ABCD2 Score in TIA

ID: 83 y/o ♀, w/o significant medical comorbidities,  came in to the ER after experiencing an episode of double vision and imbalance. 

HPI: Sx started suddenly about 2hr ago while sitting. Double vision in all directions of gaze; imbalance associated with spinning sensation; able to walk without assistance but had imbalance; Sx lasted about 20-25min and gradually disappeared on the way to the ER. BP=202mmHg during that episode even though no Hx of HTN before. No subjective Sx in the ER. The episode was NOT associated with LOC, HA, N/V, slurred speech, unilateral weakness, facial asymmetry. 

PMH: MI 10y ago, no cardiac Sx now.

Meds: ASA 81mg/d, Atorvastatin 20mg/d

All: NKDA

E/O: A+O ✗ 3; NAD; ⊘ ill/toxic

BP Both arms(triage)=193/85

BP Both arms(now)=192/81

VS otherwise unremarkable. 

Neuro: 

Pupils 3mm symmetric; reactive; ⊘ RAPD;

CN II-XII normal;

Sensory/Motor normal; ⊘ pronator drift;

Cerebellar tests normal; Gait normal; Romberg -ve;

VA: 20/40 bilat; ⊘ ▵ compared to before the episode; Fundoscopy normal;

CVS, Resp, Abdo exams unremarkable. 

CBC, rapid metabolic panel, INR, were normal; 

ECG sinus @71 with normal axis and intervals, ⊘ ST-T ▵s;

Head CT nil acute. 

I/P: An 83y/o lady with a brief episode of diplopia and imbalance most probably caused by TIA with an ABCD2 Score of 3. BP 2hr after triage 135/73 w/o anti hypertensive meds. Low risk of progression to stroke in the next 48h. Reassurance; D/C home; F/U with neurology next day; F/U precautions.

Discussion: 


TIA ➜ 10-17% risk of stroke in the next 90d; 50% in the next 2/7; if survive this primary high risk period ➜ 43% 10yr risk of MI, stroke, or vascular death; 

We can use ABCD2 Score to estimate the risk of progression to stoke in patients presenting with TIA.

ABCD2 Score(1): 

A Age: 1=age >60 years,

B Blood pressure: 1=hypertension at the acute evaluation; either sBP>140 OR dBP>90 mmHg)

C Clinical features: 2=unilateral weakness, 1=speech disturbance without weakness

D Duration of symptom: 1=10–59 min, 2=>60 min

D Diabetes: 1=present

INTERPRETATION:

LOW RISK (scores 0–3)=risk of stroke 1.0% at 2

days. Does not need hospital admission, unless other indications, e.g. new onset aFib. 

MODERATE RISK (scores 4–5)=risk of stroke 4.1% at 2 days. Hospital observation justified in most situations.

HIGH RISK (scores 6–7)=risk of stroke 8.1% at 2 days. Hospital observation recommended.

Instead you can use the online free medical calculator, MD-Calc. You can find the link to its website on the “Useful Links” page of the blog. 

Reference: 

1. Hui, D., Leung, A. K. C., & Padwal, R. (2011). Approach to internal medicine: A resource book for clinical practice. New York: Springer. doi:10.1007/978-1-4419-6505-9
Kiefer, M., Chong, C., Pocket Primary Care, 2014