Best Clinical Practice: Controversies in Transient Ischemic Attack Evaluation and Disposition in the Emergency Department

Brit Long, Alex Koyfman

Research output: Contribution to journalComment/debate

2 Citations (Scopus)

Abstract

Background Transient ischemic attack (TIA) affects over 200,000 patients annually in the United States, and it precedes approximately 14% to 23% of strokes. Patients are typically admitted for evaluation and management. Objective This review investigates the controversies of emergency department (ED) evaluation of TIA, including imaging, clinical risk scores, rapid diagnostic protocols, and disposition. Discussion TIA is a common condition, with over 200,000 patients affected annually, and is associated with risk of stroke. TIA is defined as a brief episode of neurologic dysfunction with no permanent infarction. A great deal of literature has evaluated the use of imaging, clinical risk scores, and diagnostic protocols in the evaluation of TIA. Head computed tomography noncontrast is not reliable to diagnose acute infarction. Magnetic resonance imaging with diffusion-weighted imaging displays greater diagnostic ability. Carotid imaging includes magnetic resonance angiography, computed tomography angiography, and Doppler with ultrasound. Risk scores that predict future stroke are not reliable when utilized alone. With imaging, including magnetic resonance imaging, patients with low-risk scores can be discharged. The use of ED diagnostic protocols and observation units can reduce length of stay while improving patient treatment and reducing stroke rate. An algorithm is provided for evaluation and disposition in the ED. Conclusions TIA is a condition with high risk for stroke. Imaging is often not reliable, nor is the use of risk scores alone. The American College of Emergency Physicians provides a Level B Recommendation for the use of rapid diagnostic protocols to determine patient short-term risk for stroke while avoiding the reliance on stratification instruments to discharge patients from the ED.

Original languageEnglish (US)
Pages (from-to)299-310
Number of pages12
JournalJournal of Emergency Medicine
Volume52
Issue number3
DOIs
StatePublished - Mar 1 2017

Fingerprint

Transient Ischemic Attack
Practice Guidelines
Hospital Emergency Service
Stroke
Infarction
Doppler Ultrasonography
Diffusion Magnetic Resonance Imaging
Patient Discharge
Magnetic Resonance Angiography
Neurologic Manifestations
Length of Stay
Head
Tomography
Magnetic Resonance Imaging
Observation

Keywords

  • clinical score
  • diagnostic protocol
  • ischemic stroke
  • neuroimaging
  • risk stratification
  • transient ischemic attack

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Best Clinical Practice : Controversies in Transient Ischemic Attack Evaluation and Disposition in the Emergency Department. / Long, Brit; Koyfman, Alex.

In: Journal of Emergency Medicine, Vol. 52, No. 3, 01.03.2017, p. 299-310.

Research output: Contribution to journalComment/debate

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abstract = "Background Transient ischemic attack (TIA) affects over 200,000 patients annually in the United States, and it precedes approximately 14{\%} to 23{\%} of strokes. Patients are typically admitted for evaluation and management. Objective This review investigates the controversies of emergency department (ED) evaluation of TIA, including imaging, clinical risk scores, rapid diagnostic protocols, and disposition. Discussion TIA is a common condition, with over 200,000 patients affected annually, and is associated with risk of stroke. TIA is defined as a brief episode of neurologic dysfunction with no permanent infarction. A great deal of literature has evaluated the use of imaging, clinical risk scores, and diagnostic protocols in the evaluation of TIA. Head computed tomography noncontrast is not reliable to diagnose acute infarction. Magnetic resonance imaging with diffusion-weighted imaging displays greater diagnostic ability. Carotid imaging includes magnetic resonance angiography, computed tomography angiography, and Doppler with ultrasound. Risk scores that predict future stroke are not reliable when utilized alone. With imaging, including magnetic resonance imaging, patients with low-risk scores can be discharged. The use of ED diagnostic protocols and observation units can reduce length of stay while improving patient treatment and reducing stroke rate. An algorithm is provided for evaluation and disposition in the ED. Conclusions TIA is a condition with high risk for stroke. Imaging is often not reliable, nor is the use of risk scores alone. The American College of Emergency Physicians provides a Level B Recommendation for the use of rapid diagnostic protocols to determine patient short-term risk for stroke while avoiding the reliance on stratification instruments to discharge patients from the ED.",
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N2 - Background Transient ischemic attack (TIA) affects over 200,000 patients annually in the United States, and it precedes approximately 14% to 23% of strokes. Patients are typically admitted for evaluation and management. Objective This review investigates the controversies of emergency department (ED) evaluation of TIA, including imaging, clinical risk scores, rapid diagnostic protocols, and disposition. Discussion TIA is a common condition, with over 200,000 patients affected annually, and is associated with risk of stroke. TIA is defined as a brief episode of neurologic dysfunction with no permanent infarction. A great deal of literature has evaluated the use of imaging, clinical risk scores, and diagnostic protocols in the evaluation of TIA. Head computed tomography noncontrast is not reliable to diagnose acute infarction. Magnetic resonance imaging with diffusion-weighted imaging displays greater diagnostic ability. Carotid imaging includes magnetic resonance angiography, computed tomography angiography, and Doppler with ultrasound. Risk scores that predict future stroke are not reliable when utilized alone. With imaging, including magnetic resonance imaging, patients with low-risk scores can be discharged. The use of ED diagnostic protocols and observation units can reduce length of stay while improving patient treatment and reducing stroke rate. An algorithm is provided for evaluation and disposition in the ED. Conclusions TIA is a condition with high risk for stroke. Imaging is often not reliable, nor is the use of risk scores alone. The American College of Emergency Physicians provides a Level B Recommendation for the use of rapid diagnostic protocols to determine patient short-term risk for stroke while avoiding the reliance on stratification instruments to discharge patients from the ED.

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