Emergency Medicine

ACUTE NEUROLOGICAL CONDITIONS

94 General Medical Emergencies

4 Examine the pulse rhythm, heart sounds, blood pressure (in both arms and

postural), listen for carotid bruits and perform a full neurological

assessment.

5 Risk stratify the patient using the ABCD^2 scoring system (see Table 2.8).

Table 2.8 ABCD^2 score for early risk stratification in transient ischaemic attack

Score

Age ≥60 years

Blood pressure ≥140 mmHg (SBP) and/or ≥90 mmHg (DBP)

Clinical signs

Unilateral weakness

Speech disturbance without weakness

Other

Duration

≥60 min

10–59 min

<10 min

Diabetes

1 point

1 point

2 points

1 point

0 points

2 points

1 point

0 points

1 point

Total =

(Max 7)

High risk ≥4 points: with a 7-day risk of completed stroke of 5.9–11.7%.

Low risk 0–3 points: with a 7-day risk of completed stroke of 1.2%.

DBP, diastolic blood pressure; SBP, systolic blood pressure.

Adapted with permission from Johnston C, Rothwell P, Nguyen-Huynh M et al. (2007)

Validation and refinement of scores to predict very early stroke risk after transient

ischaemic attack. Lancet 369 : 283–92.

(i) ABCD^2 score of ≥4 points is considered ‘high-risk’, with a 7-day

risk of completed stroke of 5.9–11.7%.

(ii) ABCD^2 score of 0–3 points is considered ‘low-risk’, with a 7-day

risk of completed stroke of 1.2%.

5 Check a bedside blood glucose test strip. Send blood for FBC, ESR, coagula-

tion profile, blood sugar, ELFTs and a lipid profile in all patients.

6 Perform an ECG and request a CXR.

7 Arrange an urgent CT brain scan to differentiate haemorrhage from infarc-

tion, and to look for a structural, non- vascular lesion.

8 Organize a duplex carotid ultrasound for a suspected carotid territory

ischaemic event as soon as possible, certainly for the high-risk patient with

an ABCD^2 score of ≥4 points.

MANAGEMENT

1 Give aspirin 300 mg orally, then 75–150 mg once daily as soon as the CT scan

has excluded haemorrhage.