Computed tomographic angiography in stroke and high-risk transient ischemic attack: Do not leave the emergency department without it!

Graham, Brett; Menon, Bijoy K; Coutts, Shelagh B.; Goyal, Mayank; Demchuk, Andrew M.

doi:10.1177/1747493018764172

Cited by 6 publications

(3 citation statements)

References 103 publications

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“…Furthermore, CTA is preferred over carotid Dopplers, because CTA allows for the additional assessment of the intracranial and posterior circulation vessels [7,11,12]. Urgent CTA in all patients with suspected minor ischemic cerebrovascular events can negatively impact workflow in the emergency and radiology departments, but a delay in obtaining this test in patients with high-risk events may lead to missed opportunities for stroke treatment and prevention [5].…”

Section: Why Does This Study Matter To Clinicians?mentioning

confidence: 99%

“…Most patients with ischemic stroke initially present with mild or transient symptoms [1], but transient ischemic attacks (TIA) and minor strokes do not have benign outcomes [2,3]. Urgent vascular imaging for patients with high-risk TIA or minor stroke is recommended, because the presence of vascular abnormality is associated with higher risk of disability and stroke recurrence [3,4] and guides secondary stroke prevention treatment [5,6]. The Canadian Stroke Best Practice Guidelines define a high-risk minor ischemic cerebrovascular 800 acute stroke admissions and 60,000 ED visits annually.…”

Section: Introductionmentioning

confidence: 99%

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Multidisciplinary quality improvement initiative to optimize acute neurovascular imaging for transient ischemic attack or minor stroke

et al. 2021

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Background Neurovascular imaging for patients with high-risk transient ischemic attack (TIA) or minor stroke in the emergency department (ED) with computed tomography angiography (CTA) of the head and neck is the guideline-recommended standard of care, but it is underutilized in routine practice. We conducted a quality initiative to improve adherence to guidelines. Methods Between January 2017 and March 2019, we implemented a decision support tool integrated into the electronic ordering system to guide ED physicians to order a CTA on patients with high-risk TIA or minor stroke defined as ongoing neurological deficits in the ED or resolved motor or speech deficits in the preceding 48 h. Data were collected retrospectively pre-intervention and prospectively post-intervention. We used an interrupted time-series analysis for the before-after comparison of the use of CTA among patients who met criteria (main process measure) and those who did not meet criteria (balancing measure). Results Among 861 patients with TIA or minor stroke, the proportion of patients with high-risk events imaged with a CTA in the ED increased from 12.0% pre-intervention to 77.0% post-intervention and this shift was sustained over 11 months. CTA use in those without high-risk events increased to a lesser extent (15.3% versus 42.9%). The interrupted time-series analysis showed a step change immediately post-intervention where the increase in CTA use in patients with high-risk events was 51.7% higher than its use in those without high-risk events (p < 0.001). Compared to pre-intervention, the median ED length of stay increased by 2 h and neurology consultation in the ED was more frequent (5.8% versus 19.5%) post-intervention. ConclusionWe provide a detailed framework that improved adherence to acute imaging guidelines for patients with TIA or minor stroke and anticipate that our approach could improve acute imaging for such patients in most EDs. Keywords Quality improvement • Transient ischemic attack • Stroke • ImagingRésumé Contexte L'imagerie neurovasculaire pour les patients présentant un risque élevé d'accident ischémique transitoire (AIT) ou d'accident vasculaire cérébral mineur aux services d'urgence, avec une angiographie par tomodensitométrie (CTA) de la tête et du cou, est la norme de soins recommandée par les directives, mais elle est sous-utilisée dans la pratique courante. Nous avons mené une initiative de qualité pour améliorer le respect des lignes directrices.

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Section: Why Does This Study Matter To Clinicians?mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Multidisciplinary quality improvement initiative to optimize acute neurovascular imaging for transient ischemic attack or minor stroke

et al. 2021

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“…However, we were able to prevent 66.6% (1927/2895) of patients with a relatively minor degree of stroke (NIHSS < 8) from an unnecessary emergent CTA study. We also were able to prevent time delay in IVT treatment in case an emergent CTA was regarded a regular study for all patients with AIS in some comprehensive stroke centers [ 17 , 18 ].…”

Section: Discussionmentioning

confidence: 99%

Rapid Identification of Patients Eligible for Direct Emergent Computed Tomography Angiography during Acute Ischemic Stroke: The DARE-PACE Assessment

Yiang

Chen

et al. 2022

Diagnostics

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Background: We investigated the clinical signs to establish a method for rapid identification of patients with the National Institute of Health Stroke Scale (NIHSS) score ≥ 8 eligible for direct brain CTA study; Methods: We retrospectively enrolled 2895 in patients with acute ischemic stroke (AIS). Four items in the NIHSS were selected as the main clinical signs of stroke; Results: A total of 922 (31.8%) patients had an initial NIHSS score of ≥8. The average door-to-CT time and door-to-CTA time were 13.4 ± 1.8 and 75.5 ± 44.5 min, respectively. Among 658 patients who had the priority signs, namely dense hemiplegia (D), aphasia with right arm drop (AR), and eyeball forced deviation (E), 634 patients (96.4%) with an NIHSS score ≥ 8 were identified. By using a classification and regression tree analysis, 153 patients with an NIHSS ≥ 8 were identified among 175 patients (87.4%) who had the secondary signs, namely hemiparesis with limb falls (P), aphasia (A), drowsy or worse consciousness (C), and eyeball limitation (E). The sensitivity, specificity, and accuracy were 85.4%, 97.7%, and 95.3%, respectively. Conclusions: The DARE-PACE assessment involving a checkbox list provides excellent accuracy for rapid identification of AIS patients with an NIHSS score ≥ 8 for direct CTA study to reduce the time delay for endovascular thrombectomy.

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Transient Ischemic Attack

Ferguson

2023

Evidence‐Based Emergency Care

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Computed tomographic angiography in stroke and high-risk transient ischemic attack: Do not leave the emergency department without it!

Cited by 6 publications

References 103 publications

Multidisciplinary quality improvement initiative to optimize acute neurovascular imaging for transient ischemic attack or minor stroke

Multidisciplinary quality improvement initiative to optimize acute neurovascular imaging for transient ischemic attack or minor stroke

Rapid Identification of Patients Eligible for Direct Emergent Computed Tomography Angiography during Acute Ischemic Stroke: The DARE-PACE Assessment

Transient Ischemic Attack

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