Organized Outpatient Care of Patients with Transient Ischemic Attack and Minor Stroke

Abstract

The risk of recurrent stroke after transient ischemic attack (TIA) is high. In the past 10 years, TIA has increasingly been recognized as a medical emergency. Health systems have adapted toward rapid evaluation, investigation, and secondary prevention in patients with presumed TIA and minor stroke, and the significant benefits in reducing recurrent stroke and mortality have been borne out in several landmark studies. Various scores have been developed and debated to better risk stratify patients with TIA for hospitalization or urgent referral. However, scoring systems face challenges in identifying all patients with high-risk etiologies such as atrial fibrillation and carotid stenosis, and therefore require further refinement before widespread use. Further challenges include the role of advanced imaging in TIA, and ensuring rapid access to specialist care for all patients. In the absence of definitive risk stratification methods, the authors conclude that all patients with suspected TIA and minor stroke should be assessed and treated on an urgent basis, ideally through rapid outpatient referral programs.

Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke

“…Another potential concern with the shorter length of stay is recurrent neurovascular events at home, the risk of which is highest during the first days. 1,12 To minimize this problem, we aimed to identify and hospitalize patients at 'high risk' of recurrent episodes and hence extended their length of hospital stay. 14 To qualify the clinical decision to do so, we developed a risk assessment tool using the ABCD2 score combined with imaging 26 and other essential risk factors for recurrent episodes.…”

“…4,[7][8][9][10][11] However, we do not know how acute outpatient specialist care compares with in-hospital stroke unit care. 12,13 It is still debated how to most efficiently organize the services for patients with minor stroke/TIA 12, 14-16 ; and use of hospitalization still seems widespread. 17,18 Hospitalization confers theoretical benefits over urgent outpatient clinic referral including monitoring of the patients and rapid access to revascularization, but these benefits are offset by potential drawback of hospitalization together with potential overuse of hospital resources.…”

“…17,18 Hospitalization confers theoretical benefits over urgent outpatient clinic referral including monitoring of the patients and rapid access to revascularization, but these benefits are offset by potential drawback of hospitalization together with potential overuse of hospital resources. 12,14,19,20 The risk of a re-stroke remains the main concern of outpatient treatment and an innovative approach may be a hybrid that combines benefits from both strategies. 14 In 2012, an acute outpatient clinic for patients with suspected minor stroke/TIA opened at Aarhus University Hospital, Denmark, following centralization of the acute stroke care services.…”