Diffusion-Weighted MRI in 300 Patients Presenting Late With Subacute Transient Ischemic Attack or Minor Stroke

Schulz, Ursula G.; Briley, Dennis; Meagher, Tom; Molyneux, Andrew; Rothwell, Peter M.

doi:10.1161/01.str.0000143455.55877.b9

Cited by 80 publications

(58 citation statements)

References 30 publications

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“…6 The audit also demonstrates imaging is more likely to be diagnostic when performed early. 7,8 This supports the National Stroke Strategy recommendation for immediate referral in patients presenting with a recent TIA or minor stroke. 10 Although not a subject of this audit, interventions to prevent stroke have also been shown to be time dependent, 2 again reinforcing the need for urgent evaluation and management of patients with minor stroke or TIA.…”

Section: Discussionsupporting

confidence: 52%

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An urgent access neurovascular clinic: audit of timeliness

2009

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-This study aimed to evaluate timeliness of an outpatient urgent access neurovascular clinic in a district general hospital setting through an audit of delay from event to completion of evaluation following transient ischaemic attack (TIA) or minor stroke. Participants included those referred for evaluation of suspected TIA or minor stroke. The median delay from event to completion was 16 days, with 45% seen within two weeks of symptom onset, and 15% within one week of symptom onset. A weekly TIA clinic is not capable of achieving the National Clinical Guidelines for Stroke recommendation for evaluation within one week of symptoms. This audit supports the National Stroke Strategy recommendation for immediate evaluation of patients presenting with a recent TIA or minor stroke.

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Section: Discussionsupporting

confidence: 52%

“…For this clinic, magnetic resonance imaging (MRI), including diffusion weighted imaging, was the primary brain imaging modality and carotid magnetic resonance angiogram (MRA) was the primary vascular imaging used, and they were generally performed together. 7,8 Stroke and TIA were diagnosed according to World Health Organization (WHO) criteria.…”

Section: Methodsmentioning

confidence: 99%

An urgent access neurovascular clinic: audit of timeliness

2009

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“…Four studies provided data separately for TIA and minor stroke patients. 224,225,232,233 The proportion of minor stroke patients with visible ischaemic lesions on DWI was 47% in one study, 227 70% in another study, 232 and reached 100% in two studies. 224,233 It is worth noting that the two studies in which all minor stroke patients showed a positive DWI lesion were of small sample size and enrolled patients with a definite diagnosis of TIA or minor stroke as opposed to a possible diagnosis of TIA or minor stroke -for example Kastrup and colleagues 224 included only patients with high-grade symptomatic carotid stenosis.…”

Section: Main Findingsmentioning

confidence: 93%

“…All studies except eight 57,72,134,224,225,232,233,248 restricted inclusion to TIA patients. The frequency of positive DWI findings ranged from 9% to 67% across studies (Table 22).…”

Section: Main Findingsmentioning

confidence: 99%

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

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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BackgroundPatients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.ObjectivesIs MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as ‘one-stop’ brain-carotid imaging? What is the current UK availability of services for stroke prevention?Data sourcesPublished literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.Review methodsSystematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.ResultsThe pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35–41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40–45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51–54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with ‘CT scan all patients’ MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. ‘One-stop’ CT/MR angiographic-plus-brain imaging was not cost-effective.LimitationsData on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.ConclusionsMagnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…15,16 This is of particular concern in clinical settings where urgent neurology follow-up or access to primary care is not available. Furthermore, multiple studies have documented that patients with TIA who have evidence of infarct on magnetic resonance imaging (MRI) are at substantially increased risk of stroke, [17][18][19][20][21][22] and incorporation of MRI findings into the risk stratification process substantially improves prognostication. 23 As a result, national guidelines now recommend MRI as the ''preferred'' brain imaging modality over noncontrast computed tomography (CT).…”

Section: Introductionmentioning

confidence: 99%

Incorporating Diffusion-Weighted Magnetic Resonance Imaging into an Observation Unit Transient Ischemic Attack Pathway

Oostema

DeLano

Bhatt

et al. 2014

The Neurohospitalist

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Background and Purpose: National guidelines advocate for early, aggressive transient ischemic attack (TIA) evaluations and recommend diffusion-weighted magnetic resonance imaging (MRI) for brain imaging. The purpose of this study is to examine clinician compliance, the yield of MRI, and patient-centered clinical outcomes following implementation of an emergency department observation unit (EDOU) clinical pathway incorporating routine MRI into the acute evaluation of patients with TIA. Methods: This is a prospective observational study of patients with TIA admitted from the ED. Patients with low-risk TIA were transferred to an EDOU for diagnostic testing including MRI; high-risk patients were directed to hospital admission. Clinical variables, diagnostic tests, and treatment were recorded for all patients. The primary clinical outcome was the rate of stroke or recurrent TIA, determined through telephone follow-up and medical record review at 7 and 30 days. Results: A total of 116 patients with TIA were enrolled. In all, 92 (79.3%) patients were transferred to the EDOU, of whom 69 (59.5%) were discharged without hospitalization. Compliance with the EDOU pathway was 83 (91.2%) of 92. Magnetic resonance imaging demonstrated acute infarct in 16 (15.7%) of 102 patients. Stroke (n ¼ 2) or TIA (n ¼ 3) occurred in 5 patients with TIA (4.3%, 95% confidence interval: 1.6%-10.0%) within 30 days; no strokes occurred after discharge. Conclusion: Implementation of a TIA clinical pathway incorporating MRI effectively encouraged guideline-compliant diagnostic testing; however, patient-important outcomes appear similar to diagnostic protocols without routine MRI. Further study is needed to assess the benefits and costs associated with routinely incorporating MRI into TIA evaluation.

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Diffusion-Weighted MRI in 300 Patients Presenting Late With Subacute Transient Ischemic Attack or Minor Stroke

Cited by 80 publications

References 30 publications

An urgent access neurovascular clinic: audit of timeliness

An urgent access neurovascular clinic: audit of timeliness

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

Incorporating Diffusion-Weighted Magnetic Resonance Imaging into an Observation Unit Transient Ischemic Attack Pathway

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