THE TIA SERVICE AT KINGS COLLEGE HOSPITAL. Gloria Ekeng Clinical Nurse Specialist for Stroke & TIA Kings College Hospital

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1 THE TIA SERVICE AT KINGS COLLEGE HOSPITAL Gloria Ekeng Clinical Nurse Specialist for Stroke & TIA Kings College Hospital

2 WHAT IS A TIA? A Transient Ischaemic Attack (TIA) is the term used for stroke symptoms that fully resolve within 24 hrs with no residual deficit. It is an important warning of a more serious stroke. Time window for effective treatment among high risk groups is very short.

3 KEY SYMPTOMS OF A TIA ARE Weakness Numbness clumsiness or pins and needles on one side of the body, for example in an arm, leg or the face loss of or blurred vision in one or both eyes slurred speech or difficulty finding some words

4 TIA FACTS 35 people out of every 100,000 each year have a TIA 10-20% of those who have had a TIA will go on to have a stroke within a month. The greatest risk is within the first 72 hours The risk of a recurrent stroke is 30-43% within 5 years

5 PREDICTION OF STROKE RISK In a population based study, the risk of stroke after a first TIA was 8.6% at 7 days and 12% at 30 days. In an Emergency Department (ED) based study in Northern California, the 90 day risk of stroke after a TIA was 10.5% but half of these strokes occurred very early within the first 2 days of the TIA Even more recently it has been shown that 42% of the strokes which occur in the 30 days after a TIA actually occur within the first 24 hours highlighting the need to treat TIAs as an acute medical emergency.

6 WHY BOTHER?... Stroke is preventable. TIA: very high risk factor for a stroke with greatest risk within hours. Therefore patients must be seen, assessed & treated rapidly! (very high risk pts within 24hours by specialist team) Cost to the NHS health economy (NAO Report) billion direct care costs 1.8 billion due to lost productivity & disability 2.4 billion informal care costs 2.6 million bed days / year

7 USING ABCD2 SCORE The ABCD2 Score has been shown to be predictive of the risk of stroke at 2 days after a TIA A score is assigned according to the patient s Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes (Table 1) For patients with an ABCD score of 0-3, the 2 day risk of stroke after a TIA was 1%, for those with a score of 4-5, the 2 day risk was 4.1% and for those with a score of 6-7 the risk was 8.1%

8 TABLE 1

9 PREDICTION OF STROKE RISK There are certain circumstances, however, where the ABCD Score does not quite reflect the patient s true risk. The National Clinical Guideline for Stroke state very clearly that people with crescendo TIAs (two or more TIAs in a week) should be treated as being at high risk of stroke and treated as an emergency even though they may have an ABCD 2 score of 3 or below

10 COMMON TIA MIMICS Migraine Partial seizure Ocular disorders Hypoglycaemia Vestibular disorders Brain tumour Subdural haematoma Arteritis Hyperventilation Primary cerebral amyloid

11 CASE STUDY A 64 year man presented to his GP following a 30 minute episode of speech disturbance and rightsided weakness; by the time he reached the GP s surgery, he had returned to normal and no neurological deficits were noted. MRI of the brain, carotid doppler's and ECG were performed that same day, according to the TIA Protocol. The conventional sequences of the MRI appeared normal, but the Diffusion Weighted Image MRI showed a minute area of infarction (Figure 1).

12 (FIGURE 1). Very small area of infarctio n in L MCA territory

13 THE TIA SERVICE AT KINGS The TIA service at Kings College Hospital is a fast-track service in which all patients with suspected TIA are seen, investigated and treated within 24 hours of referral, 7 days a week All suspected High Risk TIA patients are immediately admitted for observation and workup. Low Risk patients are seen within 24 hours of receipt of the referral. If high grade carotid stenosis is identified, the patient is seen by the vascular surgeons on the same day and booked for early carotid endaterectomy, usually within 48 hours.

14 HOW TO REFER TO THE TIA SERVICE. High risk patients i.e. ABCD2 score of 4 or more Recurrent TIAs Pts in AF or on Warfarin Pts with prominent head and neck pain suggesting dissection should be sent to the Emergency Department (A&E) 24 hours a day, 7 days a week, for same day investigation and admission.

15 HOW TO REFER TO THE TIA SERVICE. Low risk suspected TIAs with a score of 0-3 should be referred immediately to the TIA service: Monday to Friday by contacting the TIA Nurse specialist on or the SpR on call for stroke via KCH switchboard , or by Fax No: On weekends or out of hours, please contact the SpR on call for stroke via switchboard as the TIA nurse is not available and the Fax is not manned.

16 REFERENCES Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. Stroke 2009; 40: Lovett JK, Dennis MS, Sandercock PAG, Bamford J, Warlow CP, Rothwell PM. Very early risk of stroke after a first transient ischaemic attack. Stroke 2003; 34: Johnston SC, Gress DR, Browner WS, Sidney S. Short term prognosis after emergency department diagnosis of TIA. JAMA 2000; 284(22):

17 REFERENCES Chandratheva A, Mehta Z, Geraghty OC, Marquardt L, Rothwell PM On behalf of the Oxford Vascular Study. Population-based study of risk and predictors of stroke in the first few hours after a TIA.Neurology 2009; 72: Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF,Elkins JS, Bernstein AL, Sidney S. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369: Royal College of Physicians Intercollegiate Stroke Working Party. National clinical guidelines for stroke. 3 rd Edition, P47.