Short-term prognosis of stroke among patients diagnosed in the emergency department with a transient ischemic attack

EVESTA: Emergency VESTibular Algorithm and its impact on the acute management of benign paroxysmal positional vertigo

OBJECTIVE

To synthesise evidence-based research concerning the assessment and management of acute dizziness via construction of a comprehensive clinical algorithm. Assess its clinical impact with an aim to improve the acute management of benign paroxysmal positional vertigo (BPPV) within Wyong Public Hospital ED in four key recommendations.

METHOD

Current best practice models of care were synthesised into a single clinical, district-based peer-reviewed algorithm by a specialist focus group. An observational pre- and post-implementation study was completed to assess the impact of the algorithm on the management of BPPV. A total of 162 notes (pre [control] n = 87 and post [intervention] n = 75) met the inclusion criteria. Adherence to the BPPV clinical practice guidelines statements 1a, 3a, 4a and 6 were analysed for statistical difference in practice between the two groups.

RESULTS

Following implementation of the Emergency VESTibular Algorithm (EVESTA), compliance showed a significant improvement in Hallpike-Dix performed by 27% (95% confidence interval [CI] 14-40%; defects pre-intervention 40%: post-intervention 13%) (P < 0.001), utilisation of neuroimaging reduced by 16% (95% CI 2-30%; 40%: 24%) (P < 0.05), repositioning techniques performed increased by 33% (95% CI 18-48%; 68%: 36%) (P < 0.001). Administration of vestibular suppressant medication reduced by 30% (95% CI 15-45%; 59%: 29%) (P < 0.001). An interrupted time series analysis confirmed significant change in BPPV admissions post-project -4.23% (95% CI -7.20, -1.27%) (P = 0.041).

CONCLUSION

Diagnosis and management of acute dizziness is challenging within the ED. Synthesis of best practice into a clinical algorithm has improved the diagnosis and evidence-based treatment of BPPV. There is continued opportunity to improve the efficiency and effectiveness in the management of both central and peripheral acute dizziness within the ED.

The role of advanced neuroimaging techniques in ischemic stroke prevention

In great part due to recent advances in medical technology, ischemic cerebral stroke has become an increasingly treatable condition, which requires urgent measures and which rely on pharmacological and/or interventional measures. Due to its high prevalence, preventive measures should also be undertaken, and this is a situation where the use of advanced neuroimaging techniques could be helpful in certain underlying diseases. What is proposed here is to discuss how modern neuroimaging techniques (advanced magnetic resonance (MR) techniques and/or nuclear medicine techniques such as positron emission tomography (PET)) could help in situations that would otherwise lead to a stroke. Since both primary and secondary prevention measures are often required, we see that the techniques can be helpful in both situations. The diseases that cause stroke that can be investigated are, among others, carotid stenosis; transient ischemic attacks (TIAs) may also be followed by a major stroke if nothing is undertaken. It has been established that carotid stenosis is to be treated in the presence of a significant lesion that has neurological symptoms. The question of how to deal with these patients often arises when the relationship between the stenosis and symptoms is not significant or the symptomatology unclear. In such situations, either PET and/or fat-saturated T1 images of the carotids can help to demonstrate the embolic nature of the plaque. We have seen that carotid plaque vulnerability, which can cause embolism, can be associated with plaque inflammation (seen on PET) or plaque haemorrhage (seen on MR images). Also, while PET and MRI will demonstrate different stages of plaque vulnerability, they can both help to demonstrate vascular lesions that are at risk of causing significant ischemic events. Diffusion-weighted imaging (DWI) has shown that some TIAs may indeed be ischemic brain lesions with a transient symptomatology. The early use of DWI can thus help treat these patients more acutely. Based on this, we have seen that newer imaging techniques can provide additional knowledge about conditions that may lead to stroke and be treated. This should have a major impact on patient outcomes and ultimately on healthcare costs related to this condition.

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

BACKGROUND

Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment.

OBJECTIVE OF THE REVIEW

This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department.

DISCUSSION

Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions.

CONCLUSIONS

The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

Management and Short-Term Follow-Up Study of Transient Ischaemic Attack Patients in a University Teaching Hospital

Objective

The aim of this study was to describe the management of patients admitted to a university teaching hospital in China who were diagnosed of having transient ischaemic attack (TIA) and to determine the outcome within a 7-day and 90-day period.

Methods

A retrospective, hospital-based study included consecutive patients having TIA from July 2009 to February 2013 was performed. Demographic data, risk factors, symptoms, clinical management, ABCD2 scores were analysed. The main outcome variable was the occurrence of TIA and ischaemic stroke during the 7 and 90 days follow up periods.

Results

A total of 157 patients were evaluated. After excluding 3 patients (1.9%) because they were lost to follow-up, 154 patients were included in the study. All patients underwent a cranial computed tomogram (CT) to exclude intracranial haemorrhage. If the cranial CT scan result was negative for bleeding or other diagnoses, further comprehensive tests would be initiated following a standardised clinical assessment protocol at the time of hospitalisation. Totally 148 (96%) patients received antiplatelet therapy and 6 (4%) patients received anticoagulation therapy. Eight (5.2%) patients received stenting therapy. Only 3 (1.9%) and 6 (3.8%) TIA patients developed subsequent TIA within 7 days and 90 days respectively. Twelve (7.8%) TIA patients developed ischaemic stroke within 7 days and 19 (12.3%) within 90 days. All the 6 patients who had recurrence of TIA within 90 days proceeded to develop ischaemic stroke. The ABCD2 scores of patients experienced subsequent TIA and ischaemic stroke (4.94±1.39, n=19) were significantly higher than those of patients without recurrence (3.91±1.37, n=135; p<0.05). None of the patients who received stenting therapy developed subsequent TIA or ischaemic stroke during the follow up period.

Conclusions

Our findings suggest that in-patient evaluation and management of TIA may be a safe and effective strategy. Rapid diagnosis and implementation of treatments for TIA patients are crucial to reduce stroke risk. (Hong Kong j.emerg.med. 2014;21:92-97)

High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack

Background and Purpose

Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD² scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD² scores, in-hospital ischemic events, and in-hospital treatments after TIA admission.

Methods

We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD² scores.

Results

Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD² scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD² score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20).

Conclusions

Higher ABCD² scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of ‘low-risk’ patients.

Development of a new stroke scale in an emergency setting

Background

Early identification of stroke is crucial to maximize early management benefits in emergency departments. This study aimed to develop and validate a new stroke recognition instrument for differentiating acute stroke from stroke mimics in an emergency setting.

Methods

A prospective observational cohort study among suspected stroke patients presenting to Emergency Department in the Second Affiliated Hospital of Guangzhou Medical University was conducted from May 2012 to March 2013. The symptoms and signs of suspected stroke patients were collected. Logistic regression analysis was used to identify the factors associated with acute stroke. The symptoms and signs closely associated with acute stroke were selected to develop the new stroke scale, Guangzhou Stroke Scale (GZSS). The diagnostic value of GZSS was then compared with ROSIER, FAST and LAPSS. The primary outcome was confirmed stroke by CT within 24 h.

Results

Four hundred and sixteen suspected stroke patients (247 ischemia, 107 hemorrhage, 4 transient ischemic attack, 58 non-stroke) were assessed. A new stroke scale, GZSS (total score from −1 to 8.5), was developed and consisted of nine parameters: vertigo (−1), GCS ≤ 8 (+2), facial paralysis (+1), asymmetric arm weakness (+1), asymmetric leg weakness (+1), speech disturbance (+0.5), visual field defect (+1), systolic blood pressure ≥145 mmHg (+1) and diastolic blood pressure ≥95 mmHg (+1). Among the four scales, the discriminatory value (C-statistic) of GZSS was the best (AUC: 0.871 (p < 0.001) when compared to ROSIER (0.772), LAPSS (0.722) and FAST (0.699). At an optimal cut-off score of >1.5 on a scale from −1 to 8.5, the sensitivity and specificity of GZSS were 83.2 and 74.1 %, whilst the sensitivities and specificities of ROSIER were 77.7 and 70.7 %, FAST were 76.0 and 63.8 %, LAPSS were 56.4 and 87.9 %.

Conclusion

GZSS had better sensitivity than existing stroke scales in Chinese patients with suspected stroke. Further studies should be conducted to confirm its effectiveness in the initial differentiation of acute stroke from stroke mimics.

A New Approach to the Diagnosis of Acute Dizziness in Adult Patients

Dizziness is a common chief complaint in emergency medicine. The differential diagnosis is broad and includes serious conditions, such as stroke, cardiac arrhythmia, hypovolemic states, and acute toxic and metabolic disturbances. Emergency physicians must distinguish the majority of patients who suffer from benign self-limiting conditions from those with serious illnesses that require acute treatment. Misdiagnoses are frequent and diagnostic test costs high. The traditional approach does not distinguish benign from dangerous causes and is not consistent with best current evidence. This article presents a new approach to the diagnosis of acutely dizzy patients that highly leverages the history and the physical examination.

Radix Ilicis Pubescentis total flavonoids ameliorates neuronal damage and reduces lesion extent in a mouse model of transient ischemic attack

Flavonoids are a major component in the traditional Chinese medicine Radix Ilicis Pubescentis. Previous studies have shown that the administration of Radix Ilicis Pubescentis total flavonoids is protective in cerebral ischemia. However, to our knowledge, no studies have examined whether the total flavonoids extracted from Radix Ilicis Pubescentis prevent or ameliorate neuronal damage following transient ischemic attacks. Therefore, Radix Ilicis Pubescentis total flavonoids question and the potential underlying mechanisms. Thus, beginning 3 days before the induction of a mouse model of transient ischemic attack using tert-butyl hydroperoxide injections, mice were intragastrically administered 0.3, 0.15, or 0.075 g/kg of Radix Ilicis Pubescentis total flavonoids daily for 10 days. The results of spectrophotometric analyses demonstrated that Radix Ilicis Pubescentis total flavonoids enhanced oxygen free radical scavenging and reduced pathological alterations in the brain. Hematoxylin-eosin staining results showed that Radix Ilicis Pubescentis total flavonoids reduced hippocampal neuronal damage and cerebral vascular injury in this mouse model of transient ischemic attack. These results suggest that the antioxidant effects of Radix Ilicis Pubescentis total flavonoids alleviate the damage to brain tissue caused by transient ischemic attack.

TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo

Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such as stroke, can be substantial. Most physicians use a diagnostic paradigm developed more than 40 years ago that focuses on the type of dizziness, but this approach is flawed. This article proposes a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (TiTrATE). Patients fall into 1 of 4 major syndrome categories, each with its own differential diagnosis and set of targeted examination techniques that help make a specific diagnosis. Following an evidence-based approach could help reduce the frequency of misdiagnosis of serious causes of dizziness. In the spirit of the flipped classroom, the editors of this Neurologic Clinics issue on emergency neuro-otology have assembled a collection of unknown cases to be accessed electronically in multimedia format. By design, cases are not linked with specific articles, to avoid untoward cueing effects for the learner. The cases are real and are meant to demonstrate and reinforce lessons provided in this and subsequent articles. In addition to pertinent elements of medical history, cases include videos of key examination findings.

Prevalence, knowledge, and treatment of transient ischemic attacks in China

OBJECTIVES

To investigate the prevalence, knowledge, and treatment of TIA in a Chinese adult population.

METHODS

We conducted a complex, multistage, probability sampling-designed, cross-sectional, nationwide survey of 98,658 Chinese adults in 2010. Possible TIA cases were first identified by symptoms recall or self-reported history of TIA through face-to-face interviews, and the final diagnosis was then made by expert neurologists through phone interviews or record review.

RESULTS

The age-standardized prevalence of TIA was 2.27%. Clinically, only 16.0% of the participants were diagnosed before the study. The prevalence of TIA was higher in women and in patients who were older, had less education, were current smokers, lived in rural or undeveloped areas, and had a history of stroke, hypertension, myocardial infarction, dyslipidemia, or diabetes. Based on the survey responses, approximately 3.08% of Chinese adults had knowledge of TIA. Among patients with TIA, only 5.02% received treatment and 4.07% received guideline-recommended therapy.

CONCLUSIONS

TIA is prevalent and an estimated 23.9 million people in China may have experienced a TIA. Public knowledge on TIA is very limited. TIA appears to be largely undiagnosed and untreated in China. There is an urgent need to develop strategies to improve the identification and appropriate management of TIA.

Metabolic syndrome, platelet activation and the development of transient ischemic attack or thromboembolic stroke

Stroke is the second most common cause of mortality in the world today, where transient ischemic attack (TIA) is a period of focal ischemia, the symptoms of which resemble a thromboembolic stroke. Contrary to stroke, TIA symptoms typically last less than one hour and necrosis is absent. Stroke is often preceded by TIA, making it an important predictor of future ischemic events. The causal role of atherosclerosis in the development of TIA is well established, however, research indicates that the atherosclerotic process begins years earlier with the development of metabolic syndrome, which affects approximately 45% of the adult population worldwide. Metabolic syndrome is present if three or more of the following is present: increased waist circumference, increased triglycerides, decreased HDL, increased fasting glucose and hypertension. This syndrome causes systemic inflammation that activates the coagulation system and may cause the formation of pathological thrombi. The role of platelets in stroke has been studied and platelet activation pathways identified. ADP and thromboxane A(2) are the most common activators of platelets in normal physiology. Several pharmacological treatments have been employed to prevent the activation of platelets, the most common of which include aspirin and P2Y(12)-inhibitors. Although treatment is administered strokes and subsequent TIAs are very common in individuals that suffered an initial event. This indicates that research needs to be done in order to elucidate new therapeutic targets, but also to better treat ischemic events to not only decrease the amount of recurring events but also decrease stroke mortality worldwide.

A blood-based biomarker panel to detect acute stroke

BACKGROUND

The aim of this study was to develop an adjunctive, peripheral biomarker test to differentiate ischemic strokes, intracranial hemorrhages (ICHs), and stroke mimics in the acute setting.

METHODS

Serum samples were collected from 167 patients who presented with an acute neurologic deficit within 24 hours of symptom onset. Patients were adjudicated to ischemic stroke, ICH, and mimic pathology groups based on clinical and radiographic findings. Samples were tested for levels of 262 potential markers. A multivariate Cox proportional hazards regression model of 5 biomarkers was built by stepwise selection and validated by bootstrapping. Its discriminative capacity was quantified by C index and net reclassification improvement (NRI).

RESULTS

The final model consisted of eotaxin, epidermal growth factor receptor, S100A12, metalloproteinase inhibitor-4, and prolactin. It demonstrated a discriminative capacity for ischemic stroke versus mimic (C = .92), ischemic stroke and ICH versus mimic (C = .93), and ischemic stroke versus ICH (C = .82). The inclusion of biomarkers to a model consisting of age, race, and gender resulted in an NRI of 161% when detecting ischemic stroke versus mimic (P < .0001), an improvement of 171% when detecting ischemic strokes plus ICH versus mimic (P < .0001), and an improvement of 56% when detecting ischemic strokes versus ICH (P = .1419).

CONCLUSIONS

These results suggest that information obtained from a 5-biomarker panel may add valuable information in the early evaluation and management of patients with stroke-like symptoms.

Results of an outpatient transient ischemic attack evaluation: a 90-day follow-up study

BACKGROUND

Transient ischemic attack (TIA) is common and precedes 15% of strokes. TIA should be managed as a time-sensitive illness to prevent a subsequent stroke. However, management of TIA is heterogeneous, with little consensus about its optimal assessment.

OBJECTIVE

The objective of this study was to determine the outcome of patients with TIA evaluated in the Emergency Department (ED) and managed as outpatients within a 90-day period after discharge.

METHODS

All patients with symptoms of TIA admitted to the ED were eligible for inclusion. Patients were evaluated by an Emergency Physician who followed a decision algorithm used in the selection of patients for discharge. The main outcome variable was the occurrence of stroke during the 90 days after discharge from the ED.

RESULTS

During a 1-year period, a total of 118 patients were evaluated for TIA in the ED, representing 1.4% of ED medical admissions: 56 (47.5%) were hospitalized and 62 (52.5%) were discharged and enrolled in the outpatient TIA management. Two (3.2%) of the discharged patients could not be contacted for follow-up. Among the patients managed as outpatients, one (1.7%) presented with an ischemic stroke and 3 (5%) experienced a subsequent TIA within a period of 90 days after discharge from the ED. The rate of stroke predicted from the ABCD2 score was 9.7% at 90 days.

CONCLUSION

The results of our study suggest that outpatient management of TIA, as described in our institution's guidelines, may be a safe and effective strategy, but further confirmatory studies should be performed.

Temporal Patterns of Hospital Admissions for Transient Ischemic Attack: A Retrospective Population-based Study in the Emilia-Romagna Region of Italy

Acute cerebrovascular events are not randomly distributed over time but show specific temporal patterns of occurrence. However, most studies focused stroke and little is known about transient ischemic attack. This study aimed to explore the existence of a temporal pattern of transient ischemic attack and the possible influence by the most common risk factors. The analysis included all hospital admissions with the ICD9-CM code for TIA, recorded in the database of the Emilia Romagna region of Italy (1998-2006; n = 43642, mean age 76.8 ± 11.5 years, 45.5% males). Transient ischemic attack was most frequent in autumn and winter and less common in spring and summer (P < 0.0001), with the highest number of cases in October and the lowest in February, and also most frequent on Monday (P < 0.0001). This study shows a seasonal and weekly pattern in occurrence of transient ischemic attack, independent of sex and the presence of the most common risk factors.