Two Aces

Abstract

Background and Purpose-To evaluate a novel emergency department-based TIA triage system. Methods-We developed an approach to TIA triage and management based on risk assessment using the ABCD 2 score in combination with early cervical and intracranial vessel imaging. It was anticipated that this triage system would avoid hospitalization for the majority of TIA patients and result in a low rate of recurrent stroke. We hypothesized that the subsequent stroke rate among consecutively encountered patients managed with this approach would be lower than predicted based on their ABCD 2 scores. Results-From June 2007 to December 2009, 224 consecutive patients evaluated in the Stanford emergency department for a possible TIA were enrolled in the study. One hundred fifty-seven were discharged to complete their evaluation at the outpatient TIA clinic; 67 patients were hospitalized. One hundred sixteen patients had a final diagnosis of TIA/minor stroke or possible TIA. The stroke rates at 7, 30, and 90 days were 0.6% (0.1%-3.5%) for patients referred to the TIA clinic and 1.5% (0.3%-8.0%) for the hospitalized patients. Combining both groups, the overall stroke rate was 0.9% (0.3%-3.2%), which is significantly less than expected based on ABCD 2 scores (Pϭ0.034 at 7 days and Pϭ0.001 at 90 days). Conclusions-This emergency department-based inpatient versus outpatient TIA triage system led to a low rate of hospitalization (30%). Recurrent stroke rates were low for both the hospitalized and outpatient subgroups. (Stroke.

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

“…With respect to the timing of patient assessment after the index event, in 10 studies TIA patients were assessed within 24 hours of symptoms onset, 62,69,87,[134][135][136]138,143,155,161 in six studies within 48 hours, 137,139,141,142,150,165 in one study 140 within 72 hours and in one study 160 within 7 days. Another four studies 9,61,132,144 reported that 'patients were assessed as soon as possible after the event' but did not give a time.…”

“…The ascertainment of stroke events after TIA was carried out by face-to-face patient assessment or telephone interviews in 25 studies, 9,21,24,61,69,81,119,122,128,[132][133][134][137][138][139]144,[149][150][151][152]155,156,161,164,165 by medical records in 15 studies, 23,62,87,120,126,127,129,130,130,135,136,140,143,145,157,159 by mixed methods involving face-to-face assessment plus another method (i.e. telephone interviews, medical records, letters) in 11 studies, 65,131,[146][147][148]153,154,158,…”

“…The 16 included studies 7,73,122,156,161,173,257,263,[265][266][267][268][269][270][271] varied in terms of their primary objectives. Three were population-based studies assessing the incidence of TIA in the general population in UK, the Netherlands and Spain (OCSP, Rotterdam Study and a community-based register in Segovia, respectively).…”

Diagnosis and Management of Transient Ischemic Attack

“…Using CT/CTA to assess patients in the emergency department has allowed many patients to be safely triaged, with patients with abnormal CT/CTA admitted for observation and those with normal imaging being assessed as outpatients. 29 Other modalities for imaging cervicocephalic vessels, such as magnetic resonance angiography (MRA), are also acceptable. Carotid duplex ultrasound is an additional noninvasive modality commonly used to evaluate for hemodynamically significant carotid occlusive disease at the bifurcation.…”

“…For now, North American secondary stroke prevention guidelines do not recommend dual antiplatelet agent therapy. 29 Outpatient Versus Inpatient Assessment For stroke prevention, the location of treatment matters less than the speed of the assessment. However, in most parts of the world, assessing patients and completing urgent (on the same day, within a few hours) imaging is most easily done in the emergency department given the easy access to imaging.…”