We have detected you are using Internet Explorer. To provide the best and most secure experience, please use a modern browser as we do not support Internet Explorer.

Clinical Opal #15 - “It’s as easy as ABCD2... or not.”

Duc, a 57 year old accountant, presents to you one afternoon with a recent episode of slurred speech...

He tells you that about 4 hours previously he was talking to a colleague at work when he noticed his speech suddenly became very slurred. On specific questioning, he says that after about 7-8 minutes it completely resolved and has been normal since. There were no other symptoms at all, in particular headache or motor weakness. This has never happened before.

Duc is usually fit and well, with no significant PMH and on no regular medications. He is a non-smoker and has no FHx of premature CVD.

You suspect a TIA and discuss the need for appropriate investigation and specialist review. However, Duc tells you that he is ‘desperately busy’ at work and not in a position to get the tests done for a few days.

What is the role of the ABCD2 score as a risk stratification tool to help guide urgency of investigation and management?

The ABCD2 score is a widely known tool used to stratify risk of recurrent stroke in adults with suspected TIA. It calculates stroke risk based on the patient’s age, BP, nature and duration of symptoms, and presence of diabetes.

You calculate Duc’s ABCD2 score as 1 point, or ‘low risk’, equating to a 7 day stroke risk of 1.2%.

Risk stratification in TIA patients using ABCD2 has been widely used in the past in an attempt to prioritise urgency of investigation, especially in settings with limited resources. However, a systematic review from 2015 found that ABCD² does not reliably discriminate those at low and high risk of recurrent stroke, and in particular does not identify many patients with carotid stenosis or AF needing urgent intervention.1

The Australian Clinical Guidelines for Stroke Management recommend that ‘use of the ABCD2 risk score in isolation to determine the urgency of investigation may delay recognition of atrial fibrillation and symptomatic carotid stenosis in some patients and should be avoided.’

Therefore, regardless of his low risk score on ABCD2, Duc needs urgent assessment. The stroke guidelines recommend:

  • All TIA patients with anterior circulation symptoms should undergo early carotid imaging with CT angiography, carotid doppler ultrasound or MR angiography (preferably during the initial assessment but not delayed more than 2 days)
  • All TIA patients should routinely undergo brain imaging to exclude stroke mimics and intracranial haemorrhage
  • All TIA patients should be investigated for atrial fibrillation with ECG during initial assessment and referred for possible prolonged cardiac monitoring as required


Emergencies in General Practice course

Management of emergencies in general practice, as with Duc, is a continually evolving field. Join us from the comfort of your own home on Wednesday 20 July from 8:00PM (AEST). This course will cover the latest in research and practice updates to help you deliver better patient care.

The webinars are delivered by experienced Australian GP medical educators and promise to be practical, relevant and interactive. They will address recent practice updates through a series of emergency scenarios.

And like all Medcast courses, all content is completely independent and free of external influence. 

Click here to find out more about Emergencies in General Practice. We look forward to seeing you there!

1. Wardlaw JM, Brazzelli M, Chappell FM, Miranda H, Shuler K, Sandercock PAG, Dennis MS. ABCD2 score and secondary stroke prevention. Neurology 2015;85(4):373-380  

{{commentCount}} comment(s). You must be logged in and AHPRA verified to view and comment. LOG IN
Dr Simon Morgan

Dr Simon Morgan

Simon is a GP and Medical Educator based in Newcastle, NSW.

View more

The latest healthcare news from medcast

Examination of patients presenting following sexual violence within an intimate partner violence relationship
Examination of patients presenting following sexual violence within an intimate partner violence relationship

General practitioners (GPs) are often the first contact for patients who are victims of intimate partner violence (IPV) including sexual assault.

Erectile Dysfunction: Clinical Summary Guide
Erectile Dysfunction: Clinical Summary Guide

Did you know that an Australian study found that the majority (61%) of Australian men aged over 45 have some form of erectile dysfunction?

Clinical Opal #16 - Vaccine preventable disease
Clinical Opal #16 - Vaccine preventable disease

Jose is a 9 year unvaccinated child with a 5 day history of a low grade fever, cough and sore throat...

Netflix and chill
Netflix and chill

If a good friend suggested to you that, instead of going to the movies together, you just go home to “Netflix and chill” how would you respond?

Clinical Opal #15 - “It’s as easy as ABCD2... or not.”
Clinical Opal #15 - “It’s as easy as ABCD2... or not.”

Duc, a 57 year old accountant, presents to you one afternoon with a recent episode of slurred speech...

Strategies for surviving the news
Strategies for surviving the news

“Mass shootings are part of the American landscape….”

OA of the hip: The HIT Trial
OA of the hip: The HIT Trial

Osteoarthritis is by far and away the most common form of arthritis in Australia.

Clinical Opal #14 - CVD risk and statins in patients with CKD
Clinical Opal #14 - CVD risk and statins in patients with CKD

Graeme, a 64-year-old retired builder, presented to you for repeat prescriptions two weeks previously as a new patient to the practice...

Clinical Opal #13 - 41 year old with hip pain
Clinical Opal #13 - 41 year old with hip pain

Zoe is a 41-year-old graphic designer who presents to you with right hip pain...

Clinical Opal #12 - Deterioration post abdominoplasty
Clinical Opal #12 - Deterioration post abdominoplasty

Gail is a 63 year old post abdominoplasty who is complaining of tingling lips, abdominal cramping and watery eyes...

What makes a mental health app work?
What makes a mental health app work?

Clinicians I talk to often say that they recommend mental health apps all the time, but they find that even the most enthusiastic users seem to disengage pretty quickly.

GP Educational Intervention Improves Patient Care and My Health Record Usage with Potential to Save Government Millions
GP Educational Intervention Improves Patient Care and My Health Record Usage with Potential to Save Government Millions

A two-year study titled CHIME-GP was carried out by Medcast and the University of Wollongong. It has shown that educating GPs about potentially inappropriate or unnecessary medicines, imaging and pathology test ordering in the context of using the My...

More than a race: Medcast takes on the Shitbox Rally – Autumn 2022
More than a race: Medcast takes on the Shitbox Rally – Autumn 2022

From Wollongong, NSW to Mackay, QLD in 7 days. Medcast’s own team, Tyre Kickers, are taking on Shitbox Rally – Autumn 2022.

Clinical Opal #11 - SGLT2i-related DKA
Clinical Opal #11 - SGLT2i-related DKA

Terese is a 64-year-old retired teacher who has a 12 year history of type 2 diabetes. She also has hypertension...

Have you lost your mojo?
Have you lost your mojo?

I’m pretty sure I’ve lost mine. I lost it in the early part of 2021 and haven’t laid eyes on it since.

Promoting reproductive choice in primary care
Promoting reproductive choice in primary care

The Australian Contraception and Abortion Primary Care Practitioner Support Network (AusCAPPS) - a network for professionals working with women to optimise reproductive health

How Doctors Think
How Doctors Think

In this short video from the 2022 'Not to be missed' webinar series, Dr Simon Morgan provides some insights into how Doctors think.

Are we all ok?
Are we all ok?

Often OK is the very best I can do (especially lately), and I try to be grateful for that, but wouldn’t it be nice to be more than OK, to be flourishing, for a little more of the time! I hope I don’t have to wait for the world to be a better place be...

Clinical Opal #10 - Pre-conception care
Clinical Opal #10 - Pre-conception care

Kelly, aged 28, presents for an appointment as she is planning a pregnancy with her husband. She has no significant medical history, is nulliparous, is a non-smoker, has normal body weight, maintains a healthy diet and exercise routine, and has a con...

How connecting to my Aboriginality helps me stay strong
How connecting to my Aboriginality helps me stay strong

Being connected to your Aboriginal heritage can bring fulfilment and a sense of identity and culture but what about wellbeing?

Join Medcast. It's free and you'll get instant access to essential healthcare news, research and more.

Already a member? Log In