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Acute Med, All Updates, Resus

TIA workup renders ABCD2 unhelpful

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ABCD2 is recommended to stratify the risk of stroke in patients presenting to the ED with TIA symptoms. In some centres this is used to differentiate those that need to be admitted for further evaluation and treatment from those that can be followed up in the outpatient setting. A recent study showed that if a detailed work up was done in the ED on all TIA patients (followed by appropriate intervention), the ABCD2 score did not predict adverse outcomes, which were lower in this cohort than in the original ABCD2 cohort.

STUDY OBJECTIVE: We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack.
METHODS: This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days.
RESULTS: The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days.
CONCLUSION: The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.

An Assessment of the Incremental Value of the ABCD2 Score in the Emergency Department Evaluation of Transient Ischemic Attack
Ann Emerg Med. 2011 Jan;57(1):46-51

Acute Med, All Updates, Guidelines, ICU, Resus

New ICH Guidelines

A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association on the management of spontaneous intracerebral haemorrhage has been published in Stroke. The full text is available here.
In summary:
Medical Treatment for ICH

  • Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively
  • Patients with ICH whose INR is elevated due to oral anticoagulants (OAC) should have their warfarin withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K. Prothrombin Complex Concentrates have not shown improved outcome compared with FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP.
  • rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for OAC reversal in ICH
  • Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus rFVIIa is not recommended in unselected patients. Further research to determine whether any selected group of patients may benefit from this therapy is needed before any recommendation for its use can be made.
  • The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is unclear and is considered investigational
  • Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolism in addition to elastic stockings
  • After documentation of cessation of bleeding, low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset
    • Blood Pressure

    • Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are listed in an accompanying table and may be considered
    • In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering of systolic BP to 140 mm Hg is probably safe

    Inpatient Management and Prevention of Secondary Brain Injury

    • Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursing neuroscience intensive care expertise
    • Glucose should be monitored and normoglycemia is recommended

    Seizures and Antiepileptic Drugs

    • Clinical seizures should be treated with antiepileptic drugs
    • Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury
    • Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs
    • Prophylactic anticonvulsant medication should not be used

    Procedures/Surgery

    • Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A cerebral perfusion pressure of 50 to 70 mmHg may be reasonable to maintain depending on the status of cerebral autoregulation
    • Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness

    Intraventricular Hemorrhage Recommendation

    • Although intraventricular administration of recombinant tissue-type plasminogen activator in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational

    Clot Removal

    • For most patients with ICH, the usefulness of surgery is uncertain. Specific exceptions to this recommendation follow
    • Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended
    • For patients presenting with lobar clots ≥30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered
    • The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational
    • Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding

    Outcome Prediction and Withdrawal of Technological Support

    • Aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withdrawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.

    Prevention of Recurrent ICH

    • In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein ε2 or ε4 alleles, and greater number of microbleeds on MRI
    • After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy
    • After the acute ICH period, a goal target of a normal BP of <140/90 (<130/80 if diabetes or chronic kidney disease) is reasonable
    • Avoidance of long-term anticoagulation as treatment for nonvalvular atrial fibrillation is probably recommended after spontaneous lobar ICH because of the relatively high risk of recurrence. Anticoagulation after nonlobar ICH and antiplatelet therapy after all ICH might be considered, particularly when there are definite indications for these agents. Avoidance of heavy alcohol use can be beneficial. There is insufficient data to recommend restrictions on use of statin agents or physical or sexual activity

    Rehabilitation and Recovery

    • Given the potentially serious nature and complex pattern of evolving disability, it is reasonable that all patients with ICH have access to multidisciplinary rehabilitation. Where possible, rehabilitation can be beneficial when begun as early as possible and continued in the community as part of a well-coordinated (seamless) program of accelerated hospital discharge and home-based resettlement to promote ongoing recovery

    Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
    Stroke published online Jul 22, 2010

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    Stroke thrombolysis benefit decays with time

    Pooled results of several trials comparing recombinant tissue plasminogen activator with placebo in ischaemic stroke quantify the profile of benefit and harm for alteplase in broadly selected patients. Generally, alteplase appears to improve the outcome of one in three patients treated between 1 and 3 h from onset and of one in six patients treated in the 3–4·5 h window, but confers no net benefit beyond that time. Benefit may decrease exponentially (according to an accompanying editorial), so if you are a believer then get in there early.
    Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials
    Lancet. 2010 May 15;375(9727):1695-703

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    Carotid Artery Stenting versus Endarterectomy

    The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) compared the outcomes of carotid-artery stenting with those of carotid endarterectomy among over 2500 patients with symptomatic or asymptomatic extracranial carotid stenosis.
    The authors offer the following conclusions:

    • Stroke was more likely after carotid artery stenting.
    • Myocardial infarction was more likely after carotid endarterectomy, but the effect on the quality of life was less than the effect of stroke.
    • Younger patients had slightly fewer events after carotid-artery stenting than after carotid endarterectomy; older patients had fewer events after carotid endarterectomy.
    • The low absolute risk of recurrent stroke suggests that both carotid-artery stenting and carotid endarterectomy are clinically durable and may also reflect advances in medical therapy.

    Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis
    NEJM May 26 2010 Published Online

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    TIA and stroke definitions

    A quick reminder of the current defintions, as these have changed a couple of times over the last few years:

    • Transient ischemic attack (TIA): a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.
    • An ischemic stroke is defined as an infarction of central nervous system tissue.

    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: The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists.
    Stroke. 2009 Jun;40(6):2276-93 Full Text

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    Magnesium for subarachnoid haemorrhage

    Symptomatic cerebral vasospasm occurs in nearly one-third of patients with aneurysmal subarachnoid hemorrhage and is a major cause of disability and mortality in this population.
    Magnesium (Mg) acts as a cerebral vasodilator by blocking the voltage-dependent calcium channels.. Experimental studies suggest that Mg also inhibits glutamate release by blocking N-methyl-D-aspartate receptors, decreases intracellular calcium influx, and increases red blood cell deformability; all these changes may reduce the occurrence of cerebral vasospasm and minimise brain ischemic injury occurring after SAH.
    One hundred and ten patients within 96 hours of admission for aneurysmal subarachnoid haemorrhage (SAH) were randomised to receive iv magnesium or placebo. Nimodipine was not routinely given. Twelve patients (22%) in the magnesium group and 27 patients (51%) in the control group had delayed ischemic infarction – the primary endpoint (p< .0020; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12– 0.64). Mortality was lower and neurological outcome better in the magnesium group but these results were not statistically significant.
    Larger trials of magnesium in SAH are ongoing.
    Prophylactic intravenous magnesium sulfate for treatment of aneurysmal subarachnoid hemorrhage: A randomized, placebo-controlled, clinical study
    Crit Care Med. 2010 May;38(5):1284-90
    Update September 2012:
    A multicentre RCT showed intravenous magnesium sulphate does not improve clinical outcome after aneurysmal subarachnoid haemorrhage, therefore routine administration of magnesium cannot be recommended.
    Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebo-controlled trial
    Lancet 2012 July 7; 380(9836): 44–49 Free full text
    [EXPAND Click to read abstract]


    Background Magnesium sulphate is a neuroprotective agent that might improve outcome after aneurysmal subarachnoid haemorrhage by reducing the occurrence or improving the outcome of delayed cerebral ischaemia. We did a trial to test whether magnesium therapy improves outcome after aneurysmal subarachnoid haemorrhage.

    Methods We did this phase 3 randomised, placebo-controlled trial in eight centres in Europe and South America. We randomly assigned (with computer-generated random numbers, with permuted blocks of four, stratified by centre) patients aged 18 years or older with an aneurysmal pattern of subarachnoid haemorrhage on brain imaging who were admitted to hospital within 4 days of haemorrhage, to receive intravenous magnesium sulphate, 64 mmol/day, or placebo. We excluded patients with renal failure or bodyweight lower than 50 kg. Patients, treating physicians, and investigators assessing outcomes and analysing data were masked to the allocation. The primary outcome was poor outcome—defined as a score of 4–5 on the modified Rankin Scale—3 months after subarachnoid haemorrhage, or death. We analysed results by intention to treat. We also updated a previous meta-analysis of trials of magnesium treatment for aneurysmal subarachnoid haemorrhage. This study is registered with controlled-trials.com (ISRCTN 68742385) and the EU Clinical Trials Register (EudraCT 2006-003523-36).

    Findings 1204 patients were enrolled, one of whom had his treatment allocation lost. 606 patients were assigned to the magnesium group (two lost to follow-up), 597 to the placebo (one lost to follow-up). 158 patients (26·2%) had poor outcome in the magnesium group compared with 151 (25·3%) in the placebo group (risk ratio [RR] 1·03, 95% CI 0·85–1·25). Our updated meta-analysis of seven randomised trials involving 2047 patients shows that magnesium is not superior to placebo for reduction of poor outcome after aneurysmal subarachnoid haemorrhage (RR 0·96, 95% CI 0·86–1·08).

    Interpretation Intravenous magnesium sulphate does not improve clinical outcome after aneurysmal subarachnoid haemorrhage, therefore routine administration of magnesium cannot be recommended.

    [/EXPAND]

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    International Carotid Stenting Study (ICSS)

    Patients with symptomatic severe carotid artery stenosis do better with carotid endarterectomy than with medical therapy alone. Surgical complications such as bleeding and cranial nerve damage make the alternative strategy of carotid stenting attractive, but a new randomised trial of 1710 patients with over 50% stenosis and symptoms suggests otherwise.
    In favour of stenting, there was one event of cranial nerve palsy in the stenting group compared with 45 in the endarterectomy group, and fewer haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0.0197).

    However the incidence of stroke, death, or procedural myocardial infarction was 8.5% in the stenting group compared with 5.2% in the endarterectomy group (72 vs 44 events; HR 1.69, 1.16-2.45, p=0.006). Risks of any stroke (65 vs 35 events; HR 1.92, 1.27-2.89) and all-cause death (19 vs seven events; HR 2.76, 1.16-6.56) were higher in the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group.
    The authors point out that longer term follow up remains to be looked at, but that carotid endarterectomy should remain the treatment of choice for symptomatic patients with severe carotid stenosis suitable for surgery. However most patients had no complications from either procedure and stenting is also likely to be better than no revascularisation in patients unwilling or unable to have surgery because of medical or anatomical contraindications.
    Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial
    Lancet. 2010 Mar 20;375(9719):985-97

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    Subarachnoid haemorrhage guidelines

    Guidelines on Subarachnoid Haemorrhage are available from the American Heart Association / American Stroke Association.
    Most of the summaries are included below.
    The initial bleed
    The severity of the initial bleed should be determined rapidly because it is the most useful indicator of outcome after aneurysmal SAH, and grading scales that rely heavily on this factor are helpful in planning future care with family and other physicians
    Case review and prospective cohorts have shown that for untreated, ruptured aneurysms, there is at least a 3% to 4% risk of rebleeding in the first 24 hours—and possibly significantly higher—with a high percentage occurring immediately (within 2 to 12 hours) after the initial ictus, a 1% per day to 2% per day risk in the first month, and a long-term risk of 3% per year after 3 months. Urgent evaluation and treatment of patients with suspected SAH are therefore recommended

    Diagnosis

    1. A high level of suspicion for SAH should exist in patients with acute onset of severe headache
    2. CT scanning for suspected SAH should be performed, and lumbar puncture for analysis of CSF is strongly recommended when the CT scan is negative
    3. Selective cerebral angiography should be performed in patients with SAH to document the presence and anatomic features of aneurysms
    4. MRA and CTA may be considered when conventional angiography cannot be performed in a timely fashion

    The degree of neurological impairment using an accepted SAH grading system can be useful for prognosis and triage and should be recorded in the ED. Examples include the Hunt and Hess Scale, Fisher Scale, Glasgow Coma Scale, and World Federation of Neurological Surgeons Scale.
    Medical Measures to Prevent Rebleeding After SAH

    1. Blood pressure should be monitored and controlled to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure
    2. Bedrest alone is not enough to prevent rebleeding after SAH. It may be considered a component of a broader treatment strategy, along with more definitive measures
    3. Although older studies demonstrated an overall negative effect of antifibrinolytics, recent evidence suggests that early treatment with a short course of antifibrinolytic agents combined with a program of early aneurysm treatment followed by discontinuation of the antifibrino- lytic and prophylaxis against hypovolemia and vasospasm may be reasonable, but further research is needed. Furthermore, antifibrinolytic therapy to prevent rebleeding may be considered in certain clinical situations, eg, in patients with a low risk of vasospasm and/or a beneficial effect of delaying surgery.

    Surgical treatment

    1. Surgical clipping or endovascular coiling should be per- formed to reduce the rate of rebleeding after aneurysmal SAH
    2. Wrapped or coated aneurysms and incompletely clipped or coiled aneurysms have an increased risk of rehemorrhage compared with those that are completely occluded and therefore require long-term follow-up angiography. Com- plete obliteration of the aneurysm is recommended whenever possible
    3. For patients with ruptured aneurysms judged by an experienced team of cerebrovascular surgeons and endovascu- lar practitioners to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling can be beneficial. Nevertheless, it is reasonable to consider individual characteristics of the patient and the aneurysm in deciding the best means of repair, and management of patients in centers offering both techniques is probably indicated
    4. Although previous studies showed that overall outcome was not different for early versus delayed surgery after SAH, early treatment reduces the risk of rebleeding after SAH, and newer methods may increase the effectiveness of early aneurysm treatment. Early aneurysm treatment is reasonable and is probably indicated in the majority of cases

    Management of Cerebral Vasospasm

    1. Oral nimodipine is indicated to reduce poor outcome related to aneurysmal SAH. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain.
    2. Treatment of cerebral vasospasm begins with early management of the ruptured aneurysm, and in most cases, maintaining normal circulating blood volume and avoiding hypovolemia are probably indicated
    3. One reasonable approach to symptomatic cerebral vasospasm is volume expansion, induction of hypertension, and hemodilution (triple-H therapy)
    4. Alternatively, cerebral angioplasty and/or selective intraarterial vasodilator therapy may be reasonable after, together with, or in the place of triple-H therapy, depending on the clinical scenario

    Management of Hydrocephalus
    Temporary or permanent CSF diversion is recommended in symptomatic patients with chronic hydrocephalus after SAH
    Ventriculostomy can be beneficial in patients with ven- triculomegaly and diminished level of consciousness after acute SAH
    Management of Seizures
    The administration of prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period
    Management of Hyponatremia

    1. Administration of large volumes of hypotonic fluids and intravascular volume contraction should generally be avoided after SAH
    2. Monitoring volume status in certain patients with recent SAH using some combination of central venous pressure, pulmonary artery wedge pressure, fluid balance, and body weight is reasonable, as is treatment of volume contraction with isotonic fluids
    3. The use of fludrocortisone acetate and hypertonic saline is reasonable for correcting hyponatremia
    4. In some instances, it may be reasonable to reduce fluid administration to maintain a euvolemic state

    Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council, American Heart Association
    Stroke 2009;40;994-1025 (Full Text)
    Other AHA Stroke Guidelines

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    ABCD2 evaluated

    Investigators evaluated in admitted patients with transient ischemic attack, the accuracy of the ABCD2 (age [A], blood pressure [B], clinical features [weakness/speech disturbance] [C], transient ischemic attack duration [D], and diabetes history [D]) score in predicting ischemic stroke within 7 days.
    Of 1667 patients admitted with TIA, 23% developed an ischaemic stroke within 7 days. ABCD2 scores were available in 1054 patients, in whom a low score (0-3) had a negative likelihood ratio for disabling ischaemic stroke with 7 days of 0.16 ((5% CI 0.04-0.64) and sensitivity of 92.2% (83.4-96.5)
    The authors suggest the best application of the ABCD2 score may be to identify patients at low risk for an early disabling ischemic stroke.
    A multicenter evaluation of the ABCD2 score’s accuracy for predicting early ischemic stroke in admitted patients with transient ischemic attack.
    Ann Emerg Med. 2010 Feb;55(2):201-210
    ABCD2 Score Calculator