Risk Score refines TIA management for PCPs, emergency documents

The authors of a new body of evidence recommend the Canadian TIA Risk Score for the management of patients presenting to the emergency room or doctor’s office with what appears to be a transient ischemic attack (TIA) or a mild stroke.

“Many hospitals do not have enough stroke neurologists to treat every patient with a TIA or a mild stroke within 24 hours. Likewise, many emergency rooms around the world are overwhelmed,” says study author Jeffery J. Perry, MD, principal investigator at the Ottawa Hospital Research Institute Medscape Medical News.

“This review is in line with most of the recommendations of the American Heart Association and the Canadian Stroke Best Practice Recommendations,” he said. “However, it goes further to use the Canadian TIA score to differentiate between patients at high and low risk of subsequent stroke and offers practical suggestions for the delivery of quality care in settings without the ability to provide prompt vascular imaging.” , immediate MRI scans and immediate expert stroke assessments.”

Most patients at low risk of subsequent stroke (i.e., patients with <1% risk of subsequent stroke at 7 days) can be safely treated as an outpatient without delays in their departure for vascular imaging or neurological consultation during their first emergency room visits come, Perry added. "The Canadian TIA score can be used to determine the urgency of an evaluation by a stroke neurologist."

The study was published on October 11 in CMAJ.

Score stratifies the risk

Perry, lead author of the Canadian TIA Score validation study, said that the CMAJ The editors approached him to write the review and include the new score in the latest recommendations. To incorporate the latest evidence, Perry and colleagues reviewed the most recent position statements on TIA and minor stroke management and searched the literature for relevant articles. They note that the nomenclature regarding TIA and minor stroke is inconsistent, that there is no need to distinguish between the two from a clinical standpoint, and that the term “acute ischemic cerebrovascular syndrome” has been suggested to encompass both.

Broadly speaking, the team’s recommended strategy for diagnosing and treating the condition involves the following steps:

1. Diagnosis: Sudden loss of motor function and speech impairment are strong indicators; symptoms tend to be negative (e.g., loss of vision instead of flashing lights).

2. Risk assessment: Using the Canadian TIA score to stratify 7-day risk of stroke (low risk: <1%, medium risk: 1% to 5%, high risk: >5%).

3. Investigations: Urgent CT within 48 hours; Vascular Imaging to Identify Acutely Symptomatic Carotid Stenosis in Patients at Intermediate to High Risk as Determined by TIA Score; ECG to detect atrial fibrillation or flutter and optimize anticoagulant use; if the index of suspicion is high, echocardiography should be used to look for cardioembolic sources.

4. Management: Dual antiplatelet therapy for 21 days in intermediate and high-risk patients; hypertension should be treated; Patients should be referred for evaluation by a stroke clinic; Aggressive lifestyle changes should be initiated to lower lipid levels.

“I believe our recommendations should be incorporated into clinical guidelines,” Perry said.

reservations and concerns

Steven M. Greenberg, MD, PhD, vice chair for faculty development in the department of neurology at Massachusetts General Hospital in Boston and professor of neurology at Harvard Medical School, commented on the article for Medscape: “Although the proposed guidelines are largely evidence-based and consistent with the standard of care, there are several areas where stroke specialists might disagree and suggest alternative strategies.” Greenberg was not involved in the study.

dr Steven Greenberg

While some lower-risk traits, such as B. repetitive or stereotyped symptoms or dizziness, may be more indicative of a TIA mimic, he said that “these features need to be examined very carefully. repetitive, stereotyped, low-flow TIAs requiring urgent revascularization.”

Dizziness could be a feature of a brainstem or cerebellar TIA or a minor stroke, Greenberg said, particularly with other posterior circulatory symptoms. Validated guidelines for distinguishing peripheral vertigo from CNS vertigo are available, he noted.

“Another caveat is that the studies demonstrating the benefit of brief dual antiplatelet therapy after an acute TIA or minor stroke were based on ABCD² and not the Canadian TIA score,” he said. “It is therefore important that any score-based recommendations are applied in the overall context of existing stroke prevention guidelines.”

In addition to recommending urgent vascular imaging of patients whose presentations suggest a true TIA or minor stroke, most guidelines also recommend expanded cardiac monitoring and a transthoracic ECG to identify potential sources of embolism, Greenberg added. “Users of these guidelines should also be aware of the limited yield of head CT capable of detecting some old strokes, large acute strokes – presumably not relevant for patients with TIA or mild strokes – and acute intracranial hemorrhage.”

Louis R. Caplan, MD, founder of the Harvard Stroke Registry at Beth Israel Deaconess Medical Center in Boston and professor of neurology at Harvard Medical School, also commented on the study for Medscape.

While the review “is fine for non-stroke specialist care, ideally large referral centers could have a TIA or stroke clinic, as is found in much of western Europe,” he said. This would allow the stroke etiology to be studied for each patient.

“Many patients can be treated with the regimen outlined by the authors, but some with other conditions, such as B. atrial cardiopathy, patent foramen ovale, atrial myxoma, thrombus in cardiac ventricle or atrium, require anticoagulants,” he noted. “For some, thrombolysis and mechanical thrombectomy would be considered. Every stroke patient is different, and treatment cannot be summed up in one remedy. One size doesn’t fit all.”

In an accompanying commentary, Shelagh B. Coutts, MD, and Michael D. Hill, MD, both from the University of Calgary, presented their team’s approach to the acute management of patients with probable cerebral ischemia. Such management involves risk assessment and stratification based on clinical symptoms rather than a specific score. They also typically do a CT angiography. “If the CTA is completely normal (ie, no occlusion, atherosclerosis or arterial dissection, and no other vascular abnormality), we rely on the high negative predictive value of this result and discharge the patient home for antiplatelet therapy with outpatient follow-up. including MRI of the brain (since CT cannot reliably rule out mild ischemia) within the first week,” they write.

The review was conducted without commercial funding. Perry, Greenberg, Caplan, Coutts and Hill have not disclosed any relevant financial relationships.

CMAJ. Published online October 11, 2022. Full text

Follow Marilynn Larkin on Twitter: @MarilynL.

For more updates, follow Medscape on Facebook, TwitterInstagram and YouTube.