The Consensus Statement includes two parts, the Consensus Statement itself, and the Recommendation to the European Stroke Organisation (ESO) on revision of ESO Guidelines. Please note that the final text of the Guidelines, is decided by ESO and that the recommendation in this document may not be the final guidelines version. As soon as the guidelines are confirmed, they will appear on this website as well as on the ESO website www.eso-stroke.org

A. Karolinska Stroke Update Consensus Statement

TIA - management in TIA clinics or stroke unit care?

The following Consensus Statement was adopted by the 7th Karolinska Stroke Update meeting on November 17, 2008.

The consensus statement was proposed by the chairman of the session, Dr Peter Ringleb, Heidelberg, the co-chair Professor Vida Demarin, Zagreb, and the session secretary Dr Jean-Luc af Geijerstam, Stockholm, together with the speakers of the session. The statement was then finally approved by the participants of the meeting, after listening to the different presentations.
The speakers in this session were Professor Pierre Amarenco, Paris, and Professor Gary Ford, Newcastle.

Controversies to discuss at the 2008 consensus session:

Where should TIA-patients be treated?

• Should clinical scores (such as ABCD2) be used to assess the risk of recurrent events?
• How long should a TIA patient be kept in hospital?
• Which neuroimaging should be done after a TIA?
• Are there differences regarding pharmacological treatments between TIAs and complete strokes?

Background

Several studies demonstrated a high risk of stroke immediately after a TIA [2, 8]. Several score system based on clinical characteristics helps do distinct patients with lower from those with increased risk [3, 10]. In addition patients with severe extra- or intracranial stenosis carry a particularly high recurrence risk [7]. Observational studies showed that urgent evaluation at a TIA clinic and immediate initiation of treatment reduces stroke risk after TIA [5, 9]. It has been shown that early management of TIA-patients in a stroke unit leads to specific treatments in a significant proportion of cases [1]. It can be suspected that treatment on a stroke unit is also sufficient to reduce recurrence risk, although this has not been proven in a prospective trial.

Discussion

Which type of care should be provided to patients with a TIA depends on local situations. In patients with suspected TIA general and neurological examination followed by diagnostic brain imaging and examination of the brain supplying arteries must be performed immediately. Patients with increased stroke risk should be admitted to a stroke unit and monitored for at least 24 hours. Clinical scores and basic technical diagnostic methods can help to select those patients.
Several studies have demonstrated that many patients with completely resolved clinical symptoms have lesions on diffusion weighted MRI (DWI). However, there are only limited data, demonstrating an increased risk for stroke recurrence in DWI-positive patients as compared to patients with normal brain imaging [6, 7]. Until it is not proven convincingly that patients with DWI-lesions have higher recurrence risk as compared to those without brain lesions, CT-imaging and a thorough clinical examination done by a stroke experienced physician are sufficient as standard diagnostic.
The overall secondary prevention strategies for TIA-patients do not differ from those for patients with completed stroke. However some substances commonly used for stroke-patients are not approved for TIA-patients, e.g. Clopidogrel in Germany. In such a situation patients has to be informed about the off-label use. The role of more aggressive strategies, like dual antiplatelet therapy in the first days should be evaluated in the setting of randomized trials [4].

Conclusion

•  Patients with suspected TIA should be investigated and treated as emergencies at a TIA-clinic with specialized assessment or admitted to a stroke unit.

•  Clinical scores and basic technical diagnostic methods can be used to help

•  In patients with TIA, immediate MRI or cranial CT, is recommended.

•  In patients with TIA, minor stroke or early spontaneous recovery immediate diagnostic work-up within 24 hours, including urgent vascular imaging (ultrasound, CT-angiography, or MR angiography) is recommended.

• The overall secondary prevention strategies for TIA-patients do not differ from those for patients with completed stroke.

References:

1.    Calvet D, Lamy C, Touze E et al. (2007) Management and outcome of patients with transient ischemic attack admitted to a stroke unit. Cerebrovasc Dis 24:80-5

2.    Giles MF, Rothwell PM (2007) Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 6:1063-72

3.    Johnston SC, Rothwell PM, Nguyen-Huynh MN et al. (2007) Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 369:283-92

4.    Kennedy J, Hill MD, Ryckborst KJ et al. (2007) Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial. Lancet Neurol

5.    Lavallee PC, Meseguer E, Abboud H et al. (2007) A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 6:953-60

6.    Prabhakaran S, Chong JY, Sacco RL (2007) Impact of abnormal diffusion-weighted imaging results on short-term outcome following transient ischemic attack. Arch Neurol 64:1105-9

7.    Purroy F, Montaner J, Rovira A et al. (2004) Higher risk of further vascular events among transient ischemic attack patients with diffusion-weighted imaging acute ischemic lesions. Stroke 35:2313-9

8.    Rothwell PM, Coull AJ, Silver LE et al. (2005) Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study). Lancet 366:1773-83

9.    Rothwell PM, Giles MF, Chandratheva A et al. (2007) Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 370:1432-42

10.  Rothwell PM, Giles MF, Flossmann E et al. (2005) A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 366:29-36

B. Recommendation by Karolinska Stroke Update participants to ESO Guidelines Committee to revise ESO guidelines:

New text marked red

Stroke Services and Stroke Units

Recommendations

• It is recommended that all stroke patients should be treated in a stroke unit (Class I, Level A)

• It is recommended that patients with suspected TIA are investigated and treated  as emergencies within 24 hours at a TIA-clinic with specialized assessment (Class III, Level B) or admitted to a stroke unit.

• It is recommended that healthcare systems ensure that acute stroke patients have access to high-technology medical and surgical stroke care when required (Class III, Level B)

• The development of clinical networks, including telemedicine, is recommended to expand access to high-technology specialist stroke care (Class II, Level B)

Providing Stroke Services

All acute stroke patients require specialist multidisciplinary care delivered in a stroke unit, and selected patients will require additional high-technology interventions. Health services need to establish the infrastructure to deliver these interventions to all patients who require them: the only reason for excluding patients from stroke units is if their condition does not warrant active management. Recent consensus documents [11, 106] have defined the roles of primary and comprehensive stroke centres (table 4).

Several studies demonstrated a high risk of stroke immediately after a TIA [84, 6]. Several score system based on clinical characteristics helps do distinct patients with lower from those with increased risk [Johnston SC, Rothwell PM]. In addition patients with severe extra- or intracranial stenosis carry a particularly high recurrence risk [Purroy F]. Observational studies showed that urgent evaluation at a TIA clinic and immediate initiation of treatment reduces stroke risk after TIA [85, 86]. It has been shown that early management of TIA-patients in a stroke unit leads to specific treatments in a significant proportion of cases [Calvet D]. It can be suspected that treatment on a stroke unit is also sufficient to reduce recurrence risk, although this has not been proven in a prospective trial.

Diagnostic Imaging

Recommendations

• In patients with suspected TIA or stroke, urgent cranial CT (Class I), or alternatively MRI (Class II), is recommended (Level A)

• If MRI is used, the inclusion of diffusion-weighted imaging (DWI) and T2*-weighted gradient echo sequences is recommended (Class II, Level A)

• In patients with TIA, minor stroke or early spontaneous recovery, immediate diagnostic work-up within 24 hours, including urgent vascular imaging (ultrasound, CT angiography, or MR angiography), is recommended (Class I, Level A)

Imaging of the brain and supplying vessels is crucial in the assessment of patients with stroke and TIA. Brain imaging distinguishes ischaemic stroke from intracranial haemorrhage and stroke mimics, and identifies the type and often also the cause of stroke; it may also help to differentiate irreversibly damaged tissue from areas that may recover, thus guiding emergency and subsequent treatment, and may help to predict outcome. Vascular imaging may identify the site and cause of arterial obstruction, and identifies patients at high risk of stroke recurrence.

Observational studies showed that urgent evaluation at a TIA clinic and immediate initiation of treatment reduces stroke risk after TIA [85, 86]. It has been shown that early management of TIA-patients in a stroke unit leads to specific treatments in a significant proportion of cases [Calvet D].

References:

New references:

[Calvet D] Calvet D, Lamy C, Touze E et al. (2007) Management and outcome of patients with transient ischemic attack admitted to a stroke unit. Cerebrovasc Dis 24:80-5

[Johnston SC] Johnston SC, Rothwell PM, Nguyen-Huynh MN et al. (2007) Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 369:283-92

[Purroy F] Purroy F, Montaner J, Rovira A et al. (2004) Higher risk of further vascular events among transient ischemic attack patients with diffusion-weighted imaging acute ischemic lesions. Stroke 35:2313-9

[Rothwell PM] Rothwell PM, Giles MF, Flossmann E et al. (2005) A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 366:29-36

Existing references:

6. Rothwell PM, Coull AJ, Silver LE, Fairhead JF, Giles MF, Lovelock CE, Redgrave JN, Bull LM, Welch SJ, Cuthbertson FC, Binney LE, Gutnikov SA, Anslow P, Banning AP, Mant D, Mehta Z: Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study). Lancet 2005;366:1773-1783.

84. Giles MF, Rothwell PM: Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2007;6:1063-1072.

85. Lavallee PC, Meseguer E, Abboud H, Cabrejo L, Olivot JM, Simon O, Mazighi M, Nifle C, Niclot P, Lapergue B, Klein IF, Brochet E, Steg PG, Leseche G, Labreuche J, Touboul PJ, Amarenco P: A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007;6:953-960.

86. Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JN, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC, Welch SJ, Bosch S, Carasco-Alexander F, Silver LE, Gutnikov SA, Mehta Z: Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007;370:1432-1442