Evaluation of ABCD2 score during the development of stroke in COVID-19 patients diagnosed with transient ischemic attack in the emergency department.

BACKGROUND: The aim of the present study is to reveal the association between the risk of stroke using ABCD2 score and COVID-19 in patients who presented to our emergency department during the pandemic and were diagnosed with TIA. METHODS: According to the recommendations of the European Stroke Association, patients with an ABCD2 score of <4 were classified as low-risk, and patients with an ABCD2 score of ≥4 were classified as high-risk. Within 90 days of the patient's admission to the emergency room, the development of stroke was tracked and recorded on the system. RESULTS: Stroke occurred in 35.78% of the patients. Regarding COVID-19, 75.34% of stroke patients were positive for COVID-19 and 65.75% had COVID-19 compatible pneumonia on 'thoracic CT'. Regarding mortality, 16.4% of the patients who were positive for COVID-19 and developed a stroke died. The presence of COVID-19 compatible pneumonia on thorax CT, PCR test result and ABCD2 score were determined as independent risk factors for the development of stroke. According to the PCR test results, the probability of having a stroke decreases 0.283 times in patients who are negative for COVID-19. According to the PCR test results, the probability of having a stroke increased 2.7 times in COVID-19 positive patients. CONCLUSIONS: Adding the presence of COVID-19 and the presence of COVID-19 pneumonia to the ABCD2 score, based on the information about the increased risk of stroke in TIA patients, improves the predictive power of the score. More studies are needed in this regard.

Managing Low and Intermediate Risk Transient Ischemic Attacks in the Time of a Pandemic

Background: Transient Ischemic Attacks (TIA) are both a harbinger of acute ischemic stroke and warrant urgent evaluation and management to reduce stroke risk. Recently, there has been increasing acceptance to evaluate low-risk (ABCD2 score 0-3) patients in an outpatient setting, but there is limited data on management of intermediate (ABCD2 score 4-5) risk patients. We hypothesized that intermediate risk TIA patients being treated according to protocolized medical management and diagnostic testing would have similar clinic follow-up and re- admission rates to low-risk patients. Method(s): An interdisciplinary team developed a standardized emergency department (ED) TIA protocol using ABCD2 scores, vascular/brain imaging, and neurology consultation to identify low and intermediate risk patients safe for discharge (DC) to the outpatient neurology TIA Clinic. Providers were encouraged to start patients on 7 days of dual anti-platelet therapy (Aspirin 81 mg, Plavix 75mg) and high dose statin (Atorvastatin 80 mg) unless contraindicated. A retrospective review of all patient records with a TIA Clinic referral order was performed to determine the number of days from ED discharge to clinic follow-up while trending 30-day readmission rates to any of our facilities during calendar year 2021. The same datapoints were reviewed and compared using Mann-Whitney U, SPSS version 22 for both low and intermediate risk patient populations for the same time interval. Result(s): Following the January 2021 expansion of ABCD2 score criteria from 0 to 5, there were 324 total patients referred to the TIA Clinic. There were 198 low risk patients with ABCD2 scores from 0-3, 78% were seen in clinic, and 22% did not schedule an appointment. There were 126 intermediate risk patients with scores from 4-5, 69% were seen in clinic, and 31% did not schedule an appointment. There was no difference in outpatient follow up rates between low and intermediate groups (p value of 0.616). Only 1% of all referred patients were re-admitted and there was no difference in readmission rates between low and intermediate risk groups. None of the readmissions had acute infarcts on MRI. Conclusion(s): Our multidisciplinary team created a novel emergency-based TIA evaluation protocol with close TIA Clinic follow up which allowed us to risk stratify both low and intermediate risk patients who could be managed in an outpatient setting. There was no significant difference in readmission rates while achieving similar rates of follow up for both low and intermediate risk patients. And with dwindling bed availability during the COVID pandemic, avoiding hospital admission could preserve precious bed space. [Formula presented] No, authors do not have interests to disclose Copyright © 2022

Safety and feasibility of an ed-to-outpatient pathway for transient ischemic attack or non-disabling stroke

Introduction: The evaluation and risk stratification of patients with TIA/non-disabling ischemic stroke (TIA/NDS) arriving to the Emergency Department (ED) incurs high-cost imaging and increases ED length of stay (EDLOS). We evaluated the safety and feasibility of an ED-toOutpatient Pathway for TIA/NDS. Methods: In April 2020, we developed a risk stratification algorithm for TIA/NDS in the ED using features of the clincal presentation, limited blood tests, telemetry, and head-neck CT/CTA. Patients deemed low risk based on a 'safety checklist' were discharged with plans for expedited outpatient testing as warranted (e.g., brain MRI, echocardiogram) followed by rapid outpatient follow-up. To assess safety/feasibility of this pathway, we analyzed data of the first 101 patients prospectively enrolled through October 2020. Results: Mean age 68 years (range, 33-99);53% men;median NIHSS score 0 (range 0-3). Symptom duration was classified as <10 min (24%), 10-59 min (23%), >60 min (49%), unclear (4%). Deficits included isolated weakness (16%), isolated aphasia (15%), amaurosis fugax (6%), numbness/combined deficits/other (63%). Median ABCD2 score 3 (range 1-7). Outpatient follow-up included stroke clinic (82%), primary care (4%), not required or patient declined (6%), other hospital (1%);7% were lost to follow-up;43% had follow-up within 7 days. Imaging performed in the ED included CT/CTA only (39%), MRI/MRA only (27%), both (33%), or no imaging (1%). EDLOS was significantly less for patients when CT/CTA only was performed, as per pathway (12.8 versus 16.8 hours, p<0.05). The safety checklist was followed in 69% of patients. When the checklist was used properly, there were 0 recurrent strokes or TIAs within 90-days (versus 2 when not used correctly, p<0.05). Return rates to the ED were 8% with use of checklist and 6% without use (p=0.76). Conclusion: Our TIA/NDS pathway, implemented shortly after the outbreak of Covid-19 in the USA, significantly decreased EDLOS, and still allowed for TIA/NDS patients to be safely discharged from the ED. Acceptable risk stratification and safety is suggested by the low rates of recurrent events when the pathway was followed properly. More education is needed to ensure consistent and proper use of the pathway.