Citations

Introduction Transient Ischemic Attack (TIA) evaluation requires urgent etiology identification and targeted stroke prevention, traditionally performed via hospital admission. The literature suggests that outpatient evaluation may be safe and cost‐effective. Hence, we implemented an expedited outpatient pathway (OP) for patients presenting to our institution’s Emergency Department (ED) with TIA. To further guide future practice, we compared clinical features and outcomes between expedited OP and our well‐established inpatient pathway (IP). Methods We implemented an algorithm of direct communication between ED providers and Vascular Neurologists for all TIA patients. Certain screening studies (head CT, CT angiogram, basic laboratories) and acute therapies were implemented in the ED, whereas others (brain MRI, echocardiogram, etc) and Vascular Neurology consultations were expedited outpatient within 48–72 hours.We included all patients that underwent OP evaluation from May 2021‐May 2022. Further, we extracted patients with a final diagnosis of TIA and compared them with IP TIA patients hospitalized (2017‐2021), matched by age, gender, and clinical severity (ABCD2). Descriptive statistics were used to summarize patient demographics, clinical data, treatments, and 3‐month outcomes. Continuous variables were summarized with mean and standard deviations while categorical variables were shown as counts and percentages. Chi‐square test was used for categorical variables and Mann‐Whitney U test was used to compare continuous variables. P‐values < 0.05 were considered statistically significant and all tests were two‐sided. Statistical Analysis was completed in R 4.0.3. Results Of 43 patients who underwent expedited OP TIA workup, TIA or minor stroke was diagnosed in 21/43 (48.9%). 18 TIAs underwent comparative analyses. Mean symptom duration was longer in the IP (2.06 hours) than OP (0.99 hours), p = 0.370%. TIA was more likely to be diagnosed in the OP 14/18 (78%) versus IP 12/18 (67%), (p = 0.423). OP had more transesophageal echocardiograms (17% vs 5%, p = 0.630) and longer duration of ambulatory cardiac monitoring (mean 574.3 vs 381.7 hours, p = 0.100). IP patients were more likely to get started on anticoagulation compared to OP (38% vs 11%, p = 0.258) and high‐intensity statin (38% vs 17%, p = 0.260). All laboratories, echocardiograms and brain MR imaging were performed significantly sooner for the IP (p< 0.05 for all). IP had higher rate of return ED visits (22%) and readmissions at 3 months (11%), whereas OP had none. OP had no deaths or recurrent strokes, whereas 11% and 5.6% respectively were noted in the IP at 3 months (p = 0.310, p = 0.310). Conclusions Our study shows that routine IP evaluation for patients presenting with TIA in the ED may not offer diagnostic superiority nor lead to improvement of short‐term clinical outcomes, as compared to the expedited OP evaluation. Careful evaluation of TIA patients in the ED followed by expedited OP evaluation might be a plausible approach to help lower costs and avoid hospitalization without compromising the safety of these patients.

Introduction: Central retinal artery occlusion (CRAO) is an under-recognized stroke subtype that may benefit from hyperacute reperfusion therapies. We aimed to evaluate the ability of telestroke activations to provide CRAO diagnosis and thrombolysis. Methods: This retrospective observational study investigates all encounters conducted for acute visual loss between 2010 and 2021 in our multicentric Mayo Clinic Telestroke Network. Demographics, time from visual loss to telestroke evaluation, ocular examination, diagnostic, and therapeutic recommendations were collected for CRAO subjects. Results: Out of 9,511, 49 encounters (0.51%) were conducted for an acute ocular complaint. Five patients had possible CRAO, and 4 presented within 4.5 h from symptom onset (range 1.5–5 h). None received thrombolytic therapy. All telestroke physicians recommended ophthalmology consultation. Conclusion: Current telestroke assessment of acute visual loss is suboptimal and patients eligible for acute reperfusion therapies may not be offered treatment. Teleophthalmologic evaluations and advanced ophthalmic diagnostic tools should complement telestroke systems.

Introduction: Permanent perioperative vision loss is caused by ischemic optic neuropathy (ION) or central retinal artery occlusion (CRAO). Whereas diffusion restriction of the optic nerve (ON) on brain magnetic resonance imaging has been previously reported in perioperative posterior ION (PION), there are no reports of ON diffusion restriction in patients diagnosed with acute perioperative CRAO. We present a case of perioperative CRAO to highlight this neuroimaging finding for neuroradiologists and neurologists. Case Report: A 71-year-old male without vascular risk factors underwent maxillary bilateral antrostomy and septoplasty for chronic sinusitis. Twenty to thirty minutes upon awakening, he complained of painless left eye vision loss. Ophthalmoscopic examination showed retinal whitening, segmented arterioles, and hyperemic disc. Brain MR-diffusion weighted imaging/apparent diffusion coefficient revealed ON diffusion restriction in the proximal segment. Despite attempted reperfusion, left eye remained with no light perception at 6 months. Patients undergoing nonocular surgeries who develop perioperative vision loss related to PION may exhibit ON diffusion restriction but usually have normal ophthalmoscopic findings. CRAO shows retinal whitening, edema, segmentation of arterioles, and cherry red spot on ophthalmoscopy. A recent study reported that ON diffusion restriction in nonperioperative CRAO cases has a sensitivity and specificity of 55% and 70% to 100%. Here, PION was initially considered based on imaging. However, given the neuro-ophthalmic findings, a proximal embolus in the central retinal artery, obstructing its entrance into the proximal ON was deemed more likely. Conclusion: We highlight that proximal ON diffusion restriction on brain magnetic resonance imaging can be diagnostic of proximal thromboembolic CRAO. Future studies should evaluate the diagnostic utility and accuracy of MR-diffusion weighted imaging/apparent diffusion coefficient in perioperative visual loss.

External iliac vein stenosis related to cycling has rarely been reported as a cause of deep vein thrombosis. Ischemic stroke occurring in this condition due to paradoxical embolism across a preexisting patent foramen ovale (PFO) has yet to be reported. Here we report a case of embolic ischemic strokes in a young, avid cyclist with no prior known vascular risk factors. A thorough cerebrovascular workup revealed a right-to-left shunt on transesophageal echocardiogram that prompted venous thrombosis evaluation. Pelvic MR venogram demonstrated a 3.5 cm high-grade stenosis of the right external iliac vein, concerning for possible prior thrombotic disease. His strokes were deemed most likely a result of paradoxical emboli originating in the pelvis at the site of right external iliac vein stenosis. The patient ultimately opted for PFO closure for secondary stroke prevention, as he wished to continue daily cycling. This case highlights the importance of neurohospitalists considering iliac vein stenosis as a potential cause of embolic stroke of undetermined source, especially in young patients who are avid cyclists, as part of a thorough vascular workup.

Introduction: Central retinal artery occlusion (CRAO) is a neurovascular emergency and acute monocular visual loss should trigger a stroke code activation. As thrombolytic therapy is considered for non-arteritic CRAO in the stroke therapeutic window, we aimed to review all telestroke encounters for acute visual loss in Mayo Clinic national telestroke network, focusing on the ocular diagnosis and the management recommendations. Hypothesis: patients evaluated via telestroke for acute visual loss are less likely to receive thrombolysis Methods: We conducted a retrospective review of the Mayo Clinic Arizona Telestroke/Teleneurology (2010-2017, 6364 encounters) and Mayo Clinic Enterprise Telestroke databases (2018-2020, 3147 encounters), searching for visits requested for acute visual loss. We recorded the subjects’ demographics, time from last seen normal to telestroke evaluation, preliminary diagnosis, and therapeutic/diagnostic recommendation. Results: From a total of 9511 audio-video telestroke encounters, 49 (0.51%) had an ocular diagnosis. Out of those, 6 patients (12.2%) had a provisional diagnosis of CRAO. 4/6 (66.6%) CRAO patients presented within 4.5h from symptom onset (median 2 hours) and none received thrombolytic therapy. All telestroke physicians recommended antiplatelet, ophthalmology consultation for diagnostic evaluation and comprehensive stroke work-up. Conclusions: Telestroke evaluations for CRAO, in routine practice, are less common than the disease prevalence would predict, suggesting that education is urgently mandated to increase the index of awareness. Even when CRAO subjects are evaluated via telestroke within 4.5 hours from symptom onset, they do not receive thrombolytic therapy nor timely ophthalmologic evaluation. Telestroke visits may benefit from the inclusion of tele-ophthalmologic consults to help with establishing the diagnosis in the narrow time-window of intravenous thrombolysis.