1. TIA Hotline (ASPIRE Project) and TIA Management Thomas Jeerakathil BSc, MD, MSc, FRCP(C) February 23rd, 2009 Telehealth Presentation

2. Objectives What is a TIA and what isn’t? How can we differentiate high risk from low risk TIAs? What are the data? How urgently should TIA patients receive diagnosis, assessment, investigation and management? How to facilitate rapid assessment of TIA? The ASPIRE Project and the TIA Hotline.

3. Patient 1 Jerome is a 85 year old male with HT, CHF, hyperlipidemia. Complains of three spells in the previous four days that have been referred as TIAs Spells involve loss of consciousness Are these TIAs?

4. Diagnosing ‘spells’ Phenomenology: before, during, after the event Was the event witnessed? What did witnesses observe? What is the setting? (vascular risk factors, elderly, young without risk factors)

5. Patient 1 Upon rising from seated to standing patient develops a sense of dizziness and unsteadiness and feels very light- headed Then experiences blurring of the vision starting peripherally and loses consciousness

6. Patient 1 Upon rising from seated to standing patient develops a sense of dizziness and unsteadiness and feels very light- headed Then experiences blurring of the vision starting peripherally and loses consciousness Syncope

7. Top 6 symptoms likely to be a TIA-1 Sudden onset, lasting minutes to hours, resolves 6. Vertigo only if present with brainstem symtoms 5. Hemibody numbness 4. Double vision, crossed numbness or weakness, slurred speech, ataxia of gait

8. Top 6 symptoms likely to be a TIA - 2 3. Speech disturbance for a defined period of time (definite dysarthria, muteness or marked word finding difficulty, paraphasic speech) 2. Monocular or hemifield visual loss (not blurring of entire visual field) 1. Hemibody weakness

9. Top 7 symptoms unlikely to be a TIA 7. Postural dizziness alone 6. Tingling of all 4 extremities 5. Syncopal events 4. Momentary word finding trouble that is not new 3. Positional and recurrent numbness of one limb 2. Scintillating or flashing visual disturbances

10. Symptoms unlikely to be a TIA - 2 1. Almost anything with hyperventilation or chest pain (but make sure it isn’t cardiac!)

11. How do we identify high risk TIA? Coutts et al. Annals of Neurology 2005

12. 90 Day Prognosis after ED Dx of TIA 180 / 1707 (10.5%) patients had stroke –91 occurred in first 2 days –Age > 60, DM, Sx > 10 min, weakness, speech 428 (25.1%) had some adverse event –More than half occurred in first 4 days Johnston SC, JAMA 2000;284:2901-2906

13. 1 Independent risk factors for stroke following suspected TIA include: Independent risk factors for stroke following suspected TIA include: Age > 60 years Age > 60 years Diabetes mellitus Diabetes mellitus Motor weakness Motor weakness Speech impairment Speech impairment Symptom duration > 10 minutes Symptom duration > 10 minutes Independent Risk Factors for Stroke Following TIA Johnston et al. JAMA 2000;284:2901-6.

14. 1 ABCD rule for stratifying risk after TIA – assign points Age > 60 = 1 BP during event > 140 systolic or > 90 diastolic = 1 Clinical features: unilateral weakness = 2; speech disturbance without weakness =1; other = 0 Duration of symptoms (minutes): >= 60 = 2; 10-59 =1 ; < 10 = 0 Rothwell, Lancet 2005; 366: 29–36

15. 1 ABCD 2 Score Diabetes added and scores 1 extra point

16. Predictive Value of the ABCD2 progostic score

17. 1 Alberta TIA Study Identified all ED diagnoses of stroke across Alberta for 1 fiscal year using admin data Identified all ED diagnoses of stroke across Alberta for 1 fiscal year using admin data 2285 TIAs 2285 TIAs 2 day stroke rate 1.4% (readmissions) 2 day stroke rate 1.4% (readmissions) 7 day stroke rate 6.7% 7 day stroke rate 6.7% 30 day stroke rate 9.5% 30 day stroke rate 9.5% 1 year stroke rate 15%; stroke or death 21% 1 year stroke rate 15%; stroke or death 21% ASPIRE Consensus meeting Aug 2008; ASPIRE Consensus meeting Aug 2008; Data for ABCD symptoms/scores applied to Alberta population Data for ABCD symptoms/scores applied to Alberta population

18. 1 ABCD ABCD 2005; 3 groups ABCD 2005; 3 groups Derivation (prob and def TIA) (n=209) – 18 strokes Derivation (prob and def TIA) (n=209) – 18 strokes Validation cohort (prob and def TIA) (n=190) – 20 strokes Validation cohort (prob and def TIA) (n=190) – 20 strokes Referal population for validation cohort (all referrals) (n=378) – 20 strokes Referal population for validation cohort (all referrals) (n=378) – 20 strokes

19. 1 ABCD2 ABCD2 2007 ABCD2 2007 Evaluated ABCD and California rule each in 6 different populations Evaluated ABCD and California rule each in 6 different populations Created a combined ABCD2 score Created a combined ABCD2 score 6 study groups 6 study groups

20. 1 Symptoms – ABCD2 6 study groups; 4809 patients; 442 strokes 6 study groups; 4809 patients; 442 strokes Derivation cohorts Derivation cohorts California ED – 1707 California ED – 1707 Oxford popln based – 209 Oxford popln based – 209 Validation cohorts Validation cohorts California ED2 – 1069 California ED2 – 1069 California clinic – 962 California clinic – 962 Oxford popln based -547 Oxford popln based -547 Oxford clinic 315 Oxford clinic 315

21. 1 21 Prognostic scores for screening: caution advised Highest scores medium scores lowest scores = recurrent stroke Most events actually occur in those of medium risk! So be careful of too high a cutoff.

22. 1 Impression: Either ABCD2 >=4 OR Speech or motor symptoms can identify high risk symptoms They have similar sensitivity (88-100%) and specificity (31- 52%) to identify high risk stroke patients ASPIRE Consensus group choose these cutoffs for TIA Triaging within Alberta

23. 1 23 How urgently should high risk TIA patients be assessed? Does it make a difference?

25. Express Study

27. ASPIRE TIA Triaging Consensus Urgent triage and assessment of TIA province-wide deserves evaluation within Alberta TIA Triaging algorithm created at Aug 2008 meeting Facilitate urgent access using a TIA Hotline Backing of the APSS and the Educational Strategy of the APSS Pocket cards have been produced

31. Hotline process North - every TIA hotline call will result in contact with a Telestroke Neurologist South - TIAs will be screened by operator using risk algorithm; High or medium risk or if refering physician requests it still - Stroke Neurologist Low risk and if no specific request - fax referral in to clinic

32. ASPIRE Data The TIA Hotline and TIA Triaging Strategy overlap with APSS Educational Strategy as well as Pillar 1 - quality improvement Data will be tracked by TIA Hotlines (SARC in the south and the CCL/UCL in the north) Stroke Prevention Clinic referral forms will be faxed to a central number to track all TIAs that come to referral across the province

33. ASPIRE Outcomes Rate of recurrent stroke determined by presentations to emergency departments and admissions to hospital will be tracked using administrative data Two years ‘pre’ compared to two years ‘post’ implementation Is the TIA Hotline/Triaging strategy effective? Is it worth the cost and effort? Ongoing feedback and refinement

34. TIA Hotline ‘go live’ dates North including Red Deer (1-888-282- 4825) Goes live March 16, 2009 South excluding Red Deer (1-800-661- 1700) Goes live March 16th, 2009

35. THANK YOU!