Diagnosis Of Transient Ischemic Attack Research Articles

Feasibility and end-user perceptions of a novel digital care assistant and support program for people after stroke or transient ischemic attack (CAPS)

Abstract Background The Care Assistant and support Program for people after Stroke (CAPS) or transient ischaemic attack (TIA) is a clinician-led program designed to improve the secondary prevention of stroke. The program combines person-centred goal setting and risk-factor monitoring through a web-based clinician portal, SMS goal-aligned messages, a mobile application (app), and a wearable device. We aimed to determine the feasibility of CAPS among people living with stroke or TIA, and clinicians who would deliver the program in future. Methods Open label single group pre-posttest mixed-methods evaluation of the 12-week program. Eligible lived-experience participants were recruited through the Australian Stroke Clinical Registry. Eligibility: diagnosis of stroke or TIA in preceding 6 months - 3 years, ≥18 years old, smartphone/tablet ownership, living in the community. Following surveys and interviews of lived-experience participants, ten clinicians experienced in stroke care were invited to participate in focus groups to discuss the program. We used descriptive statistics to evaluate feasibility outcomes, i.e. participant perceptions of usability, acceptability and satisfaction, and clinician perceptions on program design and delivery. Results From 600 invitations, 34 eligible participants commenced the program (27% female, 33% TIA, median 1.7 years from index event; one withdrew). Usability of the CAPS app was rated as ‘Good’ to ‘Excellent’ (System Usability Scale), with moderate sustained usage by study conclusion (>60%). Participants frequently reviewed their health data within the app (average twice a day/participant over 12 weeks), and entered their health measurements an average 73 times/participant. The majority (≥90%) of participants thought the program fitted well into their daily lives or helped engage them in self-monitoring, with 76% indicating they would use the program, if publicly available. Clinician participants included three nurses, three allied health professionals, two neurologists, a stroke consultant, and a general practitioner (GP) in focus groups. Overall, eight had positive perceptions of the CAPS program. Three clinicians indicated the measurements collected in the app captured "vital information", and five saw the value of CAPS to improve secondary prevention. Recommended modifications to the program included tracking atrial fibrillation and blood cholesterol. Seven believed participants would receive the most benefit from the program if delivered within three months post-discharge. Six indicated that GP-led multidisciplinary care was the best model to deliver CAPS. Conclusions The CAPS program was feasible to deliver and acceptable to people living with stroke or TIA. Clinicians saw the value of CAPS for secondary prevention, with feedback prompting further focus groups with GPs to develop the potential model of care. Findings have informed the design of a Phase II randomised feasibility trial.

Pre-hospital transdermal glyceryl trinitrate for transient ischaemic attack: Data from the RIGHT-2 trial.

Ambulance trials assessing interventions in suspected stroke patients will recruit patients with currently active symptoms that will resolve into transient ischaemic attack (TIA). The safety and efficacy of glyceryl trinitrate (GTN) in the pre-specified subgroup of patients with TIA in the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial 2 (RIGHT-2) was assessed. RIGHT-2 was a pre-hospital-initiated multicentre randomized sham-controlled blinded-endpoint trial that randomized patients with presumed ultra-acute stroke within 4 h of symptom onset to transdermal GTN or sham. Final diagnosis was determined by site investigators. The primary outcome was a shift in modified Rankin Scale (mRS) scores at 90 days analysed using ordinal logistic regression reported as adjusted common odds ratio with 95% confidence intervals (CIs). Secondary outcomes included death or dependence (mRS >2). In all, 109 of 1149 (9.5%) patients had a final diagnosis of TIA (GTN 57, sham 52) with mean age 73 (SD 13) years, 19 (17.4%) had pre-morbid mRS >2, and onset to randomization was 80 min (interquartile range 49, 105). GTN lowered blood pressure by 7.4/5.2 mmHg compared with sham by hospital arrival. At day 90, GTN had no effect on shift in mRS scores (common odds ratio for increased dependence 1.47, 95% CI 0.70-3.11) but was associated with increased death or dependence (mRS >2): GTN 29 (51.8%) versus sham 23 (46.9%), odds ratio 3.86 (95% CI 1.09-13.59). Pre-hospital ultra-acute transdermal GTN did not improve overall functional outcome in patients with investigator-diagnosed TIA compared with sham treatment.

An Audit of Carotid Dopplers in Sligo University Hospital

Abstract Background Stroke is a common and often disabling condition impacting thousands of individuals in Ireland annually 1. Timely screening for underlying etiologies is important in all patients presenting with stroke or transient ischaemic attack (TIA) to reduce recurrence risk. Carotid artery disease is frequently implicated as the cause 3. The 2023 National Clinical Guideline for Stroke for the United Kingdom and Ireland recommends carotid imaging be completed within one week of diagnosis of ischemic stroke or TIA for patients in whom potential carotid intervention would be appropriate. We aimed to assess the timing of Carotid Doppler scans in our hospital for patients presenting clinically with stroke or TIA. Methods The National Integrated Medical Imaging System (NIMIS) was used to generate a list of patients that had a Carotid Doppler scan over a six- month period (1st July 2022 to 31st December 2022). NIMIS was also used to identify the indication, setting, requesting department and timeliness of scans. Results A total of 96 Carotid & Vertebral Dopplers were performed. Majority of studies were performed on males (65%). The mean age of patients was 70 (±11.5) years. Most studies (55%) were done in an inpatient setting. Of all Carotid Dopplers performed, 94 (97%) had an appropriate indication. With regards to timeliness of carotid imaging, the median time from order to study completion varied between inpatients [2 days (IQR 1-3)] and outpatients [16 days (IQR 9-38)]. The majority (95%) of inpatient studies were completed within 7-days of order, while only 14% of outpatient studies were performed in this timeframe. Of the untimely outpatient scans done to investigate stroke or TIA, 2/33 (6%) had significant carotid stenosis. Conclusion Majority of Carotid Dopplers were done for appropriate indications. While inpatients studies were largely done in a timely manner, there is a significant delay in the completion of most outpatient studies.

Additional predictors of stroke and transient ischaemic attack in BEFAST positive patients in out-of-hours emergency primary care

Introduction In patients suspected of stroke or transient ischemic attack (TIA), rapid triaging is imperative to improve clinical outcomes. For this purpose, balance-eye-face-arm-speech-time (BEFAST) items are used in out-of-hours primary care (OHS-PC). We explored the risk of stroke and TIA among BEFAST positive patients calling to the OHS-PC, and assessed whether additional predictors could improve risk stratification. Methods This is a cross-sectional study of retrospectively gathered routine care data from telephone triage tape-recordings of patients calling the OHS-PC with neurological deficit symptoms, classified as BEFAST positive. Four models–with the predictors age, sex, a history of cardiovascular or cerebrovascular disease, and cardiovascular risk factors–were fitted using logistic regression to predict the outcome stroke or TIA. Likelihood ratio testing was used to select the best model, which was subsequently internally validated. Results The risk of stroke or TIA diagnosis was 52% among 1,289 BEFAST positive patients, median age 72 years, 56% female sex. Of patients with the outcome stroke/TIA, 24% received a low urgency allocation, while 92% had signs or symptoms when calling. Only the addition of age and sex improved predicting stroke or TIA (internally validated c-statistic 0.72, 95%CI 0.69–0.75). The predicted risk of stroke or TIA remained below 20% in those aged below 40. Females aged 70 or over and males aged 55 or over, had a predicted risk above 50%. Discussion Urgency allocation appears to be suboptimal in BEFAST positive patients calling the OHS-PC. Risk stratification could be improved in this setting by adding age and sex.

Care settings of transient ischemic attack in the United States: A cohort study from the TriNetX health research network

BackgroundEvaluation and hospitalization rates after a transient ischemic attack (TIA)-like presentation vary widely in clinical practice. This study aimed to examine variations in care settings at initial TIA diagnosis in the United States. MethodsWe retrospectively analyzed an adult cohort with a first TIA principal diagnosis between January 1, 2015, and December 31, 2019, from TriNetX Diamond Network. Care settings at TIA diagnosis were defined as hospital care (including inpatient services and observation unit care without admission) and outpatient care (including any outpatient or emergency department visits). We estimated the distribution of care settings at TIA diagnosis and examined the associations of the hospital care setting with baseline age, sex, race, ethnicity, region, and stroke history. ResultsAmong the 554,315 included patients, 38.8% received hospital care at their initial TIA diagnosis. A higher percentage of hospital care was observed in the age group of 50-64 years (40.3%), Black (46.0%), Hispanic (41.2%), South (40.9%), and Midwest (43.0%) Regions, and with a history of stroke (39.6%). Multivariable logistic regression consistently showed patients who were aged 50-64 years (Odds Ratio=1.09, 95% CI: [1.07, 1.11]), Black (1.28, [1.24, 1.32]), Hispanic (1.13, [1.09, 1.18]), from South (1.20, [1.18, 1.22]) and Midwest Region (1.33, [1.30, 1.35]), and had a history of stroke (1.02, [1.00, 1.04]) to more likely receive hospital care. ConclusionsAlthough there are TIA care disparities based on demographics, most patients with initial TIA received acute care in outpatient settings. It is imperative to ensure primary providers can risk-stratify TIA patients and provide rapid and proper management.

Long-term risk factors of recurrent stroke, myocardial infarction and death in patients leaving hospital with a diagnosis of ischemic stroke or TIA

Objectives. The prevalence of patients with prior stroke is increasing globally. Accordingly, there is a need for up-to-date evidence of patient-related prognostic factors for stroke recurrence, post stroke myocardial infarction (MI) and death based on long-term follow-up of stroke survivors. For this purpose, the RIALTO study was established in 2004. Design. A prospective cohort study in which patients diagnosed with ischemic stroke (IS) or transient ischemic attack (TIA) in three Copenhagen hospitals were included. Data were collected from medical records and by structured interview. Data on first stroke recurrence, first MI and all-cause death were extracted from the Danish National Patient Registry and the Danish Civil Registration System. Results. We included 1215 patients discharged after IS or TIA who were followed up by register data from April 2004 to end of 2018 giving a median follow-up of 3.5–6.9 years depending on the outcome. At the end of follow-up 406 (33%) patients had been admitted with a recurrent stroke, 100 (8%) had a MI and 822 (68%) had died. Long-term prognostic predictors included body mass index, diabetes, antihypertensive and lipid lowering treatment, smoking, a sedentary lifestyle as well as poor self-rated health and psychosocial problems. Conclusions. Long-term risk of recurrent stroke and MI remain high in patients discharged with IS or TIA despite substantial improvements in tertiary preventive care in recent decades. Continued attention to the patient risk profile among patients surviving the early phase of stroke, including comorbidities, lifestyle, and psychosocial challenges, is warranted.

Determinants of adherence to post-stroke/transient ischemic attack secondary prevention medications: A cohort study.

Adherence to post-stroke secondary prevention medications mitigates recurrence risk. This study aimed to measure adherence to secondary prevention medications during 3 years post-ischemic stroke/transient ischemic attack, using prescription and dispensing data, and identify factors associated with suboptimal adherence. This multicenter, prospective, cohort study involved patients from the STROKE 69 cohort, which included all consecutive patients with suspected acute stroke admitted between November 2015 and December 2016 to any emergency department or stroke center in the Rhône area in France. Prescription data for antihypertensive agents, antidiabetic agents, lipid-lowering drugs, and antithrombotics were collected. Dispensing data were provided by the French regional reimbursement database. Adherence was calculated using the continuous medication acquisition index. Associations between suboptimal adherence and potential influencing factors across the World Health Organization's five dimensions were explored through univariate and multivariate analyses. From 1512 eligible patients, 365 were included. Optimal adherence to overall treatment (≥90%) was observed in 61%, 62%, and 65% of patients in the first, second, and third years, respectively. Education level (high school diploma or higher: OR = 3.24, 95% CI [1.49; 7.36]) and depression (Hospital Anxiety and Depression Scale-Depression scores 8-10: OR = 1.90, 95% CI [1.05; 3.44]) were significantly associated with suboptimal adherence. Overall adherence to secondary prevention medications was fairly good. Having an initial diagnosis of transient ischemic attack, a high level of education, or depression was associated with increased odds of suboptimal adherence, while having a history of heart rhythm disorder was associated with lower odds.

Diagnostic value of cervical vascular ultrasound in large arterial lesions of the neck in patients with transient ischemic attack

Objective To assess the diagnostic value of cervical vascular ultrasound in identifying large arterial lesions in patients with transient ischemic attack (TIA). Methods The current study matched 84 TIA patients (disease group) with 66 healthy controls (control group). The baseline patient profiles and biochemical indices of the patients were analyzed. All patients received color Doppler ultrasonography, and outcome measures of its diagnostic efficiency included plaque status, plaque properties, and the degree of carotid stenosis. The patients in the disease group were assigned to group A (TIA of the internal carotid artery system, n = 40) and group B (TIA of the vertebrobasilar artery system, n = 44), and the plaque distribution of the patients was analyzed. Results TIA patients had higher rates of diabetes, hypertension, hyperlipidemia, obesity, and smoking compared to controls (p < 0.05). Their serum TC, LDL-C, and FBG levels were significantly elevated, while HDL-C levels were decreased (p < 0.05). TIA patients had more plaques, especially soft plaques, than controls (p < 0.05). They also showed higher rates of moderate to severe carotid stenosis (p < 0.05). TIA involving the internal carotid artery system was associated with a higher risk of plaques at the entrance of the subclavian artery compared to TIA involving the vertebrobasilar artery system (p < 0.05). Conclusion The diagnostic value of cervical vascular ultrasound in patients with TIA is remarkable, and it provides a reliable monitoring approach as well as an essential screening modality for TIA. The rational use of this technique will markedly benefit the diagnosis, treatment, and prevention of TIA.

Transient ischemic attack in the vertebrobasilar vascular territory as a cause of isolated vertigo

Transient ischemic attack (TIA) in the vertebrobasilar vascular territory (VB) causes difficulties in diagnosis when it manifests only with vestibular symptoms. Issues relating to the differential diagnosis of TIA are discussed, awareness of which is necessary for the selection of informative methods of examination and the prescription of effective stroke prevention in patients with an episode of isolated dizziness. The likelihood of TIA as the cause of dizziness is increased by the patients' high cardiovascular risk, the presence of atrial fibrillation, severe instability during an attack, and head and/or neck pain. If a TIA in VB is suspected, it is advisable to perform a minimal instrumental examination, including computed tomography (CT) of the brain and CT angiography or diffusion-weighted magnetic resonance imaging (MRI) and MRI angiography. In case of doubt, additional information can be obtained by a perfusion CT or MRI as well as a post-contrast MRI. When interpreting the results of these methods of examination, their limitations in terms of application time and resolution should be taken into account.

Transient ischemic attack and pregnancy, delivery and neonatal outcomes-An evaluation of a population database.

Transient ischemic attack (TIA) is rare in women of reproductive age. We aimed to compare perinatal outcomes between women who suffered from a TIA to those who did not. A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). All women who delivered or had a maternal death in the US (2004-2014) were included in the study. Pregnancy, delivery, and neonatal outcomes were compared between women with an ICD-9 diagnosis of a TIA to those without. Overall, 9 096 788 women met the inclusion criteria. Of these, 203 women (2.2/100000) had a TIA (either before or during pregnancy). Women with TIA, compared to those without, were more likely to be older than 35 years of age, white, in the highest income quartile, be insured by private insurance and suffer from obesity and chronic hypertension. Patients in the TIA group, compared to those without, had a higher rate of pregnancy-induced hypertension (aOR 2.5, 95% CI: 1.55-4.05, P < 0.001), pre-eclampsia (aOR 3.77, 95% CI: 2.15-6.62, P < 0.001), eclampsia (aOR 28.05, 95% CI: 6.91-113.95, P < 0.001), preterm delivery (aOR 1.78, 95% CI: 1.03-3.07, P = 0.039), and maternal complications such as deep vein thrombosis (aOR 33.3, 95% CI: 8.07-137.42, P < 0.001). Regarding neonatal outcomes, patients with a TIA, compared to those without, had a higher rate of congenital anomalies (aOR 7.04, 95% CI: 2.86-17.32, P < 0.001). Women with a TIA diagnosis before or during pregnancy had a higher rate of maternal complications, including hypertensive disorders of pregnancy and venous thromboembolism, as well as an increased risk of congenital anomalies.

Abstract WP290: Stroke 90 Program

Background: Despite tremendous scientific advancements in acute stroke care, post-stroke management can be challenging. Information overload and a lack of post-discharge understanding can lead to potential stroke readmissions. Purpose Patients with a history of stroke have a significantly higher risk of readmission. Neuro-telemetry nurses designed Stroke 90 as a follow-up outreach program to reduce the stroke readmission average by 2% over six months and address knowledge gaps. After completing the program, patients will have the education and resources to prevent readmission. Methods: Neuro-telemetry nurses call stroke patients three weeks post-discharge to determine baseline knowledge of their stroke. The next six weeks reinforce individualized stroke education and reassess for continued post-discharge needs. The Plan Do Study Act (PDSA) cycle was implemented May 2021 for 11 months and only included acute ischemic or hemorrhagic stroke patients (n=154) discharged home from the Neuro-Telemetry Unit. A second PDSA cycle began in September 2022, including patients (n=356) discharged with a diagnosis of Transient Ischemic Attack, Ischemic, or Hemorrhagic Stroke from the Emergency Department, Intensive Care Unit, and Neuro-Telemetry Unit. Data is collected retrospectively by identifying patients with a final stroke diagnosis 30 days post-discharge. Outpatient visits and procedural admissions were excluded. 90-day readmissions only included inpatient hospital stays with another stroke diagnosis. Results: From September 2022 to December 2022, 6.25 patients were readmitted per month with a diagnosis of acute stroke, making the readmission average 16%. From January 2023 to June 2023, 4 stroke patients were readmitted per month, yielding a readmission average of 12%. The program demonstrated a monthly acute stroke patient reduction of 2.25 with a 3-day average length of stay (total savings of 6.75 hospital days). Conclusion: Overall, there was a 4% decrease in the readmission average, which exceeded the goal of a 2% decrease. The teach-back method is valuable for addressing knowledge gaps and decreasing post-stroke readmissions. The Stroke 90 Program significantly benefits stroke survivors as they navigate recovery.

Biomarkers of Brain Ischemia (Review)

Introduction. Strokes remain the second leading cause of death and the third leading cause of disability. Additional serum biomarker testing should be used to better diagnose transient ischemic attack (TIA), but most neurospecific biomarkers have low prognostic specificity and sensitivity. Timely identification of TIA and differential diagnosis of stroke in the first hour will ensure a shorter period of patient recovery and reduce the risk of mortality and disability. Serum biomarker studies should be included to overcome the difficulty of diagnosing TIA.Text. Neurospecific biomarkers such as S100B, GFAP, and NSE are used to diagnose acute ischemic damage to glial cells and neurons. S100B and GFAP are detected in astrocytes and NSE in neurons and cells of the neuroendocrine system. Elevated serum concentrations of these biomarkers are associated with various pathological conditions such as strokes and brain injuries and other central nervous system (CNS) lesions. Dynamic monitoring of biomarker concentrations makes it possible to evaluate the efficacy of the ongoing therapy and to identify predictors of patient deterioration for prompt correction of therapeutic procedures. To create a diagnostic panel it is necessary to study metabolic processes in ischemic tissue, taking into account concomitant diagnoses and results of neuroimaging, and to use breakthrough advances in machine learning and big data.Conclusion. The review showed that none of the assessed biomarkers can be recommended for the diagnosis of cerebral circulation disorders, but the combination of several neurospecific biomarkers can significantly improve diagnostic efficiency and find application in the differential diagnosis of stroke, intracranial hematoma, and other brain lesions for the purpose of early pharmacotherapy of CNS lesions and as surrogate endpoints during clinical trials.

Dispatcher Stroke/TIA Recognition in Emergency Medical Call Center and Out-of-Hours Service Calls in Copenhagen, Denmark.

Recognition of stroke/TIA symptoms by emergency medical services (EMS) is instrumental in providing timely recanalization treatments. We assessed the recognition of stroke/TIA by EMS via the emergency medical call center (EMCC) dispatchers and out-of-hours health service (OOHS) dispatchers. In a registry study, based on 2015-2020 data from the Copenhagen EMS, we calculated sensitivity, positive predictive value (PPV), specificity, and negative predictive value (NPV) of dispatcher suspicion of stroke or transient ischemic attack (TIA) and compared against discharge diagnosis. We included 462,029 contacts to EMCC and 2,573,865 contacts to OOHS. In total, 19,798 contacts had a stroke or TIA diagnosis at hospital discharge. Sensitivity was 0.64 for EMCC dispatchers and 0.25 for OOHS. PPV was 0.28 for EMCC and 0.22 for OOHS; specificity was 0.96 for EMCC and >0.99 for OOHS, and NPV was 0.99 for EMCC and >0.99 for OOHS. Sensitivity improved over the period of the study from 0.62 to 0.68 for EMCC and from 0.20 to 0.25 for OOHS. PPV did not change over the period for EMCC and decreased from 0.26 to 0.19 for OOHS. Both EMCC and OOHS more frequently overlooked stroke in women, in patients calling more than 3 hours after symptom onset, and for more severe strokes. For OHHS, advanced age correlated with lower recognition. As the first study reporting on OOHS setting dispatcher stroke/TIA recognition, we find a need for the improvement of stroke/TIA recognition both in EMCC and in OOHS. Solutions may include specific training of dispatchers, public awareness campaigns, and new technological solutions.

175 Navigating the transient ischaemic attack pathway—unveiling the gaps and developing a standard solution

Abstract Background Hyperacute management of a Transient Ischemic Attack (TIA) is necessary to decrease subsequent stroke. We examined our current management of TIA patients to inform a quality improvement initiative to bring our practice in line with the 2023 UK and Ireland Clinical Guidelines for Stroke. Methods We completed a retrospective cohort study of patients who attended our hospital between December 1st 2022 and February 28th 2023. Patients with a primary diagnosis of TIA were identified though the Hospital In-Patient Enquiry (HIPE). Each diagnosis was verified with electronic records review, with exploration of key investigations and management parameters. Results 41 patients were coded as TIA from HIPE. 39 were a verified TIA diagnosis, with a mean age of 68.7 years. 10.2% were seen by direct GP referral to the Acute Medical Unit (AMU), with the rest attending ED initially. The median length of Stay (LoS) in hospital was 2.75 days. Most patients were admitted under the AMU (33%) or Stroke service (26%), with a shorter LoS if the patient was admitted under these services. 38 patients underwent neuroimaging; 94.8% CT Brain, 84.6% MRI Brain, and 82.1% both CT and MRI imaging. 1 patient went directly for MRI Brain without CT imaging. 82.1% were reviewed by a stroke specialist. Dual Anti-Platelet Therapy (DAPT) was used in 3 patients, single antiplatelet in 21, and oral anticoagulation in 9. 3 patients were discharged without any anti-thrombotic therapy. Conclusion This study highlights areas for improvement in the management of TIA in our facility. Our results have informed the development of a new TIA pathway, which will encourage an ambulatory approach to investigations and management of patients with a TIA. Improved patient-centred outcomes may include improved selection for DAPT, improved neuroimaging efficiency with increased direct to MRI imaging and higher numbers of patients being reviewed by a stroke specialist clinician.

Association of Incomplete Neurovascular Imaging After Emergency Department Encounters for Transient Ischemic Attack and Odds of Subsequent Stroke: A National Medicare Analysis.

BACKGROUND. Multisociety guidelines recommend urgent brain and neurovascular imaging for patients with transient ischemic attack (TIA), to identify and treat modifiable stroke risk factors. Prior research suggests that most patients with TIA who present to the emergency department (ED) do not receive prompt neurovascular imaging. OBJECTIVE. The purpose of this study was to evaluate the association between incomplete neurovascular imaging workup during ED encounters for TIA and the odds of subsequent stroke. METHODS. This retrospective study obtained data from the Medicare Standard Analytical Files for calendar years 2016 and 2017; these files contain 100% samples of claims for Medicare beneficiaries. Information was extracted using ICD 10th revision (ICD-10) and CPT codes. Those patients who were discharged from an ED encounter with a TIA diagnosis and who underwent brain CT or brain MRI during or within 2 days of the encounter were identified. Patients were considered to have complete neurovascular imaging if they underwent cross-sectional vascular imaging of both the brain (brain CTA or brain MRA) and neck (neck CTA, neck MRA, or carotid ultrasound) during or within 2 days of the encounter. The association between incomplete neurovascular imaging and a new stroke diagnosis within the subsequent 90 days was tested by multivariable logistic regression analysis. RESULTS. The sample included 111,417 patients (47,370 men, 64,047 women; 26.0% older than 84 years) who had TIA ED encounters. A total of 37.3% of patients (41,592) had an incomplete neurovascular imaging workup. A new stroke diagnosis within 90 days of the TIA ED encounter occurred in 4.4% (3040/69,825) of patients with complete neurovascular imaging versus 7.0% (2898/41,592) of patients with incomplete neurovascular imaging. Incomplete neurovascular imaging was associated with increased likelihood of stroke within 90 days (OR, 1.30 [95% CI, 1.23-1.38]) after adjustment for patient characteristics (age, sex, race and ethnicity, high-risk comorbidities, median county household income) and hospital characteristics (region, rurality, number of beds, major teaching hospital designation). CONCLUSION. TIA ED encounters with incomplete neurovascular imaging were associated with higher odds of subsequent stroke occurring within 90 days. CLINICAL IMPACT. Increased access to urgent neurovascular imaging for patients with TIA may represent a target that could facilitate detection and treatment of modifiable stroke risk factors.

Predictive role of ABCD2, ABCD3I, C-reactive protein, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and systemic immune-inflammation index in 90-day and long-term stroke after transient ischemic attack

Objectives: Transient ischemic attack (TIA) is a neurological emergency and a precursor of ischemic stroke. ABCD2 and ABCD3I scores predict stroke after TIA, and clinicians use preclinical, clinical, and radiological parameters for calculating these scores. Our study aimed to investigate the efficacy of peripheral blood markers in predicting 90-day and long-term stroke risk after TIA. Methods: This retrospective study was conducted in Kastamonu Training and Research Hospital between January 2015 and November 2022. The demographic data of 99 patients who applied with the diagnosis of TIA and peripheral blood markers at the time of first admission to the hospital were used in the study. These parameters was evaluated in 90-day and long-term (&amp;gt;12 months) stroke after TIAs. Results: Of the 99 patients in our study, 59% (n = 58) were male. The mean age of the patients was 70 ± 13 years. ABCD2 (age, blood pressure, clinical features, duration of symptoms, and presence of diabetes mellitus) and ABCD3I (age, blood pressure, clinical features, duration of symptoms, presence of diabetes mellitus, dual TIA, and ipsilatheral carotis stenosis) scores and C-reactive protein (CRP) were statistically significant in predicting 90-day stroke. ABCD2 and ABCD3I were not effective in predicting long-term stroke. In addition, CRP, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) parameters were statistically significant in long-term stroke. CRP (AUC=793, sensitivity=82%, and specificity=81%) values were higher than ABCD2 (AUC=779, sensitivity=73%, and specificity=76%) and ABCD3I (AUC=755, sensitivity=82%, and specificity=70%) scores in predicting 90-day stroke. Conclusions: Our study showed that ABCD2, ABCD3I, and CRP effectively predict 90-day stroke after TIA. Furthermore, CRP was more effective than ABCD2 and ABCD3I scores in predicting 90-day stroke after TIA. CRP, NLR, PLR, and SII also effectively predicted long-term stroke after TIA.

Ticagrelor plus aspirin vs clopidogrel plus aspirin in mild non-cardioembolic ischemic stroke: A protocol of a randomized, controlled, active comparator arm, outcome assessor blind, feasibility study

Background &amp; Objectives: The risk of recurrence after a transient ischemic attack (TIA) or minor stroke is high especially within three months after first event. The aim of study is assessing the efficacy of ticagrelor plus aspirin in reduction of mild non-cardioembolic ischemic stroke or high risk TIA recurrence during first 3 months. Methods: This is a randomized, controlled, active comparator arm, outcome assessor blind, parallel group, feasibility study design on 90 patients with diagnosis of non-cardioembolic minor ischemic stroke or high risk TIA admitted in Bou-Ali Sina Hospital, Sari, Iran. After meeting all inclusion and exclusion criteria, patients will be randomized to ticagrelor 90 mg BID plus aspirin (ASA) 80 mg daily or clopidogrel 75 mg daily plus ASA 80 mg daily (1:1 ratio) until 21 days and then ASA 80 mg daily. Participants will be visited at month one and three. Any adverse events, serious side effects and outcome events will be recorded. The primary outcome is defined as ischemic stroke recurrence. Conclusion: Ticagrelor plus ASA is expected to be effective for prevention of recurrence in mild non-cardioembolic stroke and high risk TIA. Trial Registration: ClinicalTrials.gov: NCT04738097

The effect of discharge care plans on statin prescription rates.

Stroke discharge care bundles have been proposed to address inadequate provider statin prescription rates. Discontinuation of statins has been associated with a 37% relative risk increase in mortality in patients with a stroke diagnosis. The project site had a statin prescription rate of 86.2%. The project was initiated at a 641-bed regional community teaching medical center. Statin prescription rates upon discharge on patients with the diagnosis of transient ischemic attack or stroke were evaluated and noted to be below the benchmark of 95%. Possible interventions to improve this benchmark were discussed with key stakeholders such as the information technology team, stroke care outcomes team, and neurology service providers. The proposed intervention was incorporated into the electronic health record. Provider prescription rates were tracked monthly along with the use of the proposed intervention. A one-sided z-test was used to analyze the data collected. A stroke discharge power plan within an electronic health record was modified to increase the rate of statin prescriptions. The key modification included checking off the prescription of a statin on discharge. Reinforcement of its use was done through monthly reminders. Use of discharge care plan yielded 100% compliance. Overall compliance was 9.7%. The null hypothesis of the one-sided z-test was 89%. The p-value for all tests was <0.05. The use of a stroke discharge care plan within an electronic health record can positively affect secondary stroke prevention by increasing statin prescription rates.

Low Utility of Short-Term Rhythm Assessment Before Long-Term Rhythm Monitoring in Patients With Cryptogenic Stroke

Implantable cardiac monitors are routinely placed for long-term monitoring (LTM) after a period of negative short-term monitoring (STM) to increase atrial fibrillation (AF) detection after a cryptogenic stroke or transient ischemic attack (TIA). Optimizing AF monitoring after a cryptogenic stroke is critical to improve outcomes and reduce costs. We sought to compare the diagnostic yield of STM versus LTM, assess the impact of routine STM on hospitalization length of stay, and perform a financial analysis comparing the current model to a theoretical model wherein patients can proceed directly to LTM. Our retrospective observational cohort study analyzed patients admitted to Montefiore Medical Center between May 2017 and June 2022 with a primary diagnosis of cryptogenic stroke or TIA who underwent Holter device monitoring. Of 396 subjects, STM detected AF in 10 (2.5%) compared with a diagnostic yield of 14.6% for LTM (median time to diagnosis of 76days). Of the 386 patients with negative STM, 130 (33.7%) received an implantable cardiac monitor while an inpatient, and 256 (66.3%) did not. We calculated a point estimate of 1.67days delay of discharge attributable to the requirement for STM to precede LTM. Our model showed that the expected cost per patient in the STM-first paradigm is $28,615.33 versus $27,111.24 in the LTM-or-STM paradigm. Considering the relatively lower diagnostic yield of STM and its association with a longer length of stay and higher costs, it may be reasonable to proceed directly to LTM to optimize AF detection after a cryptogenic stroke or TIA.

Rational clinical approach to transient ischaemic attack, stroke and associated mimics: A retrospective cohort study.

The present study was performed to identify the individual clinical features and risk factors most strongly associated with the diagnosis of transient neurological symptoms with a cerebrovascular cause (transient ischaemic attack (TIA) or stroke), as compared to common TIA mimics (including retinal ischaemia, migraine and seizure). In a retrospective cohort study, consecutive patients presenting with transient neurological symptoms to TIA clinic in Royal Adelaide Hospital were included. Clinical features and risk factors were recorded in a standardised form, categorised into subgroups, and analysed using descriptive statistics and diagnostic performance indicators, such as sensitivity, specificity and likelihood ratios. For 218/1273 individuals diagnosed with stroke, the three features with the highest positive likelihood ratio were the presence of diffusion weighted imaging positive lesion on magnetic resonance imaging (23.66, 95% confidence interval (CI) 14.35-51.08), extracranial carotid atherosclerosis (3.98, 95% CI 1.19-6.87) and a history of peripheral vascular disease (3.33, 95% CI 1.64-6.27). For TIA, the three features with the highest positive likelihood ratio were extracranial carotid atherosclerosis (3.98, 95% CI 1.19-8.27), presence of atrial fibrillation (2.43, 95% CI 1.54-3.46) and pre-existing anticoagulant therapy (2.39, 95% CI 1.61-3.29). For stroke and TIA, the respective features with the lowest negative likelihood ratios were limb weakness (0.71, 95% CI 0.65-0.77) and hypertension (0.66, 95% CI 0.49-0.84). The present study demonstrated that specific clinical features and risk factors were associated with the final diagnosis at TIA clinic. These clinical features may assist with diagnosis of TIA in centres without access to a vascular neurologist.