Safety and Feasibility of a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Stroke: The Rapid Access Vascular Evaluation–Neurology (RAVEN) Approach - 19/09/19
, Sara Rostanski, MD c, Joshua Willey, MD b, Eliza C. Miller, MD b, Steven Shapiro, MD b, Rachel Mehendale, MD b, Benjamin Kummer, MD b, Babak B. Navi, MD, MS d, Mitchell S.V. Elkind, MD, MS b, eAbstract |
Study objective |
Although most transient ischemic attack and minor stroke patients in US emergency departments (EDs) are admitted, experience in other countries suggests that timely outpatient evaluation of transient ischemic attack and minor stroke can be safe. We assess the feasibility and safety of a rapid outpatient stroke clinic for transient ischemic attack and minor stroke: Rapid Access Vascular Evaluation–Neurology (RAVEN).
Methods |
Transient ischemic attack and minor stroke patients presenting to the ED with a National Institutes of Health Stroke Scale score of 5 or less and nondisabling deficit were assessed for potential discharge to RAVEN with a protocol incorporating social and medical criteria. Outpatient evaluation by a vascular neurologist, including vessel imaging, was performed within 24 hours at the RAVEN clinic. Participants were evaluated for compliance with clinic attendance and 90-day recurrent transient ischemic attack and minor stroke and hospitalization rates.
Results |
Between December 2016 and June 2018, 162 transient ischemic attack and minor stroke patients were discharged to RAVEN. One hundred fifty-four patients (95.1%) appeared as scheduled and 101 (66%) had a final diagnosis of transient ischemic attack and minor stroke. Two patients (1.3%) required hospitalization (one for worsening symptoms and another for intracranial arterial stenosis caused by zoster) at RAVEN evaluation. Among the 101 patients with confirmed transient ischemic attack and minor stroke, 18 (19.1%) had returned to an ED or been admitted at 90 days. Five were noted to have had recurrent neurologic symptoms diagnosed as transient ischemic attack (4.9%), whereas one had a recurrent stroke (0.9%). No individuals with transient ischemic attack and minor stroke died, and none received thrombolytics or thrombectomy, during the interval period. These 90-day outcomes were similar to historical published data on transient ischemic attack and minor stroke.
Conclusion |
Rapid outpatient management appears a feasible and safe strategy for transient ischemic attack and minor stroke patients evaluated in the ED, with recurrent stroke and transient ischemic attack rates comparable to historical published data.
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| Please see page 563 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: William J. Meurer, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: BPC, SR, JW, BBN, and MSVE conceived the study, designed the trial, and obtained research funding. BPC, SR, ECM, SS, RM, and BK supervised the conduct of the trial and data collection. BPC, SR, JW, ECM, SS, BK, and BBN undertook recruitment of participating centers and patients and managed the data, including quality control. BPC, JW, ECM, and MSVE provided statistical advice on study design and analyzed the data. BPC and SR drafted the article, and all authors contributed substantially to its revision. BPC takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist. This work was supported by the National Institutes of Health (grant R01 HL141811) and the Empire Clinical Research Investigator Program (New York). |
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Vol 74 - N° 4
P. 562-571 - octobre 2019 Retour au numéro
Article précédent
- Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain
- Nicole M. Dubosh, Jonathan A. Edlow, Tadahiro Goto, Carlos A. Camargo, Kohei Hasegawa
- The Future of Minor Stroke and Transient Ischemic Attack: The RAVEN Approach Is Promising but Not Ready for Prime Time
- Tracy E. Madsen, Charles R. Wira
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