Early Identification and Initial Management of Transient Neurological Event in the Emergency Department / Acute Medical Assessment Unit

1. You CANNOT diagnose TIA prospectively. ALL objective and subjective neurological symptoms and signs must have resolved before you can safely make the diagnosis. Otherwise treat as a STROKE TIA Mimics (see p2) • Migraine 2. TIA is frequently misdiagnosed. If you are unsure, discuss with a senior colleague or stroke specialist. • Syncope (hypotension) • Seizures 3. It is never an error to admit a TIA if you are unsure of diagnosis or future risk. • Psychological (functional) • Sugar (hypo or hyper) Suggestive Clinical Features of TIA: Adult presents to ED/AMAU • Sepsis • Acute/ sudden onset / maximum at with a history suggestive of TIA • Space occupying lesions onset or minor stroke • Lasting less than 24 hours (but usually Vascular Risk Factors • Previous TIA or Stroke less than 1 hour); spontaneous • Atrial fibrillation resolution Evaluation to confirm or exclude • Known Carotid artery disease • Anterior circulation signs typically diagnosis with complete • Hypertension • Type 2 Diabetes Mellitus unilateral i.e. weakness, sensory loss, physical history including • Hyperlipidaemia hemianopia detailed neurology exam • Age > 65 • Focal features • Smoking • Negative symptoms • Coronary artery and peripheral vascular disease TIA Likely ABCD2 Score Initial investigations A — age: 60 years of age or older, • CT or MRI of brain within 24 hours, if 1 point. TIA suspected ( MRI preferable) Perform ABCD2 B — blood pressure at presentation: • Imaging of carotid arteries as soon as 140/90 mmHg or greater, 1 point. possible, but no later than 72 hours, if C — clinical features: unilateral TIA suspected weakness, 2 points; speech disturbance without weakness, 1 point. Investigations • 12 lead ECG, lipids and glucose, FBC, D — duration of symptoms: 60 minutes U+E, coagulation profile or longer ( 2 points), 10-59 min ( 1 point); history of diabetes (1 point) • Consider continuous cardiac monitor x ABCD2 is a prognostic and not a 24 hours ( in patient or out patient) Management diagnostic tool Managing someone with TIA • Start Aspirin (if symptoms resolved (150 – 300mg Admission Criteria Discharge Criteria one-time loading unless contraindicated),statin medication & treat hypertension (seek advice if carotid stenosis) prior to discharge from hospital.

Consider hospital admission for the following patient groups: • Review by Consultant Geriatrician/Neurologist, if • Recurrent TIAs or recent neck injury available, is considered best practice.

• Symptomatic carotid stenosis >50% • Advise patient not to drive x 1/12 • Atrial Fibrillation on or off anticoagulation • ABCD > 3 or Focal motor/speech symptoms & long symptom duration (>1 hour) • Other cause identified (not requiring • Unavailability of rapid access to brain and carotid imaging admission) • Young patient with likely TIA due to non-atherosclerotic disease • ABCD2 score <3 and access to Ambulatory TIA • Poor social supports to alert emergency services in event of recurrent event service within 1 week

Pathways cannot cover all clinical scenarios. Ultimate responsibility for the interpretation and application of these guidelines, the use of current information and a patient's overall care and wellbeing resides with the treating clinician. Date: August 2017 Review Date: August 2019 Transient Neurological Events Most episodes of transient neurology are not TIAs and taking a careful history and a neurological examination is important before arriving at a diagnosis. The treatment of different TNEs varies. Treating some TNEs as TIAs in error may be harmful.

Transient Ischaemic Attacks (TIAs) • Sudden onset and rarely progressive symptoms. • Typically focal, unilateral symptoms with consciousness preserved. • ‘Negative symptoms’ are characteristic e.g. loss of vision in one eye, hemiparesis aphasia, hemisensory loss, hemianopia. • Typically resolve within a few minutes. • Headache, loss of consciousness and positive symptoms (e.g. unusual movements, visual phenomena) are relatively unusual. • Where ANY neurology is still present diagnosis is a STROKE.

Migraine • Atypical Migraine / Migraine with aura frequently presents as ‘TIAs.’ • Many people with migraine have never had it diagnosed. Take a careful headache history. • May not have headache at this presentation, can develop later or never (Acephalgic Migraine) . Headache typically less common / severe in older people. • Characteristically progressive / developing symptoms (e.g. numbness moving from face to arm) • Positive symptoms e.g. fortification spectra, scintillating scotomas, ‘odd ‘sensations. • Sudden severe (Thunderclap) headache or ‘new type’ headache with neurological symptoms is an indication for admission

Focal Seizure • May have history of epilepsy, stroke or head injury ,recent excess alcohol ,new psychotropic medication • Frequently progressive and /or positive symptoms, e.g. twitching, hallucination, etc. • Recurrent and stereotypical episodes . • May be associated with reduced level of consciousness, appear vacant or confused.

Syncope / Pre syncope • Lack focal signs but might have vague neurology (e.g. mild dysarthria, ‘disorientation’). • Systemic symptoms e.g. pallor, sweating, nausea (without vertigo). • May have gradual vision loss in both eyes (‘greying out', ‘receding down tunnel’). • Associated loss of / reduction in level of consciousness. • Often situational: Standing, warm environment, fasting or after a large meal. • History of fainting (including in childhood) or taking antihypertensive medication. Other causes • ‘Dizziness’: Less than 5% of people attending hospitals with dizziness have a stroke or TIA. Require detailed history and examination to assess. Consider using HINTS assessment to differentiate Peripheral from Cerebellar cause of vertigo. • Functional weakness: Variable, inconsistent neurology. ?History of anxiety/ psychiatric illness • ‘Amyloid Spells’: Small surface SAHs causing transient neurology. Like ‘migraine auras’ in older people. Sensory symptoms, transient confusion, speech or visual disturbances common. • Transient Global Amnesia: Lasting 1-8 hours, Global amnesia but biographical facts preserved, new repetitive questioning , often after activity involving valsalva. • Bells palsy, Hypoglycaemia, Delerium, Sepsis, MS, Drug overdose, SOL • Patients with new, focal neurological events need urgent brain imaging no matter the diagnosis. References: • Irish Heart Foundation: Council for Stroke National Clinical Guidelines and Recommendations for the Care of People with Stroke and Transient Ischaemic Attack, Revised Version March 2010 Available online at http://www.irishheart.ie/media/pub/strokereports/FinalMarch2010.pdf • National Institute of Clinical Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, NICE guidelines [CG68]Published date: July 2008. Available online at https://www.nice.org.uk/guidance/cg68 • A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Rothwell, PM et al. The Lancet, Volume 366 , Issue 9479 , 29 – 36 • Higher ABCD2 score predicts patients most likely to have true transient ischemic attack. Josephson SA1, Sidney S, Pham TN, Bernstein AL, Johnston SC. Stroke. 2008 Nov;39(11):3096-8. doi: 10.1161/STROKEAHA.108.514562. Epub 2008 Aug 7 • Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Rothwell PM(1), Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JN, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC, Welch SJ, Bosch S, Alexander FC, Silver LE, Gutnikov SA, Mehta Z; Early use of Existing Preventive Strategies for Stroke (EXPRESS) study. Lancet. 2007 Oct 20;370(9596):1432-42. • H.I.N.T.S. to Diagnose Stroke in the Acute Vestibular Syndrome—Three-Step Bedside Oculomotor Exam More Sensitive than Early MRI DWI • David E. Newman-Toker, Jorge C. Kattah, Arun V. Talkad, David Z. Wang, Yu-Hsiang Hsieh, David E. Newman- Toker; Stroke. Author manuscript; available in PMC 2015 Oct 5.Published in final edited form as: Stroke. 2009 Nov; 40(11): 3504–3510. Published online 2009 Sep 17. doi: 10.1161/STROKEAHA.109.551234