Rapid Assessment and Treatment of Transient Ischemic Attacks and Minor Stroke in Canadian Emergency Departments: Time for a Paradigm Shift.

A majority of acute cerebrovascular syndromes are transient ischemic attacks (TIA) or minor ischemic strokes. They are often thought of and managed as though benign, but are in fact a warning of impending disabling stroke. The risk of stroke progression or recurrence is highest in the first hours to days from initial symptom onset, with a 6.7% risk at 48 hours and a 10% risk by 7 days after a TIA.1,2 The highest risk period is early, with a median time to a recurrence or progression event of 1 day; many events occur overnight after the initial ictus.3 Many strokes are preventable after a TIA. Rapid diagnosis and treatment reduces the risk of stroke by as much as 80%4,5 and significantly reduces mortality, long-term disability, and costs.6,7 The estimated annual cost avoidance in Canada from the rapid assessment and treatment of TIA is $313.8 million (of which $269.2 million are indirect costs).8 To be most effective, the diagnosis and treatment of all TIAs and minor strokes must recognize the natural biology of the condition and should ideally occur on the same day as the event. Currently, this is not consistently achieved in Canada. There are several overlapping challenges with TIA/minor stroke management, including (1) establishing an accurate diagnosis of brain ischemia quickly; (2) establishing accurate triage approaches to risk-stratify patients; and (3) establishing systems of care that expedite both the diagnostic evaluation and initiation of treatment. Rapid access to both brain and vascular imaging is a unifying component of the solution to all these challenges. The clinical diagnosis of TIA/minor stroke is not always straightforward because a …