Episode 6: Transient Ischemic Attack (FREE SAMPLE)
Dr. Walter Himmel and Dr. Daniel Selchen discuss the key historical and physical examination maneuvers to determine whether patients with neurologic complaints have had a TIA or whether they have had a TIA mimic. They review the 3 best risk stratification rules including the ABCD2 Score to help us determine who needs to be admitted and who needs timely investigations to reduce vascular morbidity and mortality. The reasoning behind which patients require urgent carotid imaging, echocardiograms and advanced imaging such as CT Angiogram is explained, and the best medication choices are reviewed, as well as the indications for Clopidogrel, Aggrenox, Warfarin, Heparin and carotid endarterectomy in the managment of TIAs. In the second part of the episode, a simple and practical approach to the patient with dizziness is presented, and a discussion on which patients with dizziness need urgent work-up and treatment for vertebrobasilar TIA.
In this episode Dr. Himmel and Dr. Selchen answer questions like: What simple things can we do in the ED for our TIA patients to improve cerebral blood flow? How do we manage blood pressure in the ED after a TIA? What are the limitations of the best stroke risk prediction rules after TIA? How can we differentiate the common TIA and stroke mimics from a true TIA or stroke in the ED? When is IV Heparin indicated for TIA? Why is carotid doppler imaging such an important test? Which patients need an urgent CT Angiogram or MR Angiogram? Which patients with TIA require admission? Which medication is better for stroke prevention after TIA, Clopidogrel or Aggrenox? How good is Warfarin at reducing the risk of stroke in patients with Atrial Fibrillation and TIA? Should we be prescribing antihypertensives for our patients who have had a TIA? When should we suspect carotid or vertebral artery dissection as a cause for TIA? How should we interpret the Dix-Hallpike manoeuvre and the Head-thrust test? How can we differentiate peripheral vs. central causes of vertigo at the bedside? What are the best medications for patients with vertigo? and many many more…..
To Dr. Walter Himmel and Dr. Daniel Selchen
Sirs,
thank you for the useful information you provide throug this important blog. Concerning the clinical assessment of probability of embolic (from the heart or large vessels) TIA (I assume you refer to TOAST, Adams et al. Stroke 1993)I would like to suggest that suddenly occurred monoparesis is also higly predictive of an embolic mechanism. Have I missed this in listning the poadcast?, or does this is lacking in the material? I agree that this sign is more difficult to evaluate than pure cognitive symptoms as dysphasia or neglect. Nevertheless in ED this kind of problem is not unusual, and it challenges differential diagnostic work against peripheral syndromes.
Regards
Carlo Fimiani
Congratulations on your work! The TIA episode is was absolutely fantastic, I was hooked immediately. The handout makes the information stick much better and I will come back to it for sure!
I was a little surprised by the vertigo section, which heavily relied on the traditional symptom approach for classification. I remember two papers form Newman-Toker and Zee et all from Hopkins which casted doubt on that approach. I am not an expert on the topic, but after having read these two articles, I trusted the patients symptoms much less. I found that putting more emphasis on the timing, the number of episodes, the situations that bring it on (head movement etc.), associated symptoms (Meniere etc.) and foremost the physical examination is more reliable than using the often vague description of the patients to label them as one of four types of dizziness. After all patients often have dizziness for the first time in their life and often don’t know the proper words to describe their symptoms.
What do you think?
Mayo Clin Proc. 2007 Nov;82(11):1329-40. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting.
Mayo Clin Proc. 2007 Nov;82(11):1319-28 Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians.