|Home | About | Journals | Submit | Contact Us | Français|
The American Heart Association recently redefined transient ischemic attack (TIA) to exclude patients with infarction on neuroimaging. Given its advantages, MRI/DWI was recommended as the preferred imaging modality. We determined how frequently MRI/DWI was performed for TIA and ascertained the proportion of clinically-defined TIA patients who had ischemic lesions on DWI in our community in 2005.
All clinically-defined TIA cases among residents of a five-county region around Cincinnati who presented to emergency departments were identified during 2005. Demographics and medical history, whether MRI/DWI was done, and DWI findings were recorded. Generalized estimating equations were used to compare groups in order to account for the design of the study and multiple events per patient.
Of 834 TIA events in 799 patients, 323 events (40%) had MRI/DWI performed. Patients who had MRI/DWI were younger (mean 66 vs. 70yrs, p=0.03), had less severe pre-stroke disability (baseline modified Rankin Scale zero, 44% vs. 34%, p=0.02), were less likely to have prior stroke or TIA (42% vs 56%, p=0.002), and were less likely to have atrial fibrillation (10% vs. 16%, p=0.01). Of the 323 events with DWI, 51 (15%) had evidence of acute infarction. Patients with positive DWI were older (75 vs. 64yrs, p=0.0001) and more likely to have atrial fibrillation (21% vs. 7%, p=0.002).
Performing MRI/DWI on all clinically-defined TIA patients in our community would reveal more cases of actual infarction, but would more than double current use. Future studies should assess whether MRI/DWI is warranted for all TIA patients.
The long accepted definition of a transient ischemic attack (TIA) is an episode of sudden onset of neurological deficit in a vascular distribution that completely resolves within 24 hours.1 With the advent of multimodal magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI), multiple single center and registry studies have reported that acute ischemic lesions are found in 12% to 67% of TIA patients by DWI.2–10 A meta-analysis of these studies reported an aggregate 39% positive DWI rate among patients with clinically-defined TIA.10, 11 Since the 24-hour duration in the aforementioned TIA definition was arbitrary, a tissue-based definition of TIA was proposed to classify patients as having a TIA only if the symptoms fit the clinical syndrome and no ischemic lesion is identified by neuroimaging.12 It has been suggested that if this tissue-based definition is adopted, the estimates of the annual incidence of TIA in the United States would be reduced by 33% while the incidence of ischemic stroke would increase by 7%.13 The American Heart Association recently issued a statement redefining TIA as “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.”11 MRI with DWI was recommended as the preferred brain diagnostic imaging modality.
The frequency of MRI utilization in the evaluation of TIA patients in recent years is unknown. A study conducted from 1992 to 2001 in centers across the United States found that MRI was performed in less than 5% of TIA cases but that the frequency of neuroimaging (MRI or CT) had increased by more than 70% from 1992 to 2001. The proportion receiving MRI versus CT was not reported.14 Only 3% of TIA patients had an MRI within 30 days in a Canadian study conducted in 2000.15 We sought to determine the proportion of clinically-defined TIA patients who were evaluated with MRI/DWI in 2005, and among these, the proportion with ischemic lesions identified on DWI. We hypothesized that few TIA cases would be evaluated by MRI/DWI, and that about 40% of patients who had MRI/DWI would have an acute ischemic lesion identified.
The GCNKSS is a population-based epidemiological study of stroke in blacks and whites, specifically designed to measure temporal trends in incidence and racial differences in incidence of stroke and stroke risk factor profiles. The GCNKSS study population is defined as the 1.3 million residents of the Greater Cincinnati/Northern Kentucky region, which includes two southern Ohio counties and three contiguous Northern Kentucky counties that border the Ohio River. Included in this area are 16 hospitals. Although residents of nearby counties seek care at the 16 hospitals, only residents of the five study area counties were included as cases. The study period was from 1/1/2005 to 12/31/2005.
The methods of case ascertainment and data collection have been previously reported.16 Briefly, study nurses retrospectively reviewed and abstracted the medical records of all inpatients with primary or secondary stroke-related ICD-9 discharge diagnoses (430–436) from the 16 acute-care hospitals in the study region. In addition, strokes not found by inpatient screening were ascertained by monitoring all stroke-related visits to hospital emergency departments (ED) (with the exception of Cincinnati Children’s Hospital), 16 public health clinics, and 14 hospital-based outpatient clinics and family practice centers. Cases for which stroke was listed as the primary or secondary cause of death by one of the five county coroners’ offices were also included. Further monitoring was performed by examining the records of potential stroke cases in a random sample of 51 of the 832 primary care physicians’ offices and 25 of the 126 nursing homes in the GCNK region. This sampling was necessary given the large number of physician offices and nursing homes in the region. Events found by out-of-hospital monitoring were crosschecked against inpatient records to prevent double counting. Once cases of stroke or TIA were identified, a study nurse abstracted the medical record using standardized case report forms. Abstracted data included symptoms and duration, point of first healthcare provider contact (e.g., 911/EMS, ED, primary doctor), ED physical exam findings and complete vital signs, past medical and surgical history, medications prior to stroke/TIA, social history/habits, baseline modified Rankin scale (mRS) score, diagnostic tests performed in the ED or during hospitalization (including MRI/DWI) and results, treatments, and short-term outcomes. Only imaging studies performed during hospitalization were included. When available, exact times for MRI/DWI were recorded. Otherwise, the date MRI/DWI was performed was recorded. When available, symptom onset time and duration were recorded. Otherwise, onset times were categorized into 6-hour windows during the day, based on time last seen normal: morning (6:01am–noon), afternoon (12:01pm–6:00pm), evening (6:01pm–midnight), after midnight (12:01am–6:00am). Exact durations of TIA symptoms, in hours and minutes, were recorded when available. Although the exact duration of symptoms was unknown in some instances, cases were included as TIA only if it was clear that the symptoms resolved. If exact durations were not available, durations were classified as less than 10 minutes, 10 to 60 minutes, or greater than 60 minutes where possible. For analysis, all symptom durations were collapsed into these three categories. Each patient’s mRS was determined by retrospective chart review.
Study physicians reviewed every abstract and decided whether a stroke or TIA had occurred. The physicians assigned stroke subtype and mechanism to each verified case based on all available information, using definitions previously reported.1, 16 For this analysis, only patients classified as having clinically-defined TIA and evaluated in the ED were included. Data management and descriptive and comparative analyses were performed using SAS® versions 8.02 and 9.2 respectively (SAS Institute, Cary, NC). Population estimates were obtained by including the sampling weights in all analyses as dictated by the study design. Generalized estimating equations (GEE)17 were used to examine the bivariate differences between patients with MRI/DWI and those without and also to examine the bivariate differences between those DWI positive versus DWI negative. This methodology also accounted for those patients with more than one event in the time period studied. The working correlation structure giving the best model fit was obtained. A binary or multinomial distribution was specified for categorical variables, as appropriate. Values are reported as raw frequencies with weighted percentages or weighted means with standard errors.
In 2005, the records of 1,907 events coded as TIAs were examined by study nurses, 837 events were determined not to meet the clinical definition for TIA. Of the 1,070 events that were abstracted by the research nurses, physician review determined that 236 were not TIAs or strokes. Overall, 834 TIA events in 799 patients within our population were evaluated in an ED; 27 patients had 2 events each, and 4 patients had 3 events each.
Among the 834 events, 323 (40%) were evaluated by MRI/DWI. Of the 31 patients with multiple TIA events, MRI/DWI was performed for both events in 2 patients, 17 had MRI/DWI for one presentation but not for additional presentations, and 12 did not have MRI/DWI for any presentation. Patients who had MRI/DWI on at least one presentation were slightly younger (mean age 66vs. 70yrs, p=.03) and had less pre-stroke disability (baseline mRS of zero, 44% vs 34%, p=0.02) than patients who did not have MRI/DWI. They were also less likely to have had a prior stroke or TIA (42% vs 56%, p=0.002), less likely to have pre-existing diabetes (24% vs 31%, p=0.04) and were less likely to have atrial fibrillation (10% vs. 16%, p=0.01) (Table 1). Gender, race, presence of focal weakness, presence of speech deficit, and symptom duration did not differ between patients who had MRI/DWI and those who did not. Exact duration of TIA symptoms was available for 628 of the 834 events. Duration was determined to be <10 minutes in 5 of the remaining 206 events, between 10 and 60 minutes in 16 events, >60 minutes in 180 events, and unknown in 5 events. In total, duration was <10 minutes in 84 events, between 10 and 60 minutes in 284 events, and > 60 minutes in 461 events.
Among patients who did have MRI/DWI performed, an acute ischemic lesion was identified in 51 (15%). Patients with positive DWI were older than those with negative DWI (mean age 75 vs. 64yrs, p=0.0001) and were more likely to have atrial fibrillation (21% vs. 7%, p=0.002, Table 2). Race, gender, prior stroke or TIA, pre-onset disability, history of diabetes, symptom severity, and symptom duration were not associated with a positive DWI. In patients who had MRI/DWI performed, 93% had the imaging study completed within 2 days of symptom onset (Table 3).
In our study of clinically-defined TIA patients, we found that 40% of TIA events were evaluated by MRI/DWI, and that 15% of these had ischemic lesions identified on DWI. The frequency of MRI/DWI utilization in our study region was much higher than reported by Edlow et al., who found that MRI was performed in fewer than 5% of TIA cases in their study of the National Hospital Ambulatory Medical Care Survey from 1992–2001.14 Our MRI utilization rates were also much higher than the 3% reported in a Canadian study.15 Despite our relatively high rates of MRI utilization, performing MRI/DWI on all cases of TIA would more than double the current number of MRIs performed for TIAs in our community. Using the Medicare reimbursement rate of $535.42 for the technical fees (i.e., no physician billing included) of an MRI/MRA with contrast,18 performing an additional 478 MRI/DWI imaging studies within our community in 2005 would have resulted in about $250,000 of additional costs. Extrapolating the findings in our study to the United States, with an estimated 240,000 TIAs per year,19 may thus result in a minimum of $70 million increase in annual costs for the evaluation of TIA.
Our 15% positive DWI rate is less than half the 39% aggregate positive DWI rate reported in a recent meta-analysis of 19 studies.10, 11 The largest of the studies involved 300 TIA patients seen non-urgently at a TIA/minor stroke referral clinic. The positive DWI rate in that study was 16%. Within that study, the likelihood of a positive DWI decreased nonlinearly with longer time from symptom onset.3 The median time from symptom onset to MRI in the study was 17 days (interquartile range=10 to 23). Over ninety percent of patients in our study had MRI performed within 2 days of symptom onset (Table 3). Thus, we do not believe delays in performing MRI/DWI contributed to our relatively low positive DWI rate. Further, multiple studies with DWI performed greater than 24 hours from onset have reported positive rates of 30%–67%.4–6 The inclusion of these single center and imaging registry studies in the meta-analysis may have skewed the overall rates of positive DWI higher than may be the case within the general population.
We found that patients evaluated with MRI/DWI were younger, were less likely to have traditional stroke risk factors such as a previous stroke or TIA, pre-existing diabetes or atrial fibrillation. They were also less likely to have a pre-existing disability as defined by modified Rankin. However, patients in whom DWI was positive were older and more likely to have atrial fibrillation (Table 2). Thus, our reported rate of positive DWI may be lower than is truly the case. Our findings regarding the association of older age and atrial fibrillation with a positive DWI are consistent with some publications but in contrast to others.6, 20 It is unknown whether performing MRI/DWI on all TIA patients in our community would double the positive DWI rate and place our positive rates at the level reported in the meta-analysis.10, 11 The fewer imaging studies in older, higher risk patients may represent a more aggressive approach to evaluation of younger patients without a clear TIA etiology, while older patients with atrial fibrillation or other presumed etiology may be less likely to be evaluated with MRI. On the other hand, it may be that older patients may have pacemakers or other contraindications that preclude performance of MRI.
We did not find any associations between symptom type or duration and the likelihood of a positive DWI. This is in contrast to other reports that suggest that motor deficits and duration of symptoms were associated with a positive DWI.4, 20–22 The discrepancy of our findings with these reports may relate to differences in the populations studied. Two studies were conducted at a single center in Spain,21, 22 another at a center in France,20 and a single center study of 42 patients in the United States.4 By comparison, our large study of a biracial patient population comprised 16 hospitals in our region.
Our study had several limitations. First, cases were identified retrospectively from inspection of medical records, and there is always a risk of incomplete case ascertainment. However, prospective monitoring of all ED patients is not feasible. Also, since we limited our study to ED TIA patients and MRI/DWI was not performed on all cases of TIA, our 15% positive DWI rate may represent a biased estimate of the “true” DWI positive rate among clinically-defined TIA patients. However, no estimates of MRI/DWI use to date have included all presenting TIA cases. Further, the large number of patients evaluated by DWI in our study is comparable to the largest study previously published on the subject. Another limitation of our study is that we included only cases that were adjudicated by stroke physicians (after review of all available data) as true TIA. In clinical practice, the decision to perform an MRI after admission is often based on the early differential diagnosis, in contrast to our reliance on the ultimate discharge diagnosis to identify cases. Thus, our methodology would have excluded cases that met a clinical definition of a TIA but in whom MRI revealed a different discharge diagnosis. Lastly, the findings of practice patterns in our community may not be generalizable to other communities.
Performing MRI/DWI on all clinically-defined TIA patients in our community would reveal more cases of actual infarction. However, given current imaging practice patterns, marked increases in the use of MRI would be needed to evaluate every TIA patient using the preferred imaging modality as per the current national guideline. Future studies should assess the cost-benefit of any such increases in the use of MRI/DWI for TIA, whether longer term outcomes are improved by increased rates of neuroimaging, and whether MRI/DWI is warranted for all TIA patients.
Supported by NINDS 5R01NS030678
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.