Disparities in Access to Vascular Stroke Imaging and Carotid Revascularization: A Population Study

Decisions on imaging with computed tomography angiography, magnetic resonance angiography, and ultrasound in stroke or transient ischemic attack (TIA) may be influenced by factors ranging from location-based resource considerations to patient characteristics. We investigated disparities in vascular imaging utilization and carotid revascularization over 7 years in a Canadian province (Alberta, population: 4.4 million).

We used provincial administrative data encompassing patients presenting to hospital or emergency/urgent-care facilities with TIA or ischemic stroke from April 1, 2016 to March 31, 2023. We related the vascular imaging received to year, age, sex, event diagnosis, comorbidities, distance to a comprehensive stroke center, region, and stroke center type using mixed-effects logistic regressions. We similarly examined disparities in imaging for recurrent events and in receipt of carotid endarterectomy/stenting.

Among 47 963 patients (median age, 72, interquartile range, 61-82, 47.6% female) with stroke/TIA, patients who were female, older, and experienced minor stroke/TIA (versus major stroke) had lower odds of receiving computed tomography angiography or any neurovascular imaging, as did those presenting to nonstroke centers or rural sites (eg, 35.8% rural versus 75.3% urban, adjusted odds ratio [any imaging]:0.56, 95% CI, 0.34-0.94). Odds of receiving vascular imaging increased over time, including computed tomography angiography (2016:49.1% versus 2023:79.9%, adjusted odds ratio per-year since 2015 [computed tomography angiography], 1.18 [95% CI, 1.16-1.19]). Female sex and absent neurovascular imaging carried lower odds of carotid revascularization (2.4% female versus 4.4% male, adjusted odds ratio, 0.57 [95% CI, 0.52-0.63]).

Despite increasing utilization of neurovascular imaging, patients who are female, older, rural, or with minor stroke/TIA remain less likely to receive neurovascular imaging, with expected implications for receiving carotid revascularization. Female patients are less likely to undergo carotid revascularization even after accounting for receipt of imaging.