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Decker JH, Mazal AT, Bui A, Sprenger T, Skare S, Fischbein N, Zaharchuk G. NeuroMix with MRA: A Fast MR Protocol to Reduce Head and Neck CTA for Patients with Acute Neurologic Presentations. AJNR Am J Neuroradiol 2024:ajnr.A8386. [PMID: 38906674 DOI: 10.3174/ajnr.a8386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/11/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND AND PURPOSE Overuse of CT-based cerebrovascular imaging in the emergency department and inpatient settings, notably CTA of the head and neck for minor and nonfocal neurologic presentations, stresses imaging services and exposes patients to radiation and contrast. Furthermore, such CT-based imaging is often insufficient for definitive diagnosis, necessitating additional MR imaging. Recent advances in fast MRI may allow timely assessment and a reduced need for head and neck CTA in select populations. MATERIALS AND METHODS We identified inpatients or patients in the emergency department who underwent CTAHN (including noncontrast and postcontrast head CT, with or without CTP imaging) followed within 24 hours by a 3T MRI study that included a 2.5-minute unenhanced multicontrast sequence (NeuroMix) and a 5-minute intracranial time of flight MRA) during a 9-month period (April to December 2022). Cases were classified by 4 radiologists in consensus as to whether NeuroMix and NeuroMix + MRA detected equivalent findings, detected unique findings, or missed findings relative to CTAHN. RESULTS One hundred seventy-four cases (mean age, 67 [SD, 16] years; 56% female) met the inclusion criteria. NeuroMix alone and NeuroMix + MRA protocols were determined to be equivalent or better compared with CTAHN in 71% and 95% of patients, respectively. NeuroMix always provided equivalent or better assessment of the brain parenchyma, with unique findings on NeuroMix and NeuroMix + MRA in 35% and 36% of cases, respectively, most commonly acute infarction or multiple microhemorrhages. In 8/174 cases (5%), CTAHN identified vascular abnormalities not seen on the NeuroMix + MRA protocol due to the wider coverage of the cervical arteries by CTAHN. CONCLUSIONS A fast MR imaging protocol consisting of NeuroMix + MRA provided equivalent or better information compared with CTAHN in 95% of cases in our population of patients with an acute neurologic presentation. The findings provide a deeper understanding of the benefits and challenges of a fast unenhanced MR-first approach with NeuroMix + MRA, which could be used to design prospective trials in select patient groups, with the potential to reduce radiation dose, mitigate adverse contrast-related patient and environmental effects, and lessen the burden on radiologists and health care systems.
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Affiliation(s)
- Johannes H Decker
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
| | - Alexander T Mazal
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
| | - Amy Bui
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
| | - Tim Sprenger
- MR Applied Science Laboratory Europe (T.S.), GE Healthcare, Stockholm, Sweden
- Department of Clinical Neuroscience (T.S., S.S.), Karolinska Institutet, Stockholm, Sweden
| | - Stefan Skare
- Department of Clinical Neuroscience (T.S., S.S.), Karolinska Institutet, Stockholm, Sweden
| | - Nancy Fischbein
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
| | - Greg Zaharchuk
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Manea MM, Dragoş D, Dobri AM, Ghenu MI, Stoican IC, Enache II, Tuta S. The crucial role of gadolinium-enhanced MRI in a case of amaurosis fugax - a case report and literature review. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2024; 62:75-81. [PMID: 37906620 DOI: 10.2478/rjim-2023-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Indexed: 11/02/2023]
Abstract
Optic perineuritis is the inflammation of the optic nerve sheath. This affliction can lead to visual field impairment and other signs and symptoms related to the orbital space, such as pain, disc edema, ophthalmoplegia, proptosis. However, not all patients present with such suggestive symptoms, requiring a thorough assessment. We report the case of a young male admitted to our hospital for recurrent episodes of monocular blindness. Amaurosis fugax is a well-known presentation of transient ischemic attacks (TIA) and it was ruled out. Gadolinium-enhanced MRI revealed a typical aspect of optic perineuritis. It was mandatory to consider all possible causes of secondary optic perineuritis as they all represent serious clinical conditions, even if the idiopathic form is more frequent. The clinical and paraclinical evaluation of the patient excluded an underlying disease and primary optic perineuritis was diagnosed. Corticosteroid therapy is usually curative and a course of methylprednisolone was initiated for our patient with good outcome. However, response to treatment is not diagnostic as both primary and secondary optic perineuritis are normally responsive, hence thorough differential diagnosis is necessary.
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Affiliation(s)
- Maria Mirabela Manea
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
| | - Dorin Dragoş
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Departments of Internal Medicine, and Nephrology, Emergency University Hospital, Bucharest, Romania
| | - Ana-Maria Dobri
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
| | - Maria Iuliana Ghenu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Departments of Internal Medicine, and Nephrology, Emergency University Hospital, Bucharest, Romania
| | - Iulia-Cosmina Stoican
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
| | - Iulia-Ioana Enache
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
| | - Sorin Tuta
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
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Kuzan A, Kozak-Sykała A, Fiedorowicz A, Kałas W, Strządała L, Gamian A. Advanced Glycation End-Products in Blood Serum-Novel Ischemic Stroke Risk Factors? Implication for Diabetic Patients. J Clin Med 2024; 13:443. [PMID: 38256577 PMCID: PMC10816329 DOI: 10.3390/jcm13020443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/03/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
New predictors of ischemic incidents are constantly sought since they raise the awareness of patients and their doctors of stroke occurrence. The goal was to verify whether Advanced Glycation End Products (AGEs), in particular AGE10, could be one of them. The AGE10 measurement was conducted using a non-commercial ELISA assay in the blood serum of neurological patients without cerebrovascular event (n = 24), those with transient brain attack (TIA) (n = 17), and severe ischemic stroke (n = 35). Twice as many of the people with TIA or severe stroke presented high AGE10 serum concentrations compared to the patients with other neurological conditions (χ2 = 8.2, p = 0.004; χ2 = 8.0, p = 0.005, respectively). The risk of ischemic incident was significantly risen in people with higher levels of AGE10 (OR = 6.5, CI95%: 1.7-24.8; OR = 4.7, CI95%: 1.5-14.5 for TIA and stroke subjects, respectively). We observed a positive correlation (r = 0.40) between high AGE10 levels and diabetes. Moreover, all the diabetic patients that had a high AGE10 content experienced either a severe ischemic stroke or TIA. The patients with high levels of AGE10 exhibited higher grades of disability assessed by the NIHSS scale (r = 0.35). AGE10 can be considered a new biomarker of ischemic stroke risk. Patients with diabetes presenting high AGE10 levels are particularly prone to the occurrence of cerebrovascular incidents.
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Affiliation(s)
- Aleksandra Kuzan
- Department of Biochemistry and Immunochemistry, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Anna Kozak-Sykała
- Neurology and Stroke Department, Independent Public Healthcare Centre, Jankowski Regional Hospital in Przeworsk, Szpitalna 16, 37-200 Przeworsk, Poland;
| | - Anna Fiedorowicz
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland (W.K.); (L.S.); (A.G.)
| | - Wojciech Kałas
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland (W.K.); (L.S.); (A.G.)
| | - Leon Strządała
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland (W.K.); (L.S.); (A.G.)
| | - Andrzej Gamian
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland (W.K.); (L.S.); (A.G.)
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Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med 2023; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University, St. Louis, Missouri, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Penn State School of Medicine, State College, Pennsylvania, USA
- Hershey Medical Center, State College, Pennsylvania, USA
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Adventhealth Tampa, Tampa, Florida, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - James G Naples
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Health Science North Research Institute, Sudbury, Ontario, Canada
- Department of Emergency Medicine, Health Sciences North, Sudbury, Ontario, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Sharif
- Division of Critical Care and Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matt Siket
- Department of Emergency Medicine, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Emergency Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Suneel Upadhye
- Emergency Medicine, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
- Health Research Methods, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Etta Sundberg
- COO Royal Oasis Pool and Spas, Las Vegas, Nevada, USA
| | - Karen Tartt
- Absinthe Brasserie & Bar, San Francisco, California, USA
- St. George Spirits, San Francisco, California, USA
| | - Simone Vanni
- Department of Emergency Medicine, University of Florence, Firenze, Italy
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Park AJ, Reseland EJ, Edlow JA, Ellis J. The Man Who Mistook a Hat for His Wife: Case Report of Aortic Dissection Presenting with Acute Hyperfamiliarity for Faces. Ann Emerg Med 2022; 81:614-617. [PMID: 36117014 DOI: 10.1016/j.annemergmed.2022.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/01/2022]
Abstract
Acute aortic dissection is a challenging diagnosis for emergency physicians because of its high mortality and wide range of clinical presentations. We report a case of a previously healthy man who presented with hyperfamiliarity for faces syndrome as the predominant symptom of a large type A aortic dissection diagnosed by computed tomography angiography in the emergency department. Different elements of his presentation suggested possible other diagnoses, including transient global amnesia and transient ischemic attack. We discuss how evaluating these other diagnostic possibilities led to the correct diagnosis. Given increasing reports of painless aortic dissection, this case demonstrates the need to consider aortic dissection in patients with acute neurological symptoms.
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Affiliation(s)
- Andrew J Park
- Department of Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Boston, MA.
| | - Eric J Reseland
- Department of Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Boston, MA
| | - Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Joshua Ellis
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
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Timpone VM, Reid M, Jensen A, Poisson SN, Patten L, Costa B, Trivedi PS. Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging. J Am Coll Radiol 2022; 19:957-966. [PMID: 35724735 DOI: 10.1016/j.jacr.2022.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Imaging guidelines for transient ischemic attack (TIA) recommend that patients undergo urgent brain and neurovascular imaging within 48 hours of symptom onset. Prior research suggests that most patients with TIA discharged from the emergency department (ED) do not complete recommended TIA imaging workup during their ED encounters. The purpose of this study was to determine the nationwide percentage of patients with TIA discharged from EDs with incomplete imaging workup who complete recommended imaging after discharge. METHODS Patients discharged from EDs with the diagnosis of TIA were identified from the Medicare 5% sample for 2017 and 2018 using International Classification of Diseases, tenth rev, Clinical Modification codes. Imaging performed was identified using Current Procedural Terminology codes. Incomplete imaging workup was defined as a TIA encounter without cross-sectional brain, brain-vascular, and neck-vascular imaging performed within the subsequent 30 days of the initial ED encounter. Patient- and hospital-level factors associated with incomplete TIA imaging were analyzed in a multivariable logistic regression. RESULTS In total, 6,346 consecutive TIA encounters were analyzed; 3,804 patients (59.9%) had complete TIA imaging workup during their ED encounters. Of the 2,542 patients discharged from EDs with incomplete imaging, 761 (29.9%) completed imaging during the subsequent 30 days after ED discharge. Among patients with TIA imaging workup completed after ED discharge, the median time to completion was 5 days. For patients discharged from EDs with incomplete imaging, the odds of incomplete TIA imaging at 30 days after discharge were highest for black (odds ratio, 1.84; 95% confidence interval, 1.27-2.66) and older (≥85 years of age; odds ratio, 2.41; 95% confidence interval, 1.78-3.26) patients. Reference values were age cohort 65 to 69 years; male gender; white race; no co-occurring diagnoses of hypertension, hyperlipidemia, or diabetes mellitus; household income > $63,029; hospital in the Northeast region; urban hospital location; hospital size > 400 beds; academically affiliated hospital; and facility with access to MRI. CONCLUSIONS Most patients discharged from EDs with incomplete TIA imaging workup do not complete recommended imaging within 30 days after discharge.
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Affiliation(s)
- Vincent M Timpone
- Director, Stroke and Vascular Imaging and Co-Director, Neuroradiology, Spine Intervention Service, Department of Radiology, University of Colorado Hospital, Aurora, Colorado.
| | - Margaret Reid
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, Colorado
| | - Alexandria Jensen
- Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Sharon N Poisson
- Director, Vascular and Stroke Research Fellowship, Department of Neurology, University of Colorado Hospital, Aurora, Colorado
| | - Luke Patten
- Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Bernardo Costa
- Department of Radiology, University of Colorado Hospital, Aurora, Colorado
| | - Premal S Trivedi
- Director, Health Services Research, Department of Radiology, University of Colorado Hospital, Aurora, Colorado
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Edlow JA, Hoffmann B. Managing Patients With Acute Visual Loss. Ann Emerg Med 2021; 79:474-484. [PMID: 34922777 DOI: 10.1016/j.annemergmed.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Jonathan A Edlow
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Beatrice Hoffmann
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Redundant Imaging in Transient Ischemic Attack: Evidence From the Nationwide Emergency Department Sample. J Am Coll Radiol 2021; 18:1525-1531. [PMID: 34329612 DOI: 10.1016/j.jacr.2021.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/22/2021] [Accepted: 07/01/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Increasing emergency department (ED) compliance with transient ischemic attack (TIA) imaging guidelines has previously been demonstrated, along with a substantial rise in imaging utilization over the past decade. The purpose of this study was to characterize the most commonly used combinations of imaging studies during ED workup of TIA and to quantify prevalence of redundant imaging (RI). METHODS TIA discharges from EDs in the United States from 2006 to 2017 were identified in the Nationwide Emergency Department Sample. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. RI was defined as an ED encounter with any duplicate cross-sectional brain, brain-vascular, or neck-vascular imaging. Patient demographics and hospital characteristics were incorporated into a multivariable logistic regression analysis to identify significant associations with RI. RESULTS There were 184,870 discharges with TIA from EDs in 2017. RI (brain) was observed in 55,513 (30%) of encounters. RI (brain-vascular) and RI (neck-vascular) imaging was identified in 5,149 (2.8%) and 1,325 (0.7%) of encounters, respectively. Decreased odds of obtaining RI was observed in Medicaid patients(odds ratio [OR: 0.72, 95% confidence interval [CI]: 0.64-0.81), non-trauma centers(OR: 0.49, 95% CI: 0.26-0.93), rural hospital locations(OR: 0.18, 95% CI: 0.11-0.29), and weekend encounters(OR: 0.9, 95% CI: 0.85-0.96). Trend analysis from 2006 to 2017 demonstrated a rise in RI (brain) from 2.3% of encounters in 2006 to 30% of encounters in 2017. RI for patients discharged from EDs with TIA in 2017 resulted in additional charges of approximately US $8,670,832. CONCLUSION Increased imaging utilization for TIA workup across EDs in the United States is associated with rising use of redundant imaging. We identify imaging practices that could be targeted to mitigate health care expenditures, while adhering to TIA imaging guidelines.
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Lodha N, Patel P, Harrell J, Casamento-Moran A, Zablocki V, Christou EA, Poisson SN. Motor impairments in transient ischemic attack increase the odds of a positive diffusion-weighted imaging: A meta-analysis. Restor Neurol Neurosci 2020; 37:509-521. [PMID: 31594263 DOI: 10.3233/rnn-190940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Unilateral motor impairment is a key symptom used in the diagnosis of transient ischemic attack (TIA). Diffusion-weighted imaging (DWI) is a promising diagnostic tool for detecting ischemic lesions. While both motor impairments and DWI abnormalities are linked to the diagnosis of TIA, the association between these prognostic factors is not well understood. OBJECTIVE To examine the association between unilateral motor impairments and the odds of a positive DWI in TIA. Further, to determine whether the time between symptom onset and neuroimaging (delay to scan) influences the odds of a positive DWI. METHODS We used PRISMA guidelines to conduct a systematic search from 1989 to 2018. We included studies that reported number of individuals with/without unilateral motor symptoms and a positive/negative DWI. RESULTS Twenty-four studies from North America, Australia, Asia, and Europe were submitted to a meta-analysis. A pooled odds ratio of 1.80 (95% CI, 1.45-2.24, p = 0.00; I2 = 57.38) suggested that the odds of a positive DWI are greater in TIA individuals who experience motor symptoms as compared with those who experience no motor symptoms. Further, increasing the time delay to scan from the symptom onset (>2 days) did not influence the odds of a positive DWI as compared with an earlier scan (≤2 days). CONCLUSIONS The current meta-analysis provides cumulative evidence from 6710 individuals with TIA that the presence of motor symptoms increases the odds of a positive DWI by two-folds. These findings transform the clinical perception into evidence-based knowledge that motor impairments elevate the risk for brain tissue damage. Unilateral motor impairments in a cerebrovascular event should increase a physician's suspicion of detecting brain infarctions. These findings may influence the clinical management of TIA by generating faster response to motor impairments in TIA and accelerating referral to specialized stroke clinic.
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Affiliation(s)
- Neha Lodha
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Prakruti Patel
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Jane Harrell
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | | | - Victoria Zablocki
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Evangelos A Christou
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Sharon N Poisson
- Department of Neurology, University of Colorado, Aurora, CO, USA
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Li X, Wang Y, Mi X, Qiao Z, Liang Y. Impaired heart rate recovery as a predictor for poor health-related quality in patients with transient ischemic attack. Medicine (Baltimore) 2019; 98:e16938. [PMID: 31441885 PMCID: PMC6716722 DOI: 10.1097/md.0000000000016938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We aimed to investigate heart rate recovery (HRR) in patients with transient ischemic attack (TIA) and the relationship between HRR and health-related quality of life (HRQOL).All available patients were enrolled during the enrollment period. A total of 120 patients with TIA and 120 healthy controls were included in this study. A treadmill stress test was performed to calculate the HRR. The HRR were calculated as follows: HRR 1, 2, 3, and 5 minutes = heart rate at peak during exercise - heart rate at 1, 2, 3, and 5 minutes at rest. All patients enrolled were asked to fill in the Short Form 36 Health Survey to calculate HRQOL.We found that the maximum heart rate of TIA patients was significantly higher than that of healthy controls (166 ± 11 vs. 162 ± 14 beats/min, P = .015). Similarly, maximum systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in TIA group compared with healthy control group (SBP: 172 ± 15 vs. 165 ± 14 mm Hg, P < .001; DBP: 102 ± 12 vs. 93 ± 16 mm Hg, P < .001). The HRR were significantly lower in TIA group compared with control group (TIA vs. controls, HRR1: 17 ± 7 vs. 30 ± 8 beats/min, HRR2: 32 ± 11 vs. 49 ± 9 beats/min, HRR3: 43 ± 13 vs. 63 ± 12 beats/min, HRR5: 54 ± 16 vs. 73 ± 15 beats/min, all P < .001). Multivariate analysis showed that older age (P = .03) and high BMI (P = .04) were risk factors associated with abnormal HRR in patients with TIA. With regard to HRQOL, we found that role limitations due to physical problems, general health, vitality, and role limitations due to emotional problems were significantly lower in patients with abnormal HRR compared with patients with normal HRR. Multivariate analysis showed that older age (P = .04) and abnormal HRR (P = .03) were predictors for poor HRQOL in TIA patients.HRR was impaired in patients with TIA. In addition, TIA patients with abnormal HRR suffered from a significantly poorer HRQOL. Hence, given the prognostic value of HRR, patients with TIA should be monitored to prevent cardiovascular events and to improve HRQOL.
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Xie J, Qiu X, Ji C, Liu C, Wu Y. Elevated serum neopterin and homocysteine increased the risk of ischemic stroke in patients with transient ischemic attack. Pteridines 2019. [DOI: 10.1515/pteridines-2019-0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objective: To investigate the correlation between serum neopterin, homocysteine (Hcy) and the risk of developing ischemic stroke (IS) in patients with transient ischemic attack (TIA).
Methods: Ninety-two TIA patients were prospectively recruited at the First Affiliated Hospital of the Medical College, Shihezi University, Xinjiang Autonomous Region China. Of the included patients, 27 developed ischemic stroke (IS group) and other 65 cases did not (TIA group). Peripheral venous blood was obtained within 24 hours of TIA diagnosis. Serum neopterin, Hcy and serum lipid levels were tested and compared between IS and TIA groups.
Results: Serum neopterin (6.38±1.76 ng/mL vs 5.39±1.51 ng/mL), Hcy (17.95±4.10 μmol/L vs 15.30±3.66 μmol/L), TG (1.82±0.92 mmol/L vs 1.40±0.71 mmol/L) and LDL (3.31±0.67 mmol/L vs 2.69±0.62 mmol/L) of IS group were significantly higher than those of TIA group (p<0.05). The AUC of serum neopterin, Hcy, TG and LDL for predicting the risk of developing IS in patients with TIA were 0.68 (95%CI: 0.55-0.81, 0.68 (95%CI: 0.57-0.80), 0.64 (95%CI: 0.51-0.78) and 0.75 (95%CI: 0.63-0.86), respectively.
Conclusion: Serum neopterin, Hcy, TG and LDL are promising serological markers for predicting the increased risk of developing IS for patients with TIA.
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Affiliation(s)
- Jing Xie
- Department of Neurology, First Affiliated Hospital of the Medical College , Shihezi University , Xinjiang Autonomous Region 832000 PR China Urumqi
| | - Xiandi Qiu
- Department of Emergency, Zhuji People’s Hospital of Zhejiang Province , 311800 PR China Shaoxing
| | - Chunli Ji
- Department of Neurology, People’s Hospital of Manasi , Xinjiang Autonomous Region, 832200 PR China Changji
| | - Chunhong Liu
- Department of Neurology, First Affiliated Hospital of the Medical College , Shihezi University , Xinjiang Autonomous Region 832000 PR China Urumqi
| | - Yueming Wu
- Department of Intensive Care Unit, the people’s hospital of Lishui , Lishui 323000 PR China Zhejiang
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Dubosh NM, Edlow JA. Diagnosis of Subarachnoid Hemorrhage: Time for a Paradigm Shift? Acad Emerg Med 2017; 24:1514-1516. [PMID: 28767186 DOI: 10.1111/acem.13267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Nicole M. Dubosh
- Department of Emergency Medicine; Harvard Medical School; Department of Emergency Medicine; Beth Israel Deaconess Medical Center; Boston MA
| | - Jonathan A. Edlow
- Department of Emergency Medicine; Harvard Medical School; Department of Emergency Medicine; Beth Israel Deaconess Medical Center; Boston MA
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