Clinical Opal #15 - “It’s as easy as ABCD2... or not.”
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
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References
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
Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast. He also has medical education roles with the RACGP and GPSA.
Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.
Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.
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