Implementation of a Rapid, Protocol-based TIA Management Pathway.

INTRODUCTION: Our goal was to assess whether use of a standardized clinical protocol improves efficiency for patients who present to the emergency department (ED) with symptoms of transient ischemic attack (TIA). METHODS: We performed a structured, retrospective, cohort study at a large, urban, tertiary care academic center. In July 2012 this hospital implemented a standardized protocol for patients with suspected TIA. The protocol selected high-risk patients for admission and low/intermediate-risk patients to an ED observation unit for workup. Recommended workup included brain imaging, vascular imaging, cardiac monitoring, and observation. Patients were included if clinical providers determined the need for workup for TIA. We included consecutive patients presenting during a six-month period prior to protocol implementation, and those presenting between 6-12 months after implementation. Outcomes included ED length of stay (LOS), hospital LOS, use of neuroimaging, and 90-day risk of stroke or TIA. RESULTS: From 01/2012 to 06/2012, 130 patients were evaluated for TIA symptoms in the ED, and from 01/2013 to 06/2013, 150 patients. The final diagnosis was TIA or stroke in 45% before vs. 41% after (p=0.18). Following the intervention, the inpatient admission rate decreased from 62% to 24% (p<0.001), median ED LOS decreased by 1.2 hours (5.7 to 4.9 hours, p=0.027), and median total hospital LOS from 29.4 hours to 23.1 hours (p=0.019). The proportion of patients receiving head computed tomography (CT) went from 68% to 58% (p=0.087); brain magnetic resonance (MR) imaging from 83% to 88%, (p=0.44) neck CT angiography from 32% to 22% (p=0.039); and neck MR angiography from 61% to 72% (p=0.046). Ninety-day stroke or recurrent TIA among those with final diagnosis of TIA was 3% for both periods. CONCLUSION: Implementation of a TIA protocol significantly reduced ED LOS and total hospital LOS.

State-of-the-art MRI techniques in neuroradiology: principles, pitfalls, and clinical applications.

This article reviews the most relevant state-of-the-art magnetic resonance (MR) techniques, which are clinically available to investigate brain diseases. MR acquisition techniques addressed include notably diffusion imaging (diffusion-weighted imaging (DWI), diffusion tensor imaging (DTI), and diffusion kurtosis imaging (DKI)) as well as perfusion imaging (dynamic susceptibility contrast (DSC), arterial spin labeling (ASL), and dynamic contrast enhanced (DCE)). The underlying models used to process these images are described, as well as the theoretic underpinnings of quantitative diffusion and perfusion MR imaging-based methods. The technical requirements and how they may help to understand, classify, or follow-up neurological pathologies are briefly summarized. Techniques, principles, advantages but also intrinsic limitations, typical artifacts, and alternative solutions developed to overcome them are discussed. In this article, we also review routinely available three-dimensional (3D) techniques in neuro MRI, including state-of-the-art and emerging angiography sequences, and briefly introduce more recently proposed 3D quantitative neuro-anatomy sequences, and new technology, such as multi-slice and multi-transmit imaging.