Background: The possibility of outpatient evaluation of suspected transient ischemic attack has previously been considered in studies, and some have suggested that outpatient evaluation of suspected TIA may be safe and cost-effective in patients at lower risk of stroke as measured by the ABCD2 score. However, no consensus has been reached on the optimal strategy for this. During the first few months of the COVID-19 pandemic, patients were less willing to be admitted to the hospital than previously. This forced hospital staff to rapidly develop alternative outpatient follow up plans for acute conditions such as transient ischemic attack that could conceivably be managed as an outpatient.
Purpose: After the start of the COVID-19 pandemic, a pathway was developed at our health system to allow for outpatient evaluation of patients with suspected TIA who did not wish to be observed overnight in the hospital.
Description: Starting in late February 2020, patients presenting with suspected symptoms of transient ischemic attack were evaluated by the Emergency Department provider. If the on-call neurologist felt it was appropriate, these patients were offered discharge home from the Emergency Department with outpatient brain MRI. CT angiography of the head and neck was performed in the Emergency Department, and the patient was sent home with prescriptions for aspirin and statin when appropriate. The MRI was arranged at the patient’s convenience; the covering neurologist reviewed all MRI results and then contacted the patient to follow up. Outpatient Neurology follow up was arranged as the patient allowed. Sixteen patients who presented to the hospitals in our system with suspected symptoms of TIA and chose to be discharged home rather than observed overnight in the hospital were identified through review of outpatient MRI’s ordered by our neurologists. The age range of these patients was 57-78 (mean 68) and ABCD2 risk scores ranged from 1-6 (mean 3). MRI results were located for these patients (if available in our system), and inpatient and outpatient medical records of our health system were reviewed for at least one month out from the patient’s original presentation to obtain information on outcomes, when available. Of the nine MRI results which were available in our records for review, six were normal; two were abnormal but without signs of stroke, and one had a small new stroke. Follow-up information was obtained on twelve of the sixteen patients; one patient had recurrence of transient neurological symptoms and three had persistent symptoms which were not felt to be due to stroke. None of these twelve patients had any new episodes of stroke identified at least one month out from the original presentation.
Conclusions: This small observational study was limited by potential bias in patient selection for this pathway, as this was only offered to patients based on the discretion of the Emergency Department provider and the covering neurologist, and the decision to take this pathway was left up to the patient. However, a range of patients (some of whom had high ABCD2 risk scores) had no adverse outcomes after being evaluated as an outpatient for suspected TIA; this suggests that more rigorous study may identify a way to safely evaluate TIA patients as an outpatient.