Am Heart Hosp J. 2010;8(2):91–98


Lozenge Reference


Review


Management of Acute Stroke and Transient Ischemic Stroke—An Integrated, Systematic Approach from the Emergency Department to the Inpatient Setting to Discharge


Kiwon Lee, MD, FACP, FAHA


In the past two decades, we have seen major advances in the treatment of transient ischemic attack (TIA) and acute ischemic stroke. Unfortunately, these advances have not benefited the majority of TIA and stroke patients. Reasons vary and include the failure of patients and providers to recognize the severity of early symptoms, resulting in critical delays in treatment. Other reasons include the inability of isolated emergency departments (EDs) to acquire life-saving technology or enhance provider expertise in recent medical advances. Effective treatment of TIA and stroke requires an integrated, systematic approach that begins in the ED, continues in the inpatient setting, and is maintained after discharge.


troke is the third most common cause of mortality and a leading cause of disability in the US.1 Unfortunately, many patients have not benefited from the advances in stroke treatment that have occurred over the past 20 years. Although the figures vary by institution, only an estimated 2–11% of patients who qualify for tissue-type plasminogen activator (tPA) receive it during an acute ischemic stroke.2,3


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One reason for the under-use of advanced treatments may be that the symptoms associated with transient ischemic attack (TIA) and stroke are not always recognized as serious. In addition, many patients seek medical attention after they have missed the window of treatment opportunity. Another possible contributor to under-use of advanced treatments is that advanced stroke intervention requires the expertise of vascular neurologists and neurointerventionalists, which is not readily available in many emergency departments (EDs). Effective treatment of TIA and stroke requires a rapid, integrated, systematic approach, beginning with arrival of the patient at the ED and continuing with acute and subacute management in the inpatient setting through to long-term management to prevent secondary strokes.


Emergency Department Management of Acute Stroke and Transient Ischemic Attack Acute management of TIA and stroke in the ED requires rapid assessment, diagnostic testing, neuroimaging, thrombolysis or thrombectomy if indicated, early antithrombotic intervention, dedicated neurologic monitoring, and supportive care.


Diagnosing Transient Ischemic Attack versus Stroke. TIA is currently defined as “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.”4


This new definition


distinguishes itself from previous definitions in that there is no longer an arbitrary cut-off time (24 hours) after which a TIA would be considered a stroke.4


Although TIAs do not result in infarction and typically resolve quickly, they are not benign and must be treated as an emergency that could lead to stroke. Between 10 and 15% of patients who have a TIA will have a stroke within three months; half of these will occur within 48 hours.4 Prompt diagnosis and management of TIA may reduce future stroke rates. In one study, the risk dropped from 10.3% (32/310) to 2.1% (6/281) when median time to


• Correspondence: Kiwon Lee, MD, FACP, FAHA, Division of Neurocritical Care, Milstein 8 Center, Suite 300, 177 Fort Washington Avenue, New York, NY 10032. E: KL2356@columbia.edu


Winter 2010 Management of Acute Stroke and Transient Ischemic Attack 91


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