Application of the ABCD2 Score to Identify Cerebrovascular Causes of Dizziness in the Emergency Department
Dizziness is a common patient complaint in the emergency department. Approximately 5% of acute dizziness cases may have cerebrovascular causes. The ABCD2 score predicts the risk of stroke after transient ischemic attack by distinguishing transient ischemic attack from noncerebrovascular mimics. The score ranges from 0 to 7 and assigns points based on 5 clinical factors, including patient age, blood pressure, clinical features, duration of symptoms, and diabetes. This was a retrospective observational study to assess the ability of the ABCD2 score to stratify the risk of cerebrovascular diagnoses in patients presenting with dizziness. Two neurologists independently reviewed medical records to determine whether the presenting symptom was caused by a cerebrovascular event. ABCD2 scores were then assigned using clinical information from the patient's medical record. Among the 907 dizzy patients, 4% had a cerebrovascular cause. The median ABCD2 score was 3. Only 5 of 512 patients (1%) with a score of ≤3 had a cerebrovascular event, compared with 25 of 369 patients (6.8%) with a score of 4 or 5, and 7 of 26 patients (27%) with a score of 6 or 7. Interestingly, the 5 patients with ABCD2 scores ≤3 who had cerebrovascular diagnoses also had at least 2 vascular risk factors. Although future prospective studies will be needed to validate these retrospective results, this score may hold promise as an adjunctory tool in the work-up of dizzy patients. See p 1484.
Association of Statins and Statin Discontinuation With Poor Outcome and Survival Following Intracerebral Hemorrhage
3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors or statins are neuroprotective agents following stroke, including in intracerebral hemorrhage (ICH). The data from human studies regarding the effect of statins on outcome in ICH are conflicting. The primary objective of this study was to determine the relationship of statin use and ICH outcomes, and the secondary objective was to determine whether the discontinuation of statins during admission was associated with worse clinical outcomes. They analyzed 2466 patients with ICH from 2003 to 2008 from 11 hospitals in the Registry of the Canadian Stroke Network. Twenty-two percent of patients were taking statins before ICH presentation. Statin users were less likely to have severe strokes at presentation, but had similar rates of poor outcome and 30-day mortality. Twenty-nine percent of patients had their statins discontinued at admission. These patients were more likely to have severe stroke, poor outcome, and to have died by 30 days. After controlling for stroke severity, statin discontinuation was still associated with poor outcome. These associations, however, were no longer significant after excluding patients who were treated palliatively. The finding of worse outcomes with statin discontinuation may have been caused by confounding by indication, such that statin discontinuation may have been a marker of more severe strokes and underlying poor prognosis. Randomized controlled trials are needed to determine better the effect of statin use and discontinuation in ICH. See p 1518.
No Increased Risk of Symptomatic Intracerebral Hemorrhage in tPA-Treated Stroke Patients With ECASS Exclusion Criteria
The European Cooperative Acute Stroke Study (ECASS III) extended the time-to-treatment with intravenous tissue-type plasminogen activator (IV tPA) for acute ischemic stroke to 3 to 4.5 hours from onset of symptoms. In addition to current exclusion criteria for the use of IV tPA within 3 hours of symptom onset, additional and more stringent exclusion criteria were followed in the ECASS III trial, including age >80 years, National Institutes of Health Stroke Scale >25, combination of previous stroke and diabetes, oral anticoagulant use even if international normalized ratio ≤1.7, and aggressive measures to control blood pressure. This single-center retrospective review tested the hypothesis that IV thrombolysis was not safe in patients with any of these additional exclusion criteria. A total of 191 patients treated with IV tPA were identified, of which 31 patients were age >80 years, 5 patients had National Institutes of Health Stroke Scale >25, 14 patients had previous stroke and diabetes, 11 patients were on warfarin, and 19 patients required IV infusions to control blood pressure. None of these additional criteria was associated with increased risk of symptomatic intracerebral hemorrhage. Symptomatic intracerebral hemorrhage was associated with atrial fibrillation, larger final infarct volume, and elevated glucose. There was higher mortality in patients age >80 years and those with National Institutes of Health Stroke Scale >25, which likely reflects the natural history in these patients regardless of treatment. Thus it is possible, that whereas patients with these additional exclusion criteria were excluded from entry into ECASS III, it is possible that they still may benefit from treatment in this extended time window. Before treating these subgroups in the extended time window, prospective randomized studies are warranted. See p 1684.
- © 2012 American Heart Association, Inc.
- Application of the ABCD2 Score to Identify Cerebrovascular Causes of Dizziness in the Emergency Department
- Association of Statins and Statin Discontinuation With Poor Outcome and Survival Following Intracerebral Hemorrhage
- No Increased Risk of Symptomatic Intracerebral Hemorrhage in tPA-Treated Stroke Patients With ECASS Exclusion Criteria
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