Saudi Stroke Standards

TIA assessment Purpose All TIA patients should be risk stratified and receive expedited care based on their risk score to ensure prompt treatment and prevention of a stroke or other complications. Rationale  The risk of stroke is highest in the first few hours and days after a TIA and some of which could be potentially fatal or disabling. I. Two non-randomized studies supported rapid assessment and management of TIA in order to prevent recurrent strokes. II. Two studies in UK and France using historical controls reported an 80% risk reduction in recurrent stroke at 90 days with establishment of rapid referral, assessment and initiation of secondary prevention medications.  The detection of vascular stenosis or occlusion is important to categorize patients who are at risk of recurrent events or stroke.21 It also guides intensive secondary prevention.22  Urgent detection and treatment of atrial fibrillation is important in secondary prevention.  Delayed secondary prevention is associated with worse outcomes, including a higher rate of early stroke recurrence. Standards 21 (Coutts et al. 2012). 22 (Kamal et al. 2015). For all patients with suspected TIA 1. All patients with suspected TIA should be assessed by a professional with neurological expertise urgently. 2. All patients with suspected TIA should commence secondary prevention therapy immediately. 3. All patients with suspected TIA should have detailed history and clinical examination, prognostic (e.g. ABCD2 score) and investigative tests (e.g. basic blood tests, brain and carotid imaging and ECG) at the initial point of healthcare contact, whether first seen in primary or secondary care. A) For patients with suspected TIA and high risk of subsequent stroke Patients with suspected TIA with high risk of stroke (ABCD2 score of 4 or above) should have: 1. Neurological expert assessment should be done within 24 hours of symptoms onset for exclusion of stroke mimics, identification of vascular stroke treatment, identification of likely causes, and appropriate investigation (vascular imaging) and treatment once the diagnosis is confirmed. 2. Patients with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke and to be assessed within 24 hours, regardless of ABCD2 score. 3. Patients with high risk of stroke should have vascular imaging obtained and they should be seen in a specialist TIA clinic within 24 hours if available 4. If urgent assessment and intervention is not available as an out-patient for high risk patients, then they should be admitted to the hospital. For patients with suspected TIA and low risk of subsequent stroke Patients with suspected TIA who are at lower risk of stroke (ABCD2 score of 3 or below) should have: 1. Neurological expert assessment can be done within one week of onset of symptoms for exclusion of stroke mimics, identification of vascular stroke treatment, identification of likely causes, appropriate investigation and treatment 2. Patients with TIA and presents late (more than 1 week after their clinical symptoms) should be treated as having lower risk of stroke. 3. Vascular imaging should be carried out in 48 hours of onset of symptoms and TIA clinic appointment should be completed within 1 week of onset of symptoms. For all patients with confirmed TIA 1. All patients with a confirmed TIA should have ECG, brain imaging and ABCD2 scores completed. 2. All anterior circulation TIA patients should undergo early Carotid imaging with carotid doppler ultrasound, CT angiography, or MR angiography. 3. Carotid imaging ideally has to be done during the initial assessment in the ED but should not be delayed more than 48 hours. 4. Imaging for other types of TIA’s is recommended when it is deemed clinically appropriate. 5. All patients with confirmed TIA should receive education and their family members for stroke prevention via life style modification, preventative treatment and signs and symptoms of stroke requiring emergency treatment. QM