Elsevier

The Lancet Neurology

Volume 6, Issue 11, November 2007, Pages 953-960
The Lancet Neurology

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A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects

https://doi.org/10.1016/S1474-4422(07)70248-XGet rights and content

Summary

Background

Diagnosis and treatment of cerebral and retinal transient ischaemic attacks (TIAs) are often delayed by the lack of immediate access to a dedicated TIA clinic. We evaluated the effects of rapid assessment of patients with TIA on clinical decision making, length of hospital stay, and subsequent stroke rates.

Methods

We set up SOS-TIA, a hospital clinic with 24-h access. Patients were admitted if they had sudden retinal or cerebral focal symptoms judged to relate to ischaemia and if they made a total recovery. Assessment, which included neurological, arterial, and cardiac imaging, was within 4 h of admission. A leaflet about TIA with a toll-free telephone number for SOS-TIA was sent to 15 000 family doctors, cardiologists, neurologists, and ophthalmologists in Paris and its administrative region. Endpoints were stroke within 90 days, and stroke, myocardial infarction, and vascular death within 1 year.

Findings

Between January, 2003, and December, 2005, we admitted 1085 patients with suspected TIA; 574 (53%) were seen within 24 h of symptom onset. 701 (65%) patients had confirmed TIA or minor stroke, and 144 (13%) had possible TIA. 108 (17%) of the 643 patients with confirmed TIA had brain tissue damage. Median duration of symptoms was 15 min (IQR 5–75 min). Of the patients with confirmed or possible TIA, all started a stroke prevention programme, 43 (5%) had urgent carotid revascularisation, and 44 (5%) were treated for atrial fibrillation with anticoagulants. 808 (74%) of all patients seen were sent home on the same day. The 90-day stroke rate was 1·24% (95% CI 0·72–2·12), whereas the rate predicted from ABCD2 scores was 5·96%.

Interpretation

Use of TIA clinics with 24-h access and immediate initiation of preventive treatment might greatly reduce length of hospital stay and risk of stroke compared with expected risk.

Introduction

Recent advances in stroke management have placed major emphasis on the provision of hospital stroke units and on thrombolysis with alteplase (tissue plasminogen activator) to treat completed or evolving strokes.1 Transient ischaemic attacks (TIAs) precede up to a quarter of completed strokes,2 and so can give clinicians an opportunity to avoid a completed stroke and its devastating personal, social, and sometimes fatal consequences. Appropriate detection and treatment of TIAs can also obviate the need for admission to a hospital stroke unit. Diffusion-weighted imaging shows a small amount of tissue damage in most cases of TIA.3 Thus, TIAs can be thought of as mini strokes, and as medical emergencies.4

Symptoms of TIA are frequently ignored by patients and their relatives or are unrecognised by doctors, which can delay diagnosis and treatment. Even after a diagnosis of TIA, a patient can be reluctant to be admitted to hospital because the symptoms often last for only a few minutes, and the patient subsequently feels completely recovered. Once a patient agrees to be admitted to hospital, comprehensive testing and diagnosis often cannot be organised quickly or in the same hospital, particularly after 1700 h, which can delay the start of assessment substantially. Patients with a suspected TIA are frequently sent to an emergency department, but emergency medicine physicians in community hospitals might have little or no immediate access to brain and vascular imaging facilities. Frequently, patients are sent back to their family doctor and are examined as outpatients. Many patients give up at this point; others might have their TIA investigated within the next 8–15 days, or later. Because the risk of completed stroke is very high during the first week after a TIA,5, 6 such a care pathway is counterproductive, and greatly reduces the opportunity to prevent stroke.

To improve care for patients with symptoms of TIA, we set up a clinic with round-the-clock access for doctors working in the administrative region of Paris (which has 11 million inhabitants). This clinic provided a short and standardised clinical assessment followed by initiation of a comprehensive stroke prevention programme. We also used a leaflet on TIA management and treatment to increase awareness among community doctors of the importance of early diagnosis. We aimed to describe the service provided by the TIA clinic, and to assess the effects of these initiatives on the length of hospital stay and on stroke rates at 90 days as compared with rates predicted by the ABCD2 score.7 We also report the risk of major cardiovascular events within the first year after a TIA.

Section snippets

Patients and procedures

We mailed a leaflet (webappendix) on TIA to 15 000 family doctors, cardiologists, neurologists, and ophthalmologists in Paris and its administrative region, and to emergency departments of community and teaching hospitals. This leaflet included information on the definition, key symptoms, risks, main causes, and emergency treatments for TIA, and presented TIA as an opportunity to prevent a completed, potentially devastating stroke. The leaflet also informed doctors of the availability of our

Results

Between January, 2003, and December, 2005, 1085 patients with a suspected TIA were entered into the SOS-TIA programme. A mean of 30 patients were seen each month, and the number of patients seen at the TIA clinic increased by 29% between 2003 (n=316) and 2005 (n=407). 946 (87%) patients were seen by a neurologist within 24 h of the telephone call and 574 (53%) were seen by a neurologist within 24 h of symptom onset (figure 1). 665 (61%) were seen within 48 h, and 810 (75%) within 7 days. Figure

Discussion

SOS-TIA provided physicians with round-the-clock access to assessment, diagnosis, and immediate treatment for patients with suspected TIA. We report a lower rate of stroke at 90 days than was expected on the basis of ABCD2 scores. The risk of stroke in the subgroup of patients who were seen at the TIA clinic within 24 h of symptom onset was also lower than that expected from ABCD2 scores. The 1-year rate of myocardial infarction and vascular death was lower in our study (1·1%) than were annual

References (17)

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