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Safety and Feasibility of a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Stroke: The Rapid Access Vascular Evaluation-Neurology (RAVEN) Approach.

TitleSafety and Feasibility of a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Stroke: The Rapid Access Vascular Evaluation-Neurology (RAVEN) Approach.
Publication TypeJournal Article
Year of Publication2019
AuthorsChang BP, Rostanski S, Willey J, Miller EC, Shapiro S, Mehendale R, Kummer B, Navi BB, Elkind MSV
JournalAnn Emerg Med
Volume74
Issue4
Pagination562-571
Date Published2019 10
ISSN1097-6760
KeywordsAdult, Aged, Aged, 80 and over, Ambulatory Care, Emergency Service, Hospital, Feasibility Studies, Female, Humans, Ischemic Attack, Transient, Male, Middle Aged, Neurologic Examination, Recurrence, Retrospective Studies, Stroke, United States
Abstract

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.

DOI10.1016/j.annemergmed.2019.05.025
Alternate JournalAnn Emerg Med
PubMed ID31326206
PubMed Central IDPMC6756973
Grant ListR01 HL141811 / HL / NHLBI NIH HHS / United States

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