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Temporal Trends in the Use of Investigations After Stroke or Transient Ischemic Attack
Vivian T Ng1, Ahmed M Bayoumi, Jiming Fang
1*Department of Medicine, University of Toronto †Centre for Research on Inner City Health, Division of General Internal Medicine, Li KaShing Knowledge Institute, St Michael's Hospital ‡Institute of Health Policy, Management and Evaluation, University of Toronto §Institute for Clinical Evaluative Sciences ∥Department of Medical Imaging, University of Toronto ¶Sunnybrook Research Institute, Sunnybrook Health Sciences Centre #Division of General Internal Medicine, Toronto General Research Institute, University Health Network, Toronto, ON, Canada.
Insights
Investigations for stroke and transient ischemic attack (TIA) increased significantly, but medical and surgical treatments did not change. The effectiveness of increased imaging and routine echocardiography after stroke is uncertain.
Area of Science:
- Neurology
- Cardiology
- Radiology
Background:
- Guidelines recommend neuroimaging and cardiac investigations for stroke/TIA patients to determine etiology and guide treatment.
- Temporal trends and management changes associated with these investigations are not well understood.
Purpose of the Study:
- To evaluate temporal trends in the use of brain and vascular imaging, echocardiography, and antithrombotic and surgical therapy after stroke or TIA.
Main Methods:
- Analysis of 42,738 patients with stroke or TIA from the Ontario Stroke Registry (2003-2012).
- Use of the Cochran-Armitage test to determine trends over time across 1-year intervals.
Main Results:
- Brain imaging increased from 96% to 99%; ≥3 brain scans (21%-39%), MRI (13%-50%), vascular imaging (62%-88%), and echocardiography (52%-70%) all rose significantly.
- Antithrombotic therapy use increased (83%-91%), but anticoagulation and carotid revascularization rates remained unchanged.
- P<0.0001 for all significant comparisons.
Conclusions:
- Investigation use after stroke has increased, but medical and surgical management has not changed concurrently.
- While initial neurovascular imaging aligns with guidelines, the clinical effectiveness of increased imaging and routine echocardiography is uncertain.
Background:
Guidelines recommend that patients with stroke or transient ischemic attack (TIA) undergo neuroimaging and cardiac investigations to determine etiology and guide treatment. It is not known how the use of these investigations has changed over time and whether there have been associated changes in management.
Objectives:
To evaluate temporal trends in the use of brain and vascular imaging, echocardiography, and antithrombotic and surgical therapy after stroke or TIA.
Research Design:
We analyzed 42,738 patients with stroke or TIA presenting to any of the 11 regional stroke centers in Ontario, Canada between 2003 and 2012 using the Ontario Stroke Registry database. The study period was divided into 1-year intervals and we used the Cochran-Armitage test to determine trends over time.
Results:
Between 2003/2004 and 2011/2012, the proportion of patients undergoing brain imaging increased from 96% to 99%, as did the proportion receiving ≥3 brain scans (21%-39%), magnetic resonance imaging (13%-50%), vascular imaging (62%-88%), or echocardiography (52%-70%) (P<0.0001 for all comparisons). There was an increase in the proportion receiving any antithrombotic therapy (83%-91%, P<0.0001) but no change in use of anticoagulation (25% overall and 68% in subgroup with atrial fibrillation) or carotid revascularization (1.4%-1.5%, P=0.49).
Conclusions:
The use of investigations after stroke has increased over time without concomitant changes in medical or surgical management. Although initial neurovascular imaging is in accordance with practice guidelines, the use of multiple imaging procedures and routine echocardiography are of uncertain clinical effectiveness.
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