Brain Trauma Stroke
Table 3: Clinical Features and Scoring for the ABCD and ABCD2 Scores24,25
Element A Age B BP C Clinical features Category
≥60 years
SBP >140 or DBP ≥90 Other
Unilateral weakness Speech disturbance
(no weakness) Other
D Duration D Diabetes Total ≥60 minutes
10–59 minutes
ABCD ABCD2 Score 1
Score 1
0 1 0 2 1
0 2 1 0
NA NA 6
0 1 0 2 1
0 2 1 0 1 0 7
BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood pressure.
Figure 1: Area Under the Receiver Operating Characteristic Curves for the Predictive Value of the ABCD Score in the Three Cohorts Used for Validation
1 0.8 0.6 0.4 0.2 0
loosely to describe a syndrome of acutely disordered cognition, sometimes associated with a reduced level of consciousness and abnormal attention. The syndrome is very common, especially in the elderly and in patients with dementia, and presentations vary widely in terms of both speed of onset and severity.16
The differential
diagnosis is broad and includes almost any medical condition, but the most common causes are sepsis, adverse drug reaction and metabolic derangement.17
Delirium can be mistaken for a TIA in cases that are mild, when the predominant feature is interpreted as language disorder as opposed to confusion and when important clinical details are unclear, such as when a witness account is unavailable, the patient has cognitive impairment or there is a long delay between the event and assessment. Reliable differentiation between TIA and delirium is important because each carries a potentially poor prognosis – although for very different reasons – and the treatments are dissimilar. Features suggestive of delirium include the presence of a causative factor such as urinary tract sepsis, an inability of the patient to clearly remember the event, fluctuating disturbance in attention and consciousness and the absence of a clearly sudden onset.
Syncope and Pre-syncope
Syncope is the abrupt loss of consciousness associated with the loss of postural tone, usually followed by a rapid and complete recovery; pre-syncope is a premonitory sensation of syncope. Although the time course of syncope is consistent with TIA, the lack of focal neurological disturbance is definitely not and the diagnosis should therefore only be made with considerable caution. Diagnostic confusion can sometimes be caused by TIA of the brainstem causing transient quadriparesis presenting with a sudden loss of postural tone, but loss of consciousness is not a feature. Infrequently, embolus to the tip of the basilar artery can present with sudden-onset coma, but this is virtually never a transient, self-limiting condition and other signs of brainstem dysfunction are always present and obvious.18
0 0.2 Cohort 1 Source: Rothwell et al., 2005.24
The differential diagnosis of true vertigo is divided into peripheral causes, including benign positional vertigo, vestibular neuritis and Meniere’s disease, and central causes, one of which is TIA affecting the brainstem. Generally, peripheral causes of vertigo are more common than central causes. Features in the history suggestive of TIA mimics include recurrent stereotypical episodes, presence of provoking factors (head movement), other symptoms of middle ear disease (tinnitus, hearing loss) and absence of other focal brainstem symptoms (visual or speech disturbance, weakness or numbness). Features on examination that are thought to identify a central cause of vertigo include nystagmus that is not suppressed by visual fixation, a normal head thrust test and other features of posterior circulation ischaemia including dysphagia, dysarthria, limb or facial weakness, gaze palsies or upgoing plantar responses.
Delirium or Toxic Confusional State
Delirium, toxic confusional state, metabolic encephalopathy or acute confusional state are terms that are used interchangeably and often
46 0.4 0.6 Specificity Cohort 2 Cohort 3 0.8 1
Isolated Transient Focal Neurological Disturbance of Uncertain Significance
In a significant proportion of patients referred with suspected TIA, no clear diagnosis of either a cerebrovascular event or a mimic can be reached even after thorough clinical assessment and investigation. These are often presentations with isolated focal neurological disturbance with sudden onset and gradual recovery, over seconds to minutes. Several distinct syndromes can be recognised: for instance, isolated and transient vertigo with no other features to suggest a central or peripheral cause, isolated slurred speech or isolated hemisensory loss. Currently, little is known about the cause or significance of these syndromes and rigorous prospective data are required describing associated risk factors, imaging findings and prognosis. However, the outcome is often good and, unlike TIA, these are not associated with a high early risk of recurrent stroke.
Risk Prediction After Transient Ischaemic Attack
The importance of TIA lies in the subsequent risk of stroke and other vascular events. It is well recognised that major stroke is often preceded by a TIA although the symptoms may have neither alarmed the patient at the time nor have been reported to medical attention. Early cohort studies indicated that TIA was a relatively benign
EUROPEAN NEUROLOGICAL REVIEW
Sensitivity
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