Safety and Feasibility:

Outpatient Management Strategy for TIA

Dr. Williams

Background

Transient ischemic attack (TIA) is a common condition that may precede stroke. TIA patients are usually admitted for observation, but can low-risk patients be managed on an outpatient basis?

Article

Chang BP, Rostanski S, Willey J, Miller EC, Shapiro S, Mehendale R, Kummer B, Navi BB, Elkind MS. Safety and Feasibility of a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Stroke: The Rapid Access Vascular Evaluation–Neurology (RAVEN) Approach. Annals of Emergency Medicine. 2019 Oct 1;74(4):562-71.

Study Design

This was a retrospective study at an urban, academic medical center. Eligible patients were ED patients with a possible non-disabling TIA or minor stroke. The definition of disabling was based on AHA/ASA guidelines, and patients had to meet other criteria, such as the ability to follow-up within 24 hours as seen in the figure below. All patients received a head CT and a neurology consult before discharge from the ED. Eligible patients were seen in the RAVEN clinic within 24 hours of discharge where they were evaluated by a vascular neurologist and received carotid and transcranial doppler ultrasounds. They were also referred for further imaging at the discretion of the neurologist.

Results

Of the 253 patients screened, 162 were discharged with RAVEN clinic follow-up, and 95% of those patients attended their appointments.

Of the patients who followed up, 66% had a final diagnosis of TIA or minor stroke. At 90 days, 19.1% of the RAVEN patients with a diagnosis of TIA or minor stroke were readmitted or returned to the ED, 5.9% had a new TIA or stroke, and 8.9% were lost to follow-up.

There were no reported deaths in those with a final diagnosis of TIA or minor stroke, and none of these patients received thrombolytics or thrombectomy.

Conclusion

A rapid outpatient approach may be a safe and feasible strategy for select low-risk TIA and minor stroke patients, but further studies are needed before this approach can be implemented.

A significant number of patients were lost to follow-up, and there was no comparison group in this study. The study also involved the use of extensive screening criteria to determine RAVEN clinic referral, including having reliable patient follow-up.

This approach would be difficult to implement in low resource settings with underprivileged patient populations. Until further research is conducted, admission of most TIA and minor stroke patients is likely still the preferred approach.