call will result in
contact with a Telestroke Neurologist
• South - TIAs will be screened by
operator using risk algorithm;
• High or if referring physician requests it
still - Stroke Neurologist
• Low risk and if no specific request - fax
referral in to clinic
ASPIRE Data
• The TIA Hotline and TIA Triaging
Strategy overlap with APSS Educational
Strategy as well as Pillar 1 - quality
improvement
• Data will be tracked by TIA Hotlines
(SARCC in the south and the CCL/UCL
in the north)
• Stroke Prevention Clinic referral forms
will be faxed to a central number to track
all TIAs that come to referral across the
province
ASPIRE Outcomes
• Rate of recurrent stroke determined by
presentations to emergency departments
and admissions to hospital will be
tracked using administrative data
• Two years ‘pre’ compared to two years
‘post’ implementation
• Is the TIA Hotline/Triaging strategy
effective? Is it worth the cost and effort?
• Ongoing feedback and refinement
TIA Hotline ‘go live’
dates
• North including Red Deer (1-888-2824825)
• Goes live March 16, 2009
• South excluding Red Deer (1-800-6611700)
• Goes live March 16th, 2009
THANK YOU!