Redundant Imaging in Transient Ischemic Attack: Evidence From the Nationwide Emergency Department Sample

Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging

“…It is the consensus recommendation of major multidisciplinary societal guidelines that patients with TIA undergo urgent brain and neurovascular imaging as soon as possible, preferably within 48 hours of symptoms [1,[6][7][8][9]. We previously demonstrated that although ED compliance with these recommendations is improving, perhaps in response to societal guideline publications released over the past decade, there remains a large proportion of patients with TIA who do not undergo complete imaging workup during their initial ED encounters [12]. Although recommendations allow the completion of imaging within 48 hours, this study adds to our existing knowledge of imaging utilization for TIA by highlighting the low rate of successful completion of outpatient TIA imaging workup for patients discharged from EDs with incomplete imaging.…”

“…The underlying causes of delayed and incomplete TIA imaging workup after ED discharge are unclear and could include a multitude of factors, including limited access to ED and/or outpatient imaging resources, lack of provider familiarity with imaging guidelines, patients' lacking primary care physicians to assist in coordination of care, suboptimal communication of discharge instructions, and/or patient nonadherence to discharge instructions [12][13][14][15][16][17][18][19][20]. Some providers could also be discharging patients under a false sense of security after negative results on a single head CT examination, which is the most common ED neuroimaging workup in TIA and also one of the least diagnostically useful because of the limited sensitivity of CT for the detection of infarct, while omitting brain and cervical vessel imaging needed to detect vascular pathology that may have prompted the TIA episode [10,12,21].…”

“…The percentage of TIA encounters resulting in hospital admission has been decreasing over the past decade, with the majority of encounters now evaluated in the emergency department (ED) without hospital admission [10]. As such, the responsibility of implementing an appropriate and timely TIA imaging protocol for stroke risk stratification has also shifted more toward emergency medicine clinicians and multidisciplinary outpatient management systems that can facilitate urgent imaging [11].…”

“…As such, the responsibility of implementing an appropriate and timely TIA imaging protocol for stroke risk stratification has also shifted more toward emergency medicine clinicians and multidisciplinary outpatient management systems that can facilitate urgent imaging [11]. Although it has been shown that nationwide ED compliance with TIA imaging guidelines is improving, there remains a majority of nonadmitted patients who do not undergo complete TIA imaging workup during their initial ED encounters [12]. It is likely that some patients who do not undergo complete TIA imaging workup during their initial ED encounters are able undergo such imaging as outpatients during follow-up, perhaps from dedicated TIA clinics.…”

“…It is likely that some patients who do not undergo complete TIA imaging workup during their initial ED encounters are able undergo such imaging as outpatients during follow-up, perhaps from dedicated TIA clinics. It is unknown, however, what percentage of discharged patients may be lost to follow-up or are able to complete urgent TIA imaging within the recommended 48 hours of symptom onset [1,12].…”