Diagnosis Of Transient Ischemic Attack Research Articles

Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death

IntroductionThe 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. MethodsProspective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD2 score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. ResultsWe evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD2 score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. ConclusionsIn our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.

Symptomatic carotid stenosis and stroke risk in patients with transient ischemic attack according to the tissue-based definition

Background and Purpose: Symptomatic carotid stenosis (sCS), a common cause of transient ischemic attack (TIA), is correlated with higher stroke risk. We investigated the frequency and associated factors of sCS in patients with TIA and the association between sCS and stroke risk following TIA. Methods: Over a three-year period (2011–2013), 861 consecutive patients with TIA, who were admitted to the Department of Neurology at the University of Lübeck, Germany, were included in a monocenter study and prospectively evaluated. Diagnosis of TIA was in accordance with the tissue-based definition (transient neurological symptoms without evidence of infarction by brain imaging). Results: Of 827 patients (mean age, 70 ± 13.2 years; 49.7% women), 64 patients (7.7%; 95% confidence interval [CI], 5.9%–9.7%) exhibited sCS and 3 patients (0.3%) showed an occlusion of the corresponding internal carotid artery. Logistic regression revealed that sCS was associated with male sex (odds ratio [OR], 2.7; 95% CI, 1.2–3.6; p = 0.012), amaurosis fugax (OR, 8.1; 95% CI, 3.4–19–4; p < 0.001), unilateral weakness (OR, 3.4; 95% CI, 1.9–6.1; p < 0.001), symptom duration less than 1 h (OR, 2.0; 95% CI, 1.1–3.4; p = 0.019) and previous stroke (OR, 2.7; 95% CI, 1.5–4.7; p = 0.001). During hospitalization (mean, 6.6 days), five patients (0.6%; 95% CI, 0.1%–1.2%) suffered from stroke. The stroke risk was higher in patients with sCS than in those without sCS (6.3% vs. 0.1%; p < 0.001), whereas the recurrent TIA risk (2.6%) did not differ between the groups (4.7% vs. 2.5%; p = 0.29). Conclusion: SCS appears to be associated with a higher risk of stroke in patients with TIA defined according to the tissue-based definition.

Serum biomarkers for the early diagnosis of TIA: The MIND-TIA study protocol.

BackgroundA Transient Ischaemic Attack (TIA) bears a high risk of a subsequent ischaemic stroke. Adequate diagnosis of a TIA should be followed immediately by the start of appropriate preventive therapy, including antiplatelets. The diagnosis of a TIA based on symptoms and signs only is notoriously difficult and biomarkers of brain ischaemia might improve the recognition, and target management and prognosis of TIA patients. Our aim is to quantify the added diagnostic value of serum biomarkers of brain ischaemia in patients suspected of TIA.Methods/designStudy design: a cross-sectional diagnostic accuracy study with an additional six month follow-up period.Study population: 350 patients suspected of TIA in the primary care setting.Patients suspected of a TIA will be recruited by at least 200 general practitioners (GPs) in the catchment area of seven TIA outpatient clinics willing to participate in the study. In all patients a blood sample will be drawn as soon as possible after the patient has contacted the GP, but at least within 72 h after onset of symptoms. Participants will be referred by the GP to the regional TIA outpatient clinic for additional investigations, including brain imaging. The ‘definite’ diagnosis (reference standard) will be made by a panel consisting of three experienced neurologists who will use all available diagnostic information and the clinical information obtained during the outpatient clinic assessment, and a six month follow-up period. The diagnostic accuracy, and value in addition to signs and symptoms of candidate serum biomarkers will be assessed in terms of discrimination with C statistics, and calibration with plots.We aim to include 350 suspected cases, with 250 patients with indeed definite TIA (or minor stroke) according to the panel.DiscussionWe hope to find novel biomarkers that will enable a rapid and accurate diagnosis of TIA. This would largely improve the management and prognosis of such patients.Trial registrationClinicalTrials.gov Identifier NCT01954329

Outcomes of transient ischemic attack in maintenance dialysis patients and those with chronic kidney disease.

In-hospital outcomes of transient ischemic attack (TIA) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) requiring maintenance dialysis are largely unknown. We evaluated TIA-related in-hospital outcomes in these patients using a national database. Our study is observational in nature. Data from all adult (≥ 18 years) patients admitted to US hospitals between 2005 and 2011 with a primary discharge diagnosis of TIA and secondary diagnosis of CKD and ESRD were included using the Nationwide In-Patient Sample. We aimed to compare the following TIA-related outcomes between CKD and ESRD patients: (i) degree of disability (mainly functional status) derived from discharge destination, (ii) length of stay, (iii) charges of hospitalization, and (iv) mortality. The comparisons of TIA-related mortality and discharge outcomes between CKD and ESRD were analyzed after adjusting for potential confounders using logistic regression analysis. We adjusted for age, sex, co-morbidities, hospital size and hospital teaching status. A total of 18 316 dialysis and 67 256 CKD patients were admitted with TIA in the study period (2005-11). On univariate analysis, there was no difference in the rates of moderate-to-severe disability (20.5% versus 20.2%, P = 0.7) and in-hospital mortality (0.4% versus 0.2%, P = 0.07) in ESRD patients compared with those with CKD. After adjusting for age, sex and potential confounders, ESRD patients with TIA had higher odds of moderate-to-severe disability at discharge [odds ratio (OR): 1.53, 95% confidence interval (CI): 1.37-1.71, P ≤ 0.0001] and in-hospital death (OR: 2.87, 95% CI: 1.29-6.37, P = 0.009). ESRD patients with TIA have significantly higher rates of moderate-to-severe disability at discharge and in-hospital mortality when compared with the patients of other stages of CKD who are not dialysis-dependent.

Value of Whole Brain Computed Tomography Perfusion for Predicting Outcome after TIA or Minor Ischemic Stroke

About 15% of patients with transient ischemic attack (TIA) or minor ischemic stroke have functional impairment after 3 months. We studied the role of whole brain computed tomography perfusion (WB-CTP) in the emergency diagnosis of TIA or minor stroke in predicting disability at 3 months. We included patients with ongoing symptoms of a TIA or minor stroke with a National Institutes of Health Stroke Scale (NIHSS) score less than 4 who were evaluated with noncontrast CT (NCCT), CT angiography (CTA), and WB-CTP within 24 hours of symptom onset. Patients treated with thrombolysis or a premorbid modified Rankin Scale (mRS) score greater than 1 were excluded. The association between clinical or imaging features and disability (mRS score ≥2) at 3 months was analyzed with Poisson regression. Potential additional prognostic value of WB-CTP was assessed with logistic regression. We included 115 patients in 2012 to 2013. Median age was 68 years, and 66% were men. At 3 months, 20 patients (17%) were disabled. NIHSS score on admission (relative risk [RR], 3.6; 95% confidence interval [CI], 1.4-9.3), female sex (RR, 2.4; 95% CI, 1.1-5.3), early ischemic changes on NCCT (RR, 5.0; 95% CI, 2.6-9.9), extracranial or intracranial vessel stenosis ≥50% on CTA (RR, 3.0; 95% CI, 1.4-6.4), and perfusion abnormalities on WB-CTP (RR, 11.4; 95% CI, 4.6-28.2) were associated with disability at 3 months. In multivariable analysis, the relation between perfusion abnormalities and poor outcome remained essentially the same. WB-CTP showed prognostic value in addition to proved clinical and imaging predictors of disability. WB-CTP is useful to identify patients with TIA or minor ischemic stroke at high risk of functional impairment at 3-month follow-up.

Readmissions after stroke: linked data from the Australian Stroke Clinical Registry and hospital databases.

To assess the feasibility of linking a national clinical stroke registry with hospital admissions and emergency department data; and to determine factors associated with hospital readmission after stroke or transient ischaemic attack (TIA) in Australia. Data from the Australian Stroke Clinical Registry (AuSCR) at a single Victorian hospital were linked to coded, routinely collected hospital datasets for admissions (Victorian Admitted Episodes Dataset) and emergency presentations (Victorian Emergency Minimum Dataset) in Victoria from 15 June 2009 to 31 December 2010, using stepwise deterministic data linkage techniques. Association of patient characteristics, social circumstances, processes of care and discharge outcomes with all-cause readmissions within 1 year from time of hospital discharge after an index admission for stroke or TIA. Of 788 patients registered in the AuSCR, 46% (359/781) were female, 83% (658/788) had a stroke, and the median age was 76 years. Data were successfully linked for 782 of these patients (99%). Within 1 year of their index stroke or TIA event, 42% of patients (291/685) were readmitted, with 12% (35/286) readmitted due to a stroke or TIA. Factors significantly associated with 1-year hospital readmission were two or more presentations to an emergency department before the index event (adjusted odds ratio [aOR], 1.57; 95% CI, 1.02-2.43), higher Charlson comorbidity index score (aOR, 1.19; 95% CI, 1.07-1.32) and diagnosis of TIA on the index admission (aOR, 2.15; 95% CI, 1.30-3.56). Linking clinical registry data with routinely collected hospital data for stroke and TIA is feasible in Victoria. Using these linked data, we found that readmission to hospital is common in this patient group and is related to their comorbid conditions.

Rapid assessment of transient ischaemic attack in a hospital with no on-call neurologist

BackgroundRisk of stroke soon after a transient ischaemic attack (TIA) is high. Urgent care can reduce this risk. Our aim is to describe and evaluate the efficacy of rapid assessment of TIA patients in a hospital without a neurologist available 24h a day. MethodsIn February 2007, we set up a protocol of rapid management of patients with symptoms consistent with acute TIA, with the aim of prioritising urgent care and reducing hospital admissions, without increasing risk of recurrences. We analyse our results since the protocol was implemented with particular focus on the analysis of delay in neurological and neurovascular assessment, percentage and reasons for hospitalisation, and stroke recurrence rates after 3 months. ResultsFour hundred and eleven patients were studied, with a final diagnosis of TIA in 282 (68.6%). Among other diagnoses, the most frequent were a vasovagal reaction (5.6%), and a confusional syndrome (4.6%). Delay between emergency arrival and neurovascular assessment was <24h in 82% of cases, and <48h in 93%. After neurological evaluation, 28.7% of the patients were immediately admitted to hospital (most common causes: severe stenosis of a large artery and crescendo TIA). The incidence of ischaemic stroke in TIA patients was 3.55% after 3 months, and 70% of them suffered the recurrence within the first week after the initial TIA. ConclusionsIn a hospital without a neurologist available 24h a day, an early assessment and management of TIA patients can be carried out in accordance with the guidelines, and may avoid hospitalisation in most cases without increasing recurrence rates.

Transitions of care for stroke and TIA

The purpose of this study was to identify elements of a stroke population that may affect transitions of care (TOC). A retrospective analysis of the demographic characteristics of patients from an urban primary stroke center with an admitting diagnosis of transient ischemic attack, acute ischemic stroke, subarachnoid hemorrhage, or intracerebral hemorrhage was performed over an 8-month period (N = 276). A subset of this patient sample participated in a telephone survey 1 month after discharge. Hospital length of stay, age, insurance status, discharge disposition, comorbidities, and readmission rates were identified as important elements affecting TOC for stroke and TIA. Information from patient surveys indicated that emotional health, follow-up with care providers, stroke education, and point of contact are important elements during the transition periods after stroke and TIA. Both providers and patients should inform the development of a comprehensive TOC program that spans in-hospital to multiple care settings, including the home, which is essential. The advanced practice nurse is ideally suited to successfully lead these programs.

Beware of a diagnosis of TIA in a young patient

Cavernomas are abnormal vascular lesions consisting of many small lobules, like a bunch of small berries. They may be asymptomatic or they may present with seizures, in around 60% of cases, or symptoms similar to a transient ischaemic attack (TIA) or stroke. Here, the authors describe a case of a 30‐year‐old woman who presented with TIA‐like symptoms for which treatment was started. Imaging revealed a spinal cord cavernoma, after which the course of management was changed and the patient referred to the neurosurgeons.

Abstract T P217: Sex Differences in Clinical Presentation and Outcome: Patients Admitted to a Transient Ischemic Attack Emergency Department Observation Unit

Background: There are known sex differences in presenting symptoms and outcomes of stroke patients, yet little is known about sex differences in patients with transient ischemic attack (TIA). Our aim is to conduct an exploratory study of sex differences in symptoms, clinical characteristics, and outcomes among patients admitted to an ED observation unit (OU). Methods: Patients seen in a large, urban, academic ED with a diagnosis of TIA and admitted to the ED OU between 4/13 and 3/14 were included. Patients were excluded if they had persistent neurological deficits, fever &gt;100.4, heart rate &lt;60 / &gt;100 bpm, SBP &gt;180 / &lt; 100 mm Hg, pulse ox &lt;93%, or other competing ED diagnoses. Patients were evaluated using standard blood tests, EKG, echocardiogram, ED MRI/A of the head and neck, and neurology consultation. Using bivariate analyses, women and men were compared with respect to presenting symptoms, risk factors, acute infarct on MRI/A, and recurrence of symptoms. The study was approved by the hospital IRB. Analyses were conducted using Stata 12.1. Results: 136 patients met inclusion criteria; 52.2% were women. Women and men were similar in mean age (63.8, 95% CI 59.2 - 68.4, vs. 65.4, 95%CI 61.7 - 69.0) and percent non-white (22.5% vs. 24.6%, p=0.78). More women than men reported motor symptoms (53.5% vs. 30.8%, p=0.007), while more men reported visual changes (24.6% vs. 9.9%, p=0.02), dizziness (30.8% vs. 19.7%, p = 0.14), and symptoms coded as ‘other’ (36.9% vs. 22.5%, p=0.07). Women had longer median times of symptom duration (60 min, IQR 10 - 120, vs. 30 min, IQR 10 - 90). 25.5% of women vs. 22.0% of men had acute infarcts on MRI/A (p=0.68), and 5.7% of women compared to 1.5% of men reported recurrence of symptoms at 30 days (p=0.21). Conclusions: In our exploratory study of sex differences in ED TIA patients, women were less likely to report “non-traditional” symptoms, a finding contrary to current literature in stroke patients. Although these findings should be investigated in future studies of TIA patients, this may suggest an inherent bias in those referred to an ED TIA OU. Future studies should investigate potential sex differences in disposition to admission versus observation unit after TIA, cerebral distribution of acute vascular event, and the recurrence of symptoms.

Abstract 28: Defining the Diagnosis of TIA: An Inter-rater Agreement Analysis of a New Precise Diagnostic Score (PREDISC)

Background: the “gold standard” for the diagnosis of transient ischemic attack (TIA) is typically the final diagnosis of a neurologist. However, inter-rater agreement between physicians for the diagnosis of TIA is low, even among vascular neurologist. We developed a diagnostic scoring scale (PREDISC), which features well defined clinical and imaging parameters and investigated inter-rater agreement in patients with suspected TIA. Methods:fellowship-trained vascular neurologists, blinded to patient’s final diagnosis or outcomes, independently reviewed the history, clinical examination and MRI (including DWI and perfusion imaging) findings of patients with suspected TIA who were referred to our institution's TIA program. Each patient’s clinical manifestation and MRI findings were rated using the PREDISC score, an 8-point scale composed of a clinical score (0-4 points) and an Imaging score (0-4 points). The imaging score includes specific criteria for DWI positivity (4 points) as well as criteria for assessment of clinically relevant perfusion lesions (maximum 3 points for patients who are DWI negative). The final PREDISC score for confirmation that the event was caused by brain ischemia is determined as: 0-1 = unlikely, 2= possible, 3= probable, 4-8 = very likely. We assessed global agreement between the raters. Results: Three raters reviewed data from 114 patients. Using PREDISC all 3 raters scored a similar percentage of the clinical events as being “probable” or “very likely” caused by brain ischemia: 57%, 55% and 58%. Agreement was high for both total PREDISC Score (Intraclass correlation coefficient [ICC] of 0.94) and for the 4-point scale of TIA likelihood of diagnosis (AC1 agreement coefficient of 0.84). Agreement was excellent both on the clinical and imaging sub scores (ICC 0.88 and 0.95). Conclusion:Based on comparison with prior studies, inter-rater agreement for the diagnosis of TIA appears to be substantially improved with the PREDISC structured scoring system. This scale is the first to include specific criteria to assess the clinical relevance of DWI and perfusion lesions and supports the added value of MRI for assessing patients with suspected TIA. The diagnostic value of PREDISC should be confirmed in a prospective multicenter trial.

Abstract W P196: Utility of Echocardiography in the Evaluation of Transient Ischemic Attack Patients

Background: Current guidelines recommend that patients presenting with transient ischemic attack (TIA) undergo echocardiography to evaluate for a cardiac source. The aim of this study was to determine the utility of transthoracic echocardiography (TTE) in TIA patients evaluated as part of an emergency department observation unit (EDOU) protocol. Methods: Prospectively identified TIA patients presenting to the Emory University Hospital EDOU from January 1, 2011 to July 31, 2013 were eligible for this analysis if they had a final discharge diagnosis of TIA. Baseline patient characteristics, diagnostic test results, and clinical outcome at 3 months were retrospectively collected. An abnormal TTE was defined as an ejection fraction (EF) ≤ 45%, significant regional wall motion (RWM) abnormality, significant diastolic dysfunction (DD), valvular mass, presence of clot, or positive bubble study. Results: Of 236 patients discharged with a diagnosis of TIA during the study period, mean age was 62 ±15 years, 68% were female, 57% were African American, 17% had a history of prior stroke, 27% had history of cardiac disease, and mean ABCD2 score was 3.8 ±1.5. Overall, 19 (8%) patients had an abnormal bedside cardiac exam, 44 (19%) patients had an abnormal ECG, and 51 (22%) patients had an abnormal TTE including 18 with EF ≤ 45%, 6 with significant RWM abnormality, 9 with significant DD, 2 with clot, and 32 with positive bubble study; no valvular masses were seen. At 3 months, there was no significant difference in outcomes among patients with and without abnormalities on TTE (stroke 1.5% vs 1.8%, p=1.0; myocardial infarction 0 vs 1.2%, p=1.0). Among the 125 patients with no history of stroke or coronary artery disease and normal cardiac exam and ECG, TTE identified 5 (4%) patients with EF ≤ 45%, 17 (14%) patients with positive bubble study and no patients with significant RWM abnormalities, diastolic dysfunction, valvular mass, or clot; at 3 months, 2 (1.6%) of these patients had a stroke and no patients had a myocardial infarction. Conclusion: Among TIA patients with no history of stroke or coronary artery disease, normal cardiac exam, and normal ECG, TTE has a low yield.

Abstract W P216: Recognition Of Stroke By EMS Is Associated With Improved Emergency Department Quality Of Care

Objective: Hospital arrival via Emergency Medical Services (EMS) has been associated with faster evaluation and treatment of stroke. Among stroke cases presenting via EMS, we sought to determine if accurate recognition of stroke by prehospital providers was associated with increased quality of care in the Emergency Department (ED). Methods: Single center retrospective study of patients presenting via EMS between September 2009 and October 2012 with a discharge diagnosis of transient ischemic attack (TIA), ischemic stroke (IS) or intracerebral hemorrhage (ICH). Hospital and EMS databases were used to determine dispatcher and EMS provider impression, pre-hospital and in-hospital time intervals, EMS prenotification, NIH stroke scale (NIHSS), symptom duration and use of tissue plasminogen activator (tPA). Multivariable models were constructed to determine independent associations. Results: There were 399 cases identified: 14.5% TIA, 67.2% IS, and 18.3% ICH. Dispatchers correctly identified 58.2% of cases and EMS providers correctly recognized 57.6% of cases. Compared to cases missed by EMS, strokes that were correctly recognized had longer median on-scene time (17 vs. 15 min, p=0.01) but shorter transport times (12 vs. 15 min, p=0.001). Cases correctly recognized by EMS had shorter door-to-physician time (4 vs. 11 min, p&lt;0.001) and shorter door to CT time (23 vs. 48 min, p&lt;0.001). These associations were independent of age, NIHSS, symptom duration, and EMS prenotification (Door to Physician β = -4.42, p=0.027; Door to CT β= -18.81, p&lt;0.001). Among the 268 ischemic stroke patients, 155 (57.8%) were correctly recognized by EMS. Cases correctly recognized by EMS were more likely to receive tPA (15.7% vs. 3.6%, p&lt;0.001). This remained significant after adjusting for age, NIHSS, symptom duration and EMS prenotification (OR=5.54, p=0.006). Conclusion: Recognition of stroke by EMS providers was independently associated with faster door to physician time, faster door to CT time, and greater odds of receiving tPA. Quality initiatives to increase EMS recognition of stroke have the potential to improve hospital based quality of care and outcomes after stroke.

Abstract T MP74: The Diagnosis, Etiologic Classification, and Safe Discharge of Ischemic Strokes with Transient Symptoms from an Emergency Department Observation Unit

Background: Patients with a clinical diagnosis of transient ischemic attack (TIA) who have imaging evidence of infarction portend a high risk of short-term recurrent stroke. Emergency Department Observation Units (EDOU) offer an alternative to hospital admission and are becoming increasingly utilized for acute cerebrovascular emergencies. Hypothesis: We sought to determine whether an EDOU protocol emphasizing etiologic determination and individualized secondary prevention could be a safe alternative to hospital admission for suspected TIA patients with and without brain infarction. Methods: We prospectively studied 189 patients admitted to the TIA EDOU of a single tertiary care academic medical center. There was no ABCD2 cutoff for eligibility and exclusion criteria included persistent deficits or another diagnosis warranting hospitalization. Patients underwent DW-MRI/MRA of the head and neck unless contraindicated, transthoracic echocardiogram and bedside neurologist evaluation. Etiologic subtyping was determined using the Causative Classification System (CCS). 30-day follow-up was performed on all patients by telephone and/or review of medical records. This study was approved by the hospital IRB. Results: Acute ischemic stroke was diagnosed in 31 (16%) of patients, including 30 with DWI lesions and 1 in whom MRI was contraindicated, but had clinical worsening while in the EDOU. An evident or probable etiology was determined by CCS subtyping in 38% of strokes and 32% of TIAs (17% atherosclerosis, 12% cardioembolism, 5% small vessel). Of the total cohort, 84% were discharged from the EDOU including 16 (52%) with confirmed stroke. Median LOS was 22 hours (IQR: 17-25). At 30 days, one patient was found to have a small recurrent stroke (0.7%). There was 1 non-stroke related death. Twenty (11%) overall returned to the ED, the vast majority (70%) from the non-stroke cohort. Conclusions: Not all ischemic stroke patients require hospitalization. An EDOU is a safe and effective alternative for the complete diagnostic evaluation and management of patients with transient neurologic symptoms. Further study of cost and quality effectiveness in warranted.

Abstract W P220: Use Of A Prehospital Stroke Scale Increases Accuracy Of Emergency Medical Services Stroke Recognition

Background: Prehospital activation of in-hospital stroke response depends on accurate Emergency Medical Services (EMS) provider stroke recognition. While screening tools such as the Cincinnati Prehospital Stroke Scale (CPSS) have been validated, their real world impact is less clear. We determined the accuracy of prehospital stroke recognition and its relationship to CPSS documentation in a cohort of EMS transported suspect and confirmed stroke patients. Methods: We identified a prospective cohort of all suspected or confirmed ischemic stroke or transient ischemic attack (TIA) patients transported by EMS to a large primary stroke center. Data on prehospital and hospital care were abstracted from medical records. The sensitivity and positive predictive value (PPV) of EMS stroke recognition were calculated using the final hospital discharge diagnosis of ischemic stroke or TIA as the gold standard. We compared the sensitivity and PPV of EMS recognition among cases with and without a documented CPSS using chi square tests. We performed multivariable logistic regression analysis to determine the independent relationship between CPSS use and the odds of EMS stroke recognition among confirmed stroke and TIA cases. Results: Over a 12 month period, 434 EMS transported patients met inclusion criteria. The median age was 78 and 60% were female. EMS transported 371 (85.5%) patients as suspect strokes and documented a CPSS in 343 (79.0%). A total of 246 cases (56.7%) were confirmed ischemic strokes (n=186) or TIA (n=60). The sensitivity of EMS stroke recognition was 74.4% (95% CI 68.9 to 79.8) and PPV was 49.3% (95% CI 44.2 to 54.4). Sensitivity was higher among cases with CPSS documentation than without (85.9% vs. 25.5% p&lt;0.0001) as was the PPV (54.3% vs. 21.4%, p&lt;0.0001). After adjustment for age, sex, stroke severity, dispatch reason, and time from symptom onset, CPSS use was associated with substantially higher odds of EMS stroke recognition (OR 19.04, 95% CI: 7.95 to 45.59). Conclusion: EMS providers recognized three quarters of all stroke or TIA admissions, while EMS suspicion of stroke was correct only half of the time. Documentation of a CPSS was associated with substantially higher EMS stroke recognition.

Abstract T P139: Prevalence and Predictors of Mood Disorders among a National Sample of Individuals with Stroke or Transient Ischemic Attack

Intro: Depression is an independent stroke risk factor, yet little is known about comorbid mood disorders prevalence in stroke survivors. Data regarding association between mood disorders and transient ischemic attack (TIA) are scarce. Objective: To determine prevalence and predictors of comorbid mood disorders among individuals hospitalized with TIA, ischemic stroke, and hemorrhagic stroke in a national US sample. Methods: Using Nationwide Inpatient Sample (NIS) data (2000-2010), we identified individuals discharged with a primary diagnosis of acute ischemic stroke, hemorrhagic stroke, or TIA. We determined the weighted proportion of stroke hospitalizations with comorbid mood disorders (bipolar affective disorder, depression, anxiety disorders). We used survey weighted Poisson regression to estimate risk ratios. The first multivariable model adjusted for sociodemographic and hospital factors. The second model also adjusted for comorbid conditions. Results: Among 2,057,799 hospital discharges for stroke or TIA (corresponding to 10.1 million individuals in US), 83,705 (4.07%) had mood disorders. Compared to those without mood disorders, individuals with mood disorders were younger and more likely to be female, White, and had higher income and private insurance. Individuals 84 years (RR 3.61, 95% CI 3.50-3.72) after adjustment for sociodemographic and hospital factors. Further adjustment for comorbidities slightly attenuated the association (RR 3.30, 95% CL 3.19-3.40). Women were twice as likely to have mood disorders (RR 1.94, 95% CI 1.91-1.97), after adjusting for sociodemographic and hospital factors. Further adjustment for comorbidities did not affect the association. Compared to Whites, all other races were less likely to have mood disorders. Conclusions: In this national sample of individuals admitted with stroke or TIA, 4% had mood disorders. This is likely an underestimate, given lack of systematic screening for comorbid psychiatric disease. Women, younger individuals, and Whites appear to be a population at risk; however, further studies are needed to determine the true prevalence of mood disorders among individuals with TIA/stroke, to determine impact on stroke recovery and optimal treatment options.

Abstract W P185: Clinical Predictors of Stroke, TIA and Mimic among Patients with Transient Neurological Dysfunction Admitted to an Emergency Department Observation Unit

Background: In patients with resolved symptoms, transient ischemic attack (TIA) is distinguished from ischemic stroke by neuroimaging evidence of acute infarction. DW-MRI has been shown to be more sensitive at detecting infarction than CT, but is not uniformly available in the acute setting. Hypothesis: We sought to identify predictors of stroke diagnosis among a cohort of clinically suspected TIA patients undergoing an accelerated diagnostic protocol in an emergency department observation unit (EDOU). Methods: We prospectively studied 189 patients treated in the EDOU of a single tertiary care academic medical center. Patients underwent DW-MRI of the brain (unless contraindicated), and bedside neurologist evaluation. A CT scan of the brain was considered optional prior to EDOU admission. We compared the odds of extremity weakness, sensory loss, facial droop, visual disturbance, slurred speech, aphasia, dizziness, and headache between patients with final diagnosis of stroke, TIA and mimic. This study was approved by the hospital IRB. Results: Thirty-one patients (16%) were diagnosed with an acute ischemic stroke, 85 (45%) TIA, and 73 (39%) mimic. Mean age was 64.8 years (SD = 15.5; range = 30-90). DW-MRI was performed on 92% of patients. A CT scan was also performed in 80% of patients diagnosed with stroke and 0 were diagnostic. Median ABCD2 scores were 4 for stroke and TIA (IQR 3-5) and 3 for mimic (IQR 2-4). Only headache symptoms predicted lower odds of stroke (OR 0.22; 95% CI: 0.05-0.96). Both headache (OR 1.44; 95% CI: 1.03-2.03) and visual disturbance (OR 3.14; 95% CI: 1.49-6.65) increased the odds of mimic diagnosis, but were also present in 13% and 10% of stroke patients respectively. Slurred speech (OR 0.48: 95% CI: 0.25-0.93); aphasia (OR 0.34 95% CI: 0.15-0.76) and facial droop (OR 90.36: 95% CI: 0.14-0.94) significantly predicted lower odds of mimic diagnosis. Conclusions: In our investigation of patients with transient neurologic dysfunction in an EDOU, stroke diagnosis was common and could not be predicted by clinical variables alone. Early DW-MRI should be considered in all TIA patients, especially those reporting slurred speech, aphasia or facial droop.

Abstract T MP116: Coated-Platelets Predict Stroke at 30 days in Patients with Transient Ischemic Attack

Background: Coated-platelets, a subset of procoagulant platelets observed upon dual agonist stimulation with collagen and thrombin, support a robust prothrombinase activity and provide a unique measure of platelet thrombotic potential. Coated-platelet levels are increased both in non-lacunar stroke and transient ischemic attack (TIA) compared to controls free of stroke or TIA. In addition, higher levels in non-lacunar stroke are associated with stroke recurrence. We now examine whether coated-platelet levels predict stroke at 30 days in TIA patients. Methods: Consecutive patients with a diagnosis of TIA established by a board certified neurologist were enrolled in this pilot study. The diagnosis was consistent with the tissue-based definition of TIA: a transient episode of neurological dysfunction without acute infarction. The absence of infarction was demonstrated by normal brain imaging studies. Those taking anticoagulants or with dementia were excluded. Coated-platelets were determined at baseline and reported as percent of cells converted to coated-platelets. A receiver operating characteristic curve (ROC) analysis was conducted to compare the ability of coated-platelets versus chance alone to predict incident stroke at 30 days. Results: We enrolled 171 patients. Ten strokes were observed at 30 days. ROC analysis showed significant improvement in the predictive ability of the coated-platelets model compared to chance (AUC: 0.78 ± 0.07 versus 0.50 ± 0, respectively; p &lt; 0.0001). A cut-off of 51.1% for coated-platelet levels yielded a sensitivity of 0.80 (0.55-1.0; 95% CI), specificity of 0.73 (0.66-0.80), positive predictive value of 0.16 (0.06-0.26), and a negative predictive value of 0.98 (0.96-1.0). Conclusions: Among these subjects with TIA, coated platelet levels &lt;51.1% at time of presentation had a negative predictive value of 98% for stroke at 30 days. These findings suggest a role for coated-platelets in stroke risk stratification following TIA.

The accuracy of prehospital diagnosis of acute cerebrovascular accidents: an observational study.

IntroductionTime to treatment is the key factor in stroke care. Although the initial medical assessment is usually made by a non-neurologist or a paramedic, it should ensure correct identification of all acute cerebrovascular accidents (CVAs). Our aim was to evaluate the accuracy of the physician-made prehospital diagnosis of acute CVA in patients referred directly to the neurological emergency department (ED), and to identify conditions mimicking CVAs.Material and methodsThis observational study included consecutive patients referred to our neurological ED by emergency physicians with a suspicion of CVA (acute stroke, transient ischemic attack (TIA) or a syndrome-based diagnosis) during 12 months. Referrals were considered correct if the prehospital diagnosis of CVA proved to be stroke or TIA.ResultsThe prehospital diagnosis of CVA was correct in 360 of 570 cases. Its positive predictive value ranged from 100% for the syndrome-based diagnosis, through 70% for stroke, to 34% for TIA. Misdiagnoses were less frequent among ambulance physicians compared to primary care and outpatient physicians (33% vs. 52%, p < 0.001). The most frequent mimics were vertigo (19%), electrolyte and metabolic disturbances (12%), seizures (11%), cardiovascular disorders (10%), blood hypertension (8%) and brain tumors (5%). Additionally, 6% of all admitted CVA cases were referred with prehospital diagnoses other than CVA.ConclusionsEmergency physicians appear to be sensitive in diagnosing CVAs but their overall accuracy does not seem high. They tend to overuse the diagnosis of TIA. Constant education and adoption of stroke screening scales may be beneficial for emergency care systems based both on physicians and on paramedics.

Adding computed tomography and transcranial Doppler findings to the ABCD2 score to predict long-term risk of stroke after transient ischaemic attack or minor stroke.

The ABCD(2) score can predict the early risk of stroke after transient ischaemic attack or minor stroke. However, there is no simple and practical assessment method for the long-term risks. Computed tomography (CT) and transcranial Doppler (TCD) findings were added to the ABCD(2) score to build an ABCD(2) L(2) score and whether the new scoring system could improve the predictive value of the ABCD(2) score for the long-term risk of stroke was determined. From January 2004 to December 2005, all patients with a definite diagnosis of transient ischaemic attack or minor stroke at the Prince of Wales Hospital were consecutively enrolled and followed up until August 2008. CT and TCD were performed. The areas under the curve were used to quantify the ABCD(2) and ABCD(2) L(2) scores and related items. All 481 patients completed the follow-up. The shortest follow-up time was 0.17months (until death), the longest follow-up time was 55.60months and the mean follow-up time was 40.3±11.0months. In total, 277 (57.6%) patients showed lesions on CT scans and 195 (40.6%) patients were found with intracranial large artery atherosclerosis. Further strokes occurred in 74 (15.4%) patients, including four (0.83%) patients who died of ischaemic stroke during the follow-up period. The area under the curve increased from 0.650 (0.586-0.715) for the ABCD(2) score to 0.700 (0.637-0.764) for the ABCD(2) L(2) score. Adding CT and TCD results to the ABCD(2) score to increase its predictability for long-term risk of stroke recurrence might be a meaningful exploration.