Redundant Imaging in Transient Ischemic Attack: Evidence From the Nationwide Emergency Department Sample

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

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Does emergency department blood pressure influence hospital length of stay for transient ischemic attack?

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2004.07.069 ◽

2004 ◽

Vol 44 (4) ◽

pp. S21

Author(s):

B. Peake ◽

S.N. Ganti ◽

W.W. Decker ◽

L.G. Stead

Keyword(s):

Blood Pressure ◽

Emergency Department ◽

Length Of Stay ◽

Transient Ischemic Attack ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Ischemic Attack

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Systolic blood pressure as a predictor of transient ischemic attack/minor stroke in emergency department patients under age 80: a prospective cohort study

BMC Neurology ◽

10.1186/s12883-019-1466-4 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Andrew M. Penn ◽

Nicole S. Croteau ◽

Kristine Votova ◽

Colin Sedgwick ◽

Robert F. Balshaw ◽

...

Keyword(s):

Blood Pressure ◽

Emergency Department ◽

Transient Ischemic Attack ◽

Final Diagnosis ◽

Conditional Inference ◽

Minor Stroke ◽

Logistic Regression Models ◽

Stroke Mimics ◽

Stroke Mimic ◽

Ischemic Attack

Abstract Background Elevated blood pressure (BP) at emergency department (ED) presentation and advancing age have been associated with risk of ischemic stroke; however, the relationship between BP, age, and transient ischemic attack/minor stroke (TIA/MS) is not clear. Methods A multi-site, prospective, observational study of 1084 ED patients screened for suspected TIA/MS (symptom onset < 24 h, NIHSS< 4) between December 2013 and April 2016. Systolic and diastolic BP measurements (SBP, DBP) were taken at ED presentation. Final diagnosis was consensus adjudication by stroke neurologists; patients were diagnosed as either TIA/MS or stroke-mimic (non-cerebrovascular conditions). Conditional inference trees were used to define age cut-points for predicting binary diagnosis (TIA/MS or stroke-mimic). Logistic regression models were used to estimate the effect of BP, age, sex, and the age-BP interaction on predicting TIA/MS diagnosis. Results Over a 28-month period, 768 (71%) patients were diagnosed with TIA/MS: these patients were older (mean 71.6 years) and more likely to be male (58%) than stroke-mimics (61.4 years, 41%; each p < 0.001). TIA/MS patients had higher SBP than stroke-mimics (p < 0.001). DBP did not differ between the two groups (p = 0.191). SBP was predictive of TIA/MS diagnosis in younger patients, after accounting for age and sex; an increase of 10 mmHg systolic increased the odds of TIA/MS 18% (odds ratio [OR] 1.18, 95% CI 1.00–1.39) in patients < 60 years, and 23% (OR 1.23, 95% CI 11.12–1.35) in those 60–79 years, while not affecting the odds of TIA/MS in patients ≥80 years (OR 0.99, 95% CI 0.89–1.07). Conclusions Raised SBP in patients younger than 80 with suspected TIA/MS may be a useful clinical indicator upon initial presentation to help increase clinicians’ suspicion of TIA/MS. Trial registration ClinicalTrials.gov NCT03050099 (10-Feb-2017) and NCT03070067 (3-Mar-2017). Retrospectively registered.

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Compliance With Imaging Guidelines for Workup of Transient Ischemic Attack

Stroke ◽

10.1161/strokeaha.120.029858 ◽

2020 ◽

Vol 51 (8) ◽

pp. 2563-2567

Author(s):

Vincent M. Timpone ◽

Alexandria Jensen ◽

Sharon N. Poisson ◽

Premal S. Trivedi

Keyword(s):

Emergency Department ◽

Trend Analysis ◽

Transient Ischemic Attack ◽

Emergency Departments ◽

Odds Ratio ◽

International Classification Of Diseases ◽

Multivariable Logistic Regression Analysis ◽

Primary Analysis ◽

Ischemic Attack ◽

Neurovascular Imaging

Background and Purpose: Multiple societal guidelines recommend urgent brain and neurovascular imaging in patients with transient ischemic attack (TIA) to identify and treat risk factors that may lead to future stroke. The purpose of this study was to evaluate whether national imaging utilization for workup of TIA complies with society guidelines. Methods: Analysis utilized the Nationwide Emergency Department Sample. Primary analysis was performed on a 2017 cohort, and secondary trend analysis was performed on cohorts from 2006 to2017. Patients diagnosed and discharged from emergency departments with TIA were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. Demographics, health insurance, patient income, and hospital-type covariates were analyzed using a hierarchical multivariable logistic regression analysis to identify predictors of obtaining neurovascular imaging during an emergency department encounter. Results: In 2017, there were 167 999 patients evaluated and discharged from emergency departments with TIA. The percentage of patients receiving brain and neurovascular imaging was 78.5% and 43.2%, respectively. The most common imaging workup utilized was a solitary computed tomography–brain without any neurovascular imaging (30.9% of encounters). Decreased odds of obtaining neurovascular imaging was observed in Medicaid patients (odds ratio, 0.65 [95% CI, 0.58–0.74]), rural hospitals (odds ratio, 0.26 [95% CI, 0.17–0.41]), nontrauma centers (odds ratio, 0.40 [95% CI, 0.21–0.74]), and weekend encounters (odds ratio, 0.91 [95% CI, 0.85–0.96]). Trend analysis demonstrated a steady rise in brain and neurovascular imaging in 2006 from 34.9% and 6.8% of encounters, respectively, to 78.5% and 43.2% of encounters in 2017. Conclusions: Compliance with imaging guidelines is improving; however, the majority of TIA patients discharged from the emergency department do not receive recommended neurovascular imaging during their encounter. Follow-up studies are needed to determine whether delayed or incomplete vascular screening increases the risk of future stroke.

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Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2019.06.018 ◽

2020 ◽

Vol 38 (4) ◽

pp. 741-745

Author(s):

Robert T. Dahlquist ◽

Joseph M. Young ◽

Karina Reyner ◽

Ali Farzad ◽

Richard B. Moleno ◽

...

Keyword(s):

Emergency Department ◽

Transient Ischemic Attack ◽

Ischemic Attack

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LO89: A multi-disciplinary quality improvement project to improve adherence to best practice guidelines for emergency department patients with transient ischemic attack

CJEM ◽

10.1017/cem.2019.131 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S40

Author(s):

A. Verma ◽

A. Kapoor ◽

J. Kim ◽

N. Kujbid ◽

K. Si ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Transient Ischemic Attack ◽

Retrospective Chart Review ◽

Stroke Recurrence ◽

Improvement Project ◽

Support Tool ◽

High Risk Patients ◽

Risk Patients ◽

Ischemic Attack

Background: Canadian Stroke Guidelines recommend that Transient Ischemic Attack (TIA) patients at highest risk of stroke recurrence should undergo immediate vascular imaging. Computed tomography angiography (CTA) of the head and neck is recommended over carotid doppler because it allows for enhanced visualization of the intracranial and posterior circulation vasculature. Imaging while patients are in the emergency department (ED) is optimal for high-risk patients because the risk of stroke recurrence is highest in the first 48 hours. Aim Statement: At our hospital, a designated stroke centre, less than 5% of TIA patients meet national recommendations by undergoing CTA in the ED. We sought to increase the rate of CTA in high risk ED TIA patients from less than 5% to at least 80% in 10 months. Measures & Design: We used a multi-faceted approach to improve our adherence to guidelines including: 1) education for staff ED physicians; 2) agreements between ED and radiology to facilitate rapid access to CTA; 3) agreements between ED and neurology for consultations regarding patients with abnormal CTA; and 4) the creation of an electronic decision support tool to guide ED physicians as to which patients require CTA. We measured the rate of CTA in high risk patients biweekly using retrospective chart review of patients referred to the TIA clinic from the ED on a biweekly basis. As a balancing measure, we also measured the rate of CTA in non-high risk patients. Evaluation/Results: Data collection is ongoing. An interim run chart at 19 weeks shows a complete shift above the median after implementation, with CTA rates between 70 and 100%. At the time of submission, we had no downward trends below 80%, showing sustained improvement. The CTA rate in non-high risk patients did also increase. Disucssion/Impact: After 19 weeks of our intervention, 112 (78.9%) of high risk TIA patients had a CTA, compared to 10 (9.8%) in the 19 weeks prior to our intervention. On average, 10-15% of high risk patients will have an identifiable lesion on CTA, leading to immediate change in management (at minimum, an inpatient consultation with neurology). Our multi-faceted approach could be replicated in any ED with the engagement and availability of the same multi-disciplinary team (ED, radiology, and neurology), access to CTA, and electronic orders.

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Outcomes of Atherothrombotic Transient Ischemic Attack and Minor Stroke in an Emergency Department: Results of an Outpatient Management Program

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2010.09.009 ◽

2011 ◽

Vol 57 (5) ◽

pp. 510-516 ◽

Cited By ~ 7

Author(s):

Juan Torres Macho ◽

Gabriela Peña Lillo ◽

David Pérez Martínez ◽

Ana González Mansilla ◽

Sergio Gámez Díez ◽

...

Keyword(s):

Emergency Department ◽

Transient Ischemic Attack ◽

Management Program ◽

Minor Stroke ◽

Outpatient Management ◽

Ischemic Attack

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How do we manage emergency department patients diagnosed with transient ischemic attack?

CJEM ◽

10.2310/8000.2011.110533 ◽

2012 ◽

Vol 14 (01) ◽

pp. 20-24 ◽

Cited By ~ 7

Author(s):

Jeffrey J. Perry ◽

Jonathan Kerr ◽

Cheryl Symington ◽

Jane Sutherland

Keyword(s):

Emergency Department ◽

Transient Ischemic Attack ◽

Data Extraction ◽

Tertiary Care ◽

Clinical Findings ◽

Stroke Rate ◽

Historical Cohort ◽

History Of ◽

Emergency Department Patients ◽

Ischemic Attack

ABSTRACTIntroduction:Multiple studies have demonstrated low rates of antithrombotic use, low neuroimaging rates, and high subsequent risk of stroke at 90 days following an emergency department (ED) diagnosis of transient ischemic attack (TIA). This study assessed the use of antithrombotic medications, neuroimaging, and subsequent 90-day stroke rate for patients in a more recent cohort of ED patients discharged home with TIA.Methods:We conducted a 1-year historical cohort study of all patients discharged with a TIA at a tertiary care ED (census 60,000 visits/year), which was one of the four sites participating in one of the aforementioned studies. Data were extracted from paper and electronic records onto standardized data extraction forms. Clinical findings, medications, and tests were recorded.Results:A total of 211 patients were enrolled in the study. The patients had the following characteristics: the mean age was 71.2 years (SD 13.8 years), 56.9% were female, 53.1% had a history of hypertension, 26.5% had a history of ischemic heart disease, and 17.1% had a previous stroke. The most frequent neurologic deficit was unilateral weakness (53.6%), and most deficits lasted for more than 60 minutes (71.6%). Antithrombotic medications were used for 96.7% of patients at ED discharge. Neuroimaging was conducted in 94.3% of patients while in the ED. Our cohort had a 90-day stroke rate of 1.9%.Conclusions:This study established that most TIA patients receive neuroimaging in the ED and are started on or maintained on antithrombotic agents. Clinicians are encouraged to ensure that electrocardiography is done routinely and to involve Neurology in follow-up care.

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