CTA your TIA?

[watermanMD]

Do you CTA your TIA’s?
Ex: 15min word finding difficulty, garbled speech. Resolved and asymptomatic on my assessment. Otherwise intact. CT s/con was already done and negative. By the time I saw them, 4-5 hrs since. New onset AFib. Probably embolic.

Hyper-conservative attendings in residency may have said to stroke alert it. More wondering about CTA in ED vs just clicking that admit button for MRI and stroke workup given now asymptomatic. Just curious as to your practice…

(Not talking about CTA’ing the super soft stroke-like sx’s)

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[Mount Asclepius]

If you have already decided on admit, then you are overthinking this. How does any additional testing change your emergent management of this patient? They can obtain CTA, carotid dopplers, MRI and/or TTE as an inpatient.

 

[cyanide12345678]

I CTA. Essentially every stroke gets a Ct head and CTA from me.

I don’t have neurology and a CTA requiring intervention changes where i transfer these people.

Edit: didn’t notice you asked about TIA specifically. If they are really old and I’m transferring for a TIA to get Mri, neurology and the remaining work up then i would CTA, but usually that’s after talking to neurology too who will ask for it. If the story isn’t all that great and they are likely going home then i won’t bother with one. Then they just go home.

 

[Rendar5]

Only if neurology requests or there’s concern for dissection. Otherwise I limit cta’s to my strokes and not tia’s

 

[Mount Asclepius]

There is a clear difference between strokes and TIAs in the utilization of CTA. The OPs post refers to TIAs.

 

[thegenius]

There is a clear difference between strokes and TIAs in the utilization of CTA. The OPs post refers to TIAs.

And what is that?

 

[Mount Asclepius]

And what is that?

Indication for emergent thrombectomy.

 

[thegenius]

Indication for emergent thrombectomy.

I’m just saying. This TIA is going to get vascular imaging. We both know that. We also know it’s not technically an emergency. If treated properly at the onset, it can happen at hour 6 or 9 or 12 or even 24 or so. So you write he was overthinking it, and there really isn’t any thought about it at all. In that case he gets admitted, I write for vascular imaging either as urgent or routine, and admit. I have spent as much time as you have on this particular thing. As long as the pt doesn’t stay in the ED longer than he should.

 

[southerndoc]

As @Rendar5 said, if it's a TIA (true resolution of symptoms) and I'm admitting, then no CTA. They can get an MRA with their MRI. It's easy to send them over for a CTA if they develop symptoms again. If they have a large vessel occlusion, it's rare for them to completely resolve their symptoms and redevelop them. I've seen significant improvement, but that's not a TIA because they still have residual symptoms. A TIA is complete resolution of symptoms, and for those patients, they don't need a CTA in the ED. If I am discharging a TIA, I may or may not order a CTA to look for significant stenosis prior to discharge.

 

[pkwraith]

Our neurologists likes CT-A for every TIA, even though it is not medically necessary, so like a good cog in the machine, I do what they want.

 

[CliveStaples]

I get them, because I have had a not insignificant number of TIA patients that have re-developed stroke-like symptoms during their ED or inpatient stay, and having the information on their vessels sooner than later helps their treatment process.

 

[gro2001]

Everyone needs vessel imaging somewhat soon after their acute event. If you're absolutely sure it's TIA (completely resolved symptoms, and you are sure because you looked really hard for the things that are commonly missed, like you walked them, checked visual fields, and did a good speech exam) AND they can get and MRI/MRA within the next few hours then it's fine not to. If it's a stroke (that just improved a lot but did not completely resolve) or for some reason you can't be 100% sure, then a CTA.

Sure, you can probably farm out the decision making to the neurologist. But if they aren't a stroke specialist, they might not be as on the ball in terms of thinking through acute presentations as you would think. I personally think that emergency physicians should take a bigger role in neuroemergencies as we have in trauma and cardiac emergencies.

 

[Mount Asclepius]

Our local practice pattern is to discharge most TIAs. Given that, our standard protocol is to obtain a CTA prior to discharge. However, if admitting a TIA (resolved symptoms), I don’t see why it matters whether or not you obtain a CTA in the ED or within 24 hours following admission. I’ll obtain at the same time as CT if convenient. In a busy department though it shouldn’t tie up the scanner or admission further.

 

[thegenius]

Our neurologists likes CT-A for every TIA, even though it is not medically necessary, so like a good cog in the machine, I do what they want.

I have no problem with people admitting TIAs without vascular imaging. I also don’t want to have an argument at all with the Hospitalist. It’s not worth it. “I talked to Neuro (or maybe I didn’t), vascular imaging has been ordered (or maybe not).” No big deal. Next patient.

 

[thegenius]

Everyone needs vessel imaging somewhat soon after their acute event. If you're absolutely sure it's TIA (completely resolved symptoms, and you are sure because you looked really hard for the things that are commonly missed, like you walked them, checked visual fields, and did a good speech exam) AND they can get and MRI/MRA within the next few hours then it's fine not to. If it's a stroke (that just improved a lot but did not completely resolve) or for some reason you can't be 100% sure, then a CTA.

Sure, you can probably farm out the decision making to the neurologist. But if they aren't a stroke specialist, they might not be as on the ball in terms of thinking through acute presentations as you would think. I personally think that emergency physicians should take a bigger role in neuroemergencies as we have in trauma and cardiac emergencies.

??? The neurologists I work with (approx 10 across 3 different hospitals) rely basically entirely on imaging all the time. Slam dunk cases? Pts end up with MRA, CTA, and sometimes even carotid imaging. Lord knows why. Borderline cases? Imaging. Unsure? Imaging. Sure? Imaging. Non neuro presentations? Imaging. 9:00 AM? Imaging. 8:30 PM? Honesty if you slipped up and said “I’m taking care of a leopard gecko and it has slurred speech and a facial droop” they be like “give aspirin and get imaging.”

Their book of neuro diagnostics and interventions is only composed of a few pages and especially the case for community neurologists, it is not a head scratcher. It’s “get imaging”

 

[bearstanley]

i CTA all of my TIAs. i "kind of" have neurology at one of my hospitals, but i don't consult them for anything other than acute stroke symptoms within the tpa window.

my rationale is that vessel imaging is needed (as has been said above), and anecdotally, the CTA has changed management (for me anyway) on my last three TIAs-- two caught small carotid dissections that i had to transfer for vascular, and the third actually had radiographic LVO with resolved symptoms; that one went to the thrombectomy center, but i don't think he got a thrombectomy.

 

[Rendar5]

i CTA all of my TIAs. i "kind of" have neurology at one of my hospitals, but i don't consult them for anything other than acute stroke symptoms within the tpa window.

my rationale is that vessel imaging is needed (as has been said above), and anecdotally, the CTA has changed management (for me anyway) on my last three TIAs-- two caught small carotid dissections that i had to transfer for vascular, and the third actually had radiographic LVO with resolved symptoms; that one went to the thrombectomy center, but i don't think he got a thrombectomy.

I've never understood the point of transferring a cervical artery dissections. It's just treated with antiplatelet medications like many TIA's. I work primarily at a stroke center and our neurologists always consult the neurointerventionalists and the answer is always the same.

 

[gro2001]

??? The neurologists I work with (approx 10 across 3 different hospitals) rely basically entirely on imaging all the time. Slam dunk cases? Pts end up with MRA, CTA, and sometimes even carotid imaging. Lord knows why. Borderline cases? Imaging. Unsure? Imaging. Sure? Imaging. Non neuro presentations? Imaging. 9:00 AM? Imaging. 8:30 PM? Honesty if you slipped up and said “I’m taking care of a leopard gecko and it has slurred speech and a facial droop” they be like “give aspirin and get imaging.”

Their book of neuro diagnostics and interventions is only composed of a few pages and especially the case for community neurologists, it is not a head scratcher. It’s “get imaging”

That's the correct approach, in my opinion, and basically my practice (both as a neurointensivist and when I cover stroke). The majority of stroke neurologists do the same.

 

[RustedFox]

Sometimes I call stroke alerts now just to get workups rolling and get the patients out of the department; because they're all going to get admitted anyways because they're all turbo old and vasculopathic anyways.

I'm kidding.


Kind of.

 

[Jabbed]

Sometimes I call stroke alerts now just to get workups rolling and get the patients out of the department; because they're all going to get admitted anyways because they're all turbo old and vasculopathic anyways.

I'm kidding.


Kind of.

No lie, the fastest way to get a CT abdomen/pelvis done is to call a stroke alert.

 

[pkwraith]

I always joke that the incidence of Trauma alerts and Stroke alerts being activated increase significantly near the last 30 minutes of a doctor's shift (also opioid prescriptions rate)

 

[Kryptocoin]

A true TIA doesn't need CTA imaging. At my old hospital, we usually d/c them to f/u with neuro the next day for outpt w/u. We didn't admit them.

My current facility is another story. TIAs and CVAs get the same workup. CT/CTA/MRA/MRI. Our neurologists are pretty aggressive and will even TPA an NIH score of 1.

Having seen a few fatal TPA related bleeds, I rarely order them and I make sure nurses order it under the neurologist's name.