Do all ED patients presenting with TIA get complete imaging workup?

2021 04 22 23 05 5088 Brain Stroke 400

Black individuals and elderly patients who present at the emergency department (ED) with transient ischemic attack (TIA) -- also known as ministroke -- are less likely to receive complete imaging workups, according to research presented November 30 at the RSNA meeting.

The findings are concerning, especially in light of the fact that risk of stroke following TIA increases over time, at 7.6% after one year, and 16.1% after five years, according to presenter Dr. Vincent Timpone of the University of Colorado in Aurora.

"We know that, if diagnosed and treated early, risk of stroke following TIA can be mitigated upwards of 80%," he said, citing a 2007 study published in the Lancet.

Current TIA treatment guidelines recommend that patients undergo brain and neurovascular imaging (MRI, CT if MRI unavailable, CT angiography or MRI angiography, ultrasound) within 24 to 48 hours of the appearance of symptoms, Timpone noted. But many patients don't get this full workup, he said.

"[Research shows that] 20% of patients presenting with TIA are discharged from the emergency department without brain imaging, and more than half are discharged with incomplete neurovascular imaging," he said.

Timpone and colleagues sought to assess what percentage of TIA patients discharged from the ED go on to have complete imaging workup as outpatients. They analyzed two years of Medicare data (2017 to 2018), identifying 6,346 patients who were diagnosed with TIA in the ED.

The group defined incomplete imaging workup as that which did not include cross-sectional brain, brain-vascular, and neck-vascular imaging at the time of the patient's initial presentation in the ED, or within 30 days post discharge. They also assessed patient and site factors such as age, gender, race/ethnicity, comorbidities, income, and hospital size.

Of the study cohort, 40% had an incomplete imaging workup. Of those, 30% had appropriate imaging workup within 30 days after being released, with a median time to completion of this follow-up of five days -- well beyond the recommended 24 to 48 hours, Timpone noted.

Three factors appeared to contribute to patients being discharged from the ED without a thorough imaging review:

  • Black race (odds risk, 3.00)
  • Age 85 or older (odds risk, 2.61)
  • Larger hospitals (odds risk, 2.11)

Since Black and older individuals are already affected by healthcare disparities across a variety of pathologic processes -- including ischemic stroke -- it's even more important to address this particular healthcare disparity, he said.

"Future research is needed to determine individuals' stroke risk after delayed or incomplete TIA workup," he said. "[We need to investigate] patient- and hospital-level causes for disparities in TIA imaging and provide solutions to improve equitable access to imaging."

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