Trends in Transient Ischemic Attack Hospitalizations in the United States

Care settings of transient ischemic attack in the United States: A cohort study from the TriNetX health research network

BACKGROUND

Evaluation and hospitalization rates after a transient ischemic attack (TIA)-like presentation vary widely in clinical practice. This study aimed to examine variations in care settings at initial TIA diagnosis in the United States.

METHODS

We retrospectively analyzed an adult cohort with a first TIA principal diagnosis between January 1, 2015, and December 31, 2019, from TriNetX Diamond Network. Care settings at TIA diagnosis were defined as hospital care (including inpatient services and observation unit care without admission) and outpatient care (including any outpatient or emergency department visits). We estimated the distribution of care settings at TIA diagnosis and examined the associations of the hospital care setting with baseline age, sex, race, ethnicity, region, and stroke history.

RESULTS

Among the 554,315 included patients, 38.8% received hospital care at their initial TIA diagnosis. A higher percentage of hospital care was observed in the age group of 50-64 years (40.3%), Black (46.0%), Hispanic (41.2%), South (40.9%), and Midwest (43.0%) Regions, and with a history of stroke (39.6%). Multivariable logistic regression consistently showed patients who were aged 50-64 years (Odds Ratio=1.09, 95% CI: [1.07, 1.11]), Black (1.28, [1.24, 1.32]), Hispanic (1.13, [1.09, 1.18]), from South (1.20, [1.18, 1.22]) and Midwest Region (1.33, [1.30, 1.35]), and had a history of stroke (1.02, [1.00, 1.04]) to more likely receive hospital care.

CONCLUSIONS

Although there are TIA care disparities based on demographics, most patients with initial TIA received acute care in outpatient settings. It is imperative to ensure primary providers can risk-stratify TIA patients and provide rapid and proper management.

Clinical Characteristics, Functional Outcome, and Socioeconomic Impact of Ischemic Stroke among Young Egyptian Adults

BACKGROUND

Stroke in young patients results in disproportionately high societal cost given the productive life-years lost. Little is known about stroke in young Egyptian patients. We aimed to analyze clinicodemographic characteristics, functional outcome, and socioeconomic impact of ischemic stroke among young Egyptian adults.

METHODS

This is a prospective, observational cohort study of consecutively recruited patients with acute ischemic stroke (AIS), 18-50 years, between September 2022 and September 2023 at a tertiary stroke center in the south of Egypt. We recorded baseline demographic and cardiovascular risk factors, stroke severity, stroke subtype according to the TOAST classification, intravenous thrombolysis, employment, and ambulation status pre- and post-stroke, post-stroke complications, and 90-day functional outcome measured by the modified Rankin Scale (mRS).

RESULTS

Our cohort comprised 210 patients, 38.0 (±7.8) years, 89 (42%) females. Mean NIHSS score was 11.2 (±4.8); in-hospital case fatality was 9% (19 patients). Dyslipidemia (n = 105, 50%), smoking (n = 105, 50%), and hypertension (n = 67, 32%) were the most prevalent cardiovascular risk factors. At 90 days, 58 (29%) patients had a 90-day mRS 0-1 and 53 (26%) met criteria for depression diagnosis. Sixty-nine of the 116 employed individuals (59%) remained out of work after 90 days of stroke, 61 of whom were single earners in their household. 36/60 (60%) thrombolysis-eligible patients received it; an additional 98 otherwise thrombolysis-eligible patients presented >4.5 h from symptom onset. Patients receiving IV thrombolysis were significantly more likely to have resumed full-time work at 90 days (32% vs. 11%, p = 0.006) but with no significant difference in 90-day mRS.

CONCLUSIONS

Young adult AIS patients in Egypt experience high rates of post-stroke depression and face challenges in their ability to work and provide for their families. Since most patients have treatable cardiovascular risk factors and only about two-thirds of eligible patients receive thrombolysis, reinforcing primary prevention, education about early stroke signs, and benefits of acute can improve outcomes and have significant potential societal benefit.

Diverging Temporal Trends in Stroke Incidence in Younger vs Older People: A Systematic Review and Meta-analysis

Importance

Overall stroke incidence is falling in high-income countries, but data on time trends in incidence of young stroke (ie, stroke in individuals younger than 55 years) are conflicting. An age-specific divergence in incidence, with less favorable trends at younger vs older ages, might be a more consistent underlying finding across studies.

Objective

To compare temporal trends in incidence of stroke at younger vs older ages in high-income countries.

Data Sources

PubMed and EMBASE were searched from inception to February 2022. One additional population-based study (Oxford Vascular Study) was also included.

Study Selection

Studies reporting age-specific stroke incidence in high-income countries at more than 1 time point.

Data Extraction and Synthesis

For all retrieved studies, 2 authors independently reviewed the full text against the inclusion criteria to establish their eligibility. Meta-analysis was performed with the inverse variance-weighted random-effects model. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.

Main Outcomes and Measures

The main outcome was age-specific divergence (<55 vs ≥55 years) in temporal trends in stroke incidence (relative temporal rate ratio [RTTR]) in studies extending to at least 2000. RTTRs were calculated for each study and pooled by random-effects meta-analysis, with stratification by administrative vs prospective population-based methodology, sex, stroke subtype (ischemic vs intracerebral hemorrhage vs subarachnoid hemorrhage) and geographical region.

Results

Among 50 studies in 20 countries, 26 (13 prospective population-based and 13 administrative studies) reported data allowing calculation of the RTTR for stroke incidence at younger vs older ages across 2 or more periods, the latest extending beyond 2000. Reported trends in absolute incidence of young individuals with stroke were heterogeneous, but all studies showed a less favorable trend in incidence at younger vs older ages (pooled RTTR = 1.57 [95% CI, 1.42-1.74]). The overall RTTR was consistent by stroke subtype (ischemic, 1.62 [95% CI, 1.44-1.83]; intracerebral hemorrhage, 1.32 [95% CI, 0.91-1.92]; subarachnoid hemorrhage, 1.54 [95% CI, 1.00-2.35]); and by sex (men, 1.46 [95% CI, 1.34-1.60]; women, 1.41 [95% CI, 1.28-1.55]) but was greater in studies reporting trends solely after 2000 (1.51 [95% CI, 1.30-1.70]) vs solely before (1.18 [95% CI, 1.12-1.24]) and was highest in population-based studies in which the most recent reported period of ascertainment started after 2010 (1.87 [95% CI, 1.55-2.27]).

Conclusions and Relevance

Temporal trends in stroke incidence are diverging by age in high-income countries, with less favorable trends at younger vs older ages, highlighting the urgent need to better understand etiology and prevention of stroke at younger ages.

Association of Younger vs Older Ages With Changes in Incidence of Stroke and Other Vascular Events, 2002-2018

Importance

Some studies have reported increasing stroke incidence at younger ages (<55 years) but have often relied only on administrative data, and more population-based studies of adjudicated stroke are required. An understanding of the drivers of any increase in incidence of young stroke also requires comparisons with stroke trends at older ages and with trends in incidence of other vascular events at younger ages.

Objective

To determine temporal changes in incidence of stroke and other major vascular events at younger vs older ages.

Design, Setting, and Participants

Prospective population-based incidence study conducted from April 2002 to March 2018 with a mean catchment population of 94 567 in Oxfordshire, England.

Exposures

Calendar time, premorbid vascular risk factors, and occupation.

Main Outcomes and Measures

Changes in incidence of stroke, transient ischemic attack (TIA), and other major vascular events (myocardial infarction, sudden cardiac death, and peripheral vascular events) stratified by age, sex, diagnostic workup, etiology, and severity.

Results

A total of 2429 incident strokes were ascertained (mean age, 73.6 [SD, 14.4] years; 51.3% female). From 2002-2010 to 2010-2018, stroke incidence increased significantly among participants younger than 55 years (incidence rate ratio [IRR], 1.67; 95% CI, 1.31-2.14) but fell significantly among participants aged 55 years or older (IRR, 0.85; 95% CI, 0.78-0.92; P < .001 for difference). The significant increase in incidence at younger than 55 years was independent of sex, stroke severity, pathological subtype, and changes in investigation and was also seen for TIA (IRR, 1.87; 95% CI, 1.36-2.57) but not for myocardial infarction and other major vascular events (IRR, 0.73; 95% CI, 0.58-0.93). Although TIA and stroke at younger than 55 years were significantly associated with diabetes (risk ratio [RR], 3.47; 95% CI, 2.54-4.74), hypertension (RR, 2.52; 95% CI, 2.04-3.12), current smoking (RR, 2.38; 95% CI, 1.92-2.94), and obesity (RR, 1.36; 95% CI, 1.07-1.72), the significant increase in incidence from 2002-2010 to 2010-2018 was still seen in individuals without these risk factors. The increase was greatest in professional/managerial occupations (IRR, 2.52; 95% CI, 1.75-3.62) and least in partially skilled/unskilled occupations (IRR, 1.17; 95% CI, 0.79-1.74). The proportion of TIAs and strokes among those younger than 55 years without known vascular risk factors increased significantly over time (45 [30.4%] vs 115 [42.4%]; absolute difference, 12.0%; 95% CI, 2.6-21.5), especially in patients with cryptogenic events (10 [18.5%] vs 63 [49.2%]; absolute difference, 30.7%; 95% CI, 17.2-44.2; P < .001; P = .002 for heterogeneity).

Conclusions and Relevance

Comparing persons living in Oxfordshire, England, in 2002-2010 vs 2010-2018, there was a significant increase in stroke incidence in those younger than 55 years, but a decrease in those aged 55 years or older. Given the absence of this divergence for other vascular events, further research is needed to understand the causes of this difference.

Recent advances in the management of transient ischemic attacks

Transient ischemic attack (TIA) constitutes an important clinical condition, indicating the presence of considerable risk for a subsequent ischemic stroke. Its prompt diagnosis and management have the potential for reducing the risk of neurologic disability, highlighting the critical need to prioritize the care of patients with TIA. The risk of ischemic stroke following a TIA is directly related to its etiopathogenesis, and recognizable causes are commonly categorized within one of three domains: cerebrovascular pathology, cardiac dysfunction, and hematologic disorders. Therefore, the clinical approach to patients suspected of having suffered a TIA demands a comprehensive evaluation, including testing of possible etiologic conditions in all three of these domains, best carried out in an expedited fashion since the stroke risk is greatest in the hours and days that follow the index event. The present is a review of the existing literature addressing the diagnosis, evaluation, prioritization, and management strategies available to clinicians who provide care to patients with TIA.

Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis

IMPORTANCE

Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome.

OBJECTIVE

To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting.

DATA SOURCES

MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020.

STUDY SELECTION

Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer.

DATA EXTRACTION AND SYNTHESIS

The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models.

MAIN OUTCOMES AND MEASURES

Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days).

RESULTS

The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.

Compliance With Imaging Guidelines for Workup of Transient Ischemic Attack

Background and Purpose:

Multiple societal guidelines recommend urgent brain and neurovascular imaging in patients with transient ischemic attack (TIA) to identify and treat risk factors that may lead to future stroke. The purpose of this study was to evaluate whether national imaging utilization for workup of TIA complies with society guidelines.

Methods:

Analysis utilized the Nationwide Emergency Department Sample. Primary analysis was performed on a 2017 cohort, and secondary trend analysis was performed on cohorts from 2006 to2017. Patients diagnosed and discharged from emergency departments with TIA were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. Demographics, health insurance, patient income, and hospital-type covariates were analyzed using a hierarchical multivariable logistic regression analysis to identify predictors of obtaining neurovascular imaging during an emergency department encounter.

Results:

In 2017, there were 167 999 patients evaluated and discharged from emergency departments with TIA. The percentage of patients receiving brain and neurovascular imaging was 78.5% and 43.2%, respectively. The most common imaging workup utilized was a solitary computed tomography–brain without any neurovascular imaging (30.9% of encounters). Decreased odds of obtaining neurovascular imaging was observed in Medicaid patients (odds ratio, 0.65 [95% CI, 0.58–0.74]), rural hospitals (odds ratio, 0.26 [95% CI, 0.17–0.41]), nontrauma centers (odds ratio, 0.40 [95% CI, 0.21–0.74]), and weekend encounters (odds ratio, 0.91 [95% CI, 0.85–0.96]). Trend analysis demonstrated a steady rise in brain and neurovascular imaging in 2006 from 34.9% and 6.8% of encounters, respectively, to 78.5% and 43.2% of encounters in 2017.

Conclusions:

Compliance with imaging guidelines is improving; however, the majority of TIA patients discharged from the emergency department do not receive recommended neurovascular imaging during their encounter. Follow-up studies are needed to determine whether delayed or incomplete vascular screening increases the risk of future stroke.

Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

BACKGROUND

Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably.

OBJECTIVES

We sought to identify factors associated with the decision to admit patents with TIA.

DESIGN

We conducted a secondary analysis of a prior study's data including semi-structured interviews, administrative data, and chart review.

PARTICIPANTS

We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011.

APPROACH

For the qualitative data, we focused on interviewees' responses to the prompt: "Tell me what influences you in the decision to or not to admit TIA patients." We used administrative data to identify admission rates and chart review data to identify ABCD² scores (a tool to classify stroke risk after TIA).

KEY RESULTS

Providers' decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD² score, and concerns about facilities' ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD² scores and related guidelines in admission decision-making.

CONCLUSIONS

Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians' uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.

Acute EEG Patterns Associated With Transient Ischemic Attack

BACKGROUND

Transient ischemic attack (TIA) is characterized by stroke-like neurologic signs and symptoms in the absence of demonstrable structural neuropathology. There is no test for TIA, with classification often reliant on subjective, retrospective report. Functional brain measures such as the electroencephalogram (EEG) may be helpful in objectively detecting and describing the pathophysiology of TIA, but this has not been adequately examined.

METHODS

EEG was obtained from a single electrode over the left frontal lobe during 3-minute resting-state and auditory oddball conditions administered to consecutive patients within 72 hours of admission to the acute stroke ward of a tertiary hospital. Separately, patients were classified by their treating team as having suffered either an ischemic stroke (n = 10) or a TIA (n = 10). Relative power of delta, theta, alpha, and beta EEG frequency bands were extracted for comparison between the 2 clinical groups and an existing normative sample of 10 healthy, age-, gender-, and education-matched older adults.

RESULTS

Analysis of variance with post hoc testing identified pronounced delta activity in stroke patients, while alpha and beta power were elevated in TIA patients. Both patient groups exhibited attenuated theta activity compared with healthy controls. Receiver operating characteristic curve analysis identified thresholds for each EEG frequency capable of distinguishing the 3 participant groups.

CONCLUSIONS

TIA, ischemic stroke, and healthy aging are each associated with distinct electrophysiological profiles. These preliminary findings suggest that acute EEG may be helpful in elucidating the pathophysiology and reversibility of TIA symptoms, and further exploration of the value of this unique functional brain data is encouraged.

Cardiac troponin for predicting all-cause mortality in patients with acute ischemic stroke: a meta-analysis

Cardiac troponins are specific biomarkers of cardiac injury. However, the prognostic usefulness of cardiac troponin in patients with acute ischemic stroke is still controversial. The objective of this meta-analysis was to investigate the association of cardiac troponin elevation with all-cause mortality in patients with acute ischemic stroke. PubMed and Embase databases were searched for relevant studies up to April 31, 2017. All observational studies reporting an association of baseline cardiac troponin-T (cTnT) or troponin-I (cTnI) elevation with all-cause mortality risk in patients with acute ischemic stroke were included. Pooled adjusted risk ratio (RR) and corresponding 95% confidence interval (CI) were obtained using a random effect model. Twelve studies involving 7905 acute ischemic stroke patients met our inclusion criteria. From the overall pooled analysis, patients with elevated cardiac troponin were significantly associated with increased risk of all-cause mortality (RR: 2.53; 95% CI: 1.83-3.50). The prognostic value of cardiac troponin elevation on all-cause mortality risk was stronger (RR: 3.54; 95% CI: 2.09-5.98) during in-hospital stay. Further stratified analysis showed elevated cTnT (RR: 2.36; 95% CI: 1.47-3.77) and cTnI (RR: 2.79; 95% CI: 1.68-4.64) level conferred the similar prognostic value of all-cause mortality. Acute ischemic stroke patients with elevated cTnT or cTnI at baseline independently predicted an increased risk of all-cause mortality. Determination of cardiac troponin on admission may aid in the early death risk stratification in these patients.

Recent advances in the management of transient ischemic attacks

Significant advances in our understanding of transient ischemic attack (TIA) have taken place since it was first recognized as a major risk factor for stroke during the late 1950's. Recently, numerous studies have consistently shown that patients who have experienced a TIA constitute a heterogeneous population, with multiple causative factors as well as an average 5-10% risk of suffering a stroke during the 30 days that follow the index event. These two attributes have driven the most important changes in the management of TIA patients over the last decade, with particular attention paid to effective stroke risk stratification, efficient and comprehensive diagnostic assessment, and a sound therapeutic approach, destined to reduce the risk of subsequent ischemic stroke. This review is an outline of these changes, including a discussion of their advantages and disadvantages, and references to how new trends are likely to influence the future care of these patients.

Differentiating Incident from Recurrent Stroke Using Administrative Data: The Impact of Varying Lengths of Look-Back Periods on the Risk of Misclassification

BACKGROUND/AIMS

Administrative data are widely used to monitor epidemiological trends in stroke and outcomes; yet there is scant empirical guidance on how to best differentiate incident from recurrent stroke.

METHODS

We identified all hospital admissions in New South Wales, Australia, with a principal stroke diagnosis from July 1, 2013 to June 30, 2014, linked to 12 years of previous admissions. We calculated the proportion of cases identified with a prior stroke to determine the number of years of look-back required to minimise misclassification of incident and recurrent strokes.

RESULTS

Using the maximum available look-back period of 12 years, 1,171 out of 8,364 eligible stroke cases (14.0%) had a stroke history. A 1-year look-back period identified only 25.1% of these patients and 1 in 10 stroke cases were misclassified as incident. With a 10-year clearance period, less than 1 in 100 stroke cases were misclassified as incident. The risk of misclassification was lower in patients younger than 65 years and in those with haemorrhagic stroke.

CONCLUSION

Hospital administrative data sets linked to prior admissions can be used to distinguish recurrent from incident stroke. The risk of misclassifying recurrent stroke cases as incident events is negligible with a look-back period of 10 years.