Rapid Assessment and Treatment of Transient Ischemic Attacks and Minor Stroke in Canadian Emergency Departments

Kamal, Noreen; Hill, Michael D; Blacquiere, Dylan; Boulanger, Jean-Martin; Boyle, Karl; Buck, Brian; Butcher, Ken; Camden, Marie‐Christine; Casaubon, Leanne K.; Côté, Robert; Demchuk, Andrew M.; Dowlatshahi, Dar; Dubuc, Véronique; Field, Thalia S.; Ghrooda, Esseddeeg; Gioia, Laura; Gladstone, David J.; Goyal, Mayank; Gubitz, Gordon; Harris, Devin; Hart, Robert G.; Hunter, Gary; Jeerakathil, Thomas; Jin, Albert; Khan, Khurshid; Lang, Eddy; Lanthier, Sylvain; Lindsay, M. Patrice; Mackey, Ariane; Mandzia, Jennifer; Mehdiratta, Manu; Minuk, Jeffrey; Oczkowski, Wieslaw; Odier, Céline; Penn, Andrew M.; Perry, Jeffrey J.; Pettersen, Jacqueline A.; Phillips, Stephen J.; Poppe, Alexandre Y; Saposnik, Gustavo; Selchen, Daniel; Shamy, Michel; Sharma, Mukul; Shoamanesh, Ashkan; Shuaib, Ashfaq; Silver, Frank L.; Stotts, Grant; Swartz, Richard H.; Tamayo, Arturo; Teitelbaum, Jeanne; Verreault, Steve; Wein, Theodore; Yip, Samuel; Coutts, Shelagh B.

doi:10.1161/strokeaha.115.010454

Cited by 24 publications

(16 citation statements)

References 20 publications

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“…Further, IVT has a low-risk profile in minor stroke [14,18]. Thus, the rapid assessment and treatment of patients with minor stroke is crucial and should be emphasized [19].…”

Section: Discussionmentioning

confidence: 99%

Delayed Intravenous Thrombolysis in Patients with Minor Stroke

et al. 2018

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Background: The actions and responses of the hospital personnel during acute stroke care in the emergency department (ED) may differ according to the severity of a patient’s stroke symptoms. We investigated whether the time from arrival at ED to various care steps differed between patients with minor and non-minor stroke who were treated with intravenous tissue plasminogen activator (IV tPA). Methods: We included consecutive patients who received IV tPA during a 1.5 year-period in 5 hospitals. Minor stroke was defined as a National Institutes of Health Stroke Scale (NIHSS) score < 5. We compared various intervals from arrival at the ED to treatment between patients with minor stroke and those with non-minor stroke (NIHSS score ≥5). Delayed treatment was defined as a door-to-needle time > 40 min. Results: During the study period, 356 patients received IV tPA treatment. The median door-to-needle time was significantly longer in the minor stroke group than it was in the non-minor stroke group (43 min [interquartile range [IQR] 35.5–55.5] vs. 37 min [IQR 30–46], p < 0.001). The minor stroke group had a significantly longer door-to-notification time (7 min [IQR 4.5–12] vs. 5 min [IQR 3–8], p < 0.001) and door-to-imaging time (20 min [IQR 15–26.5] vs. 16 min [IQR 11–21], p < 0.001) than did the non-minor stroke group. However, the imaging-to-needle time was not different between the groups. Multivariable analyses revealed that minor stroke was associated with delayed treatment (OR 2.54 [95% CI 1.52–4.30], p = 0.001). Conclusions: Our findings show that the door-to-needle time was longer in patients with minor stroke than it was in those with non-minor stroke, mainly owing to delayed action in the initial steps of neurology notification and imaging. Our findings suggest that some quality improvement initiatives are necessary for patients with suspected stroke with minor symptoms.

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“…Further, IVT has a low-risk profile in minor stroke [14,18]. Thus, the rapid assessment and treatment of patients with minor stroke is crucial and should be emphasized [19].…”

Section: Discussionmentioning

confidence: 99%

Delayed Intravenous Thrombolysis in Patients with Minor Stroke

et al. 2018

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“…Guidelines currently recommend assessment and management within 24 hours of symptoms onset for high-risk patients. 45 Given the challenges in triaging all patients for 24-hour follow-up, various risk scores (ABCD, ABCD, 2 California scores) 46 have been developed to predict stroke risk after TIA, and implemented to evaluate for the need for rapid referral, or hospital admission for monitoring. 46,47 The ABCD score stands for age, blood pressure, clinical features (weakness, speech disturbance), and duration.…”

Section: Risk Stratification In Tia: Getting It Rightmentioning

confidence: 99%

“…5). 45 Overall, although the predictive abilities of ABCD 2 and similar scores have been addressed in many studies, limitations remain and the results are conflicting. Furthermore, scores requiring imaging add complexity to an otherwise simple score and remain to be fully validated.…”

Section: Risk Stratification In Tia: Getting It Rightmentioning

confidence: 99%

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

Joundi

Saposnik

2017

Semin Neurol

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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.

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“…It also assists with predicting the prognosis for recurrent cerebrovascular events. 2 For TIA patients, angiography of the neck arteries identifies those with critical carotid artery stenosis (i.e., > 50%). Early carotid artery revascularization (i.e., carotid endarterectomy or stent) is critical for symptomatic critical carotid stenosis (i.e., > 50%).…”

mentioning

confidence: 99%