New Strategy for TIA and Minor Stroke Patients

Columbia University Irving Medical Center is among the first centers in the country–if not the first–to adopt a new approach to evaluate patients with minor stoke in the emergency department. 

Common practice in U.S. hospitals is to admit patients with minor stroke or transient ischemic attacks (TIAs), but Columbia instead sends many patients home with an appointment for the following day at the new Rapid Access Vascular Evaluation-Neurology (RAVEN) outpatient clinic.

People who experience a TIA or minor stroke have a 10% chance of having a major stroke in the next 90 days, so patients need to be evaluated for appropriate preventive measures. In the United States, the medical community has not reached a consensus regarding the best evaluation approach for patients who come to the emergency department with TIA and minor strokes. 

“Should they be admitted to the hospital and evaluated there because of the risk? Or is it safe to send them home to have an evaluation the next day as an outpatient?” says Mitchell S.V. Elkind, MD, professor of neurology and epidemiology (in the Gertrude H. Sergievsky Center), who led the creation of the clinic.

An outpatient approach could have benefits for both patients and hospitals: reducing patients’ psychological distress and exposure to hospital infections, preserving needed hospital beds for sicker patients, improving flow through the emergency department, and saving money.

Inspired by studies in Europe that show an outpatient approach is both safe and cost-effective, faculty in the VP&S and Weill Cornell neurology and emergency medicine departments collaborated with NewYork-Presbyterian to create the outpatient clinic and protocols for deciding which patients are eligible.

The first study of the RAVEN clinic, published last fall in the Annals of Emergency Medicine, showed that the approach is a safe and feasible strategy for select TIA and minor stroke patients.

The study found no differences in outcomes between RAVEN patients and historical published data of patients evaluated as inpatients. An editorial on the study said that if the results were confirmed in a larger trial, the approach has “the potential to result in a change in current clinical practice and practice guidelines.”

In the three years since the clinic opened, Dr. Elkind said patients continue to report satisfaction with the approach, which shows no increase in the risk of stroke.

“Patients with TIA and minor stroke who meet several criteria indicating low risk can be safely referred for outpatient evaluation,” he says. “This is an example of a study idea borne out of a very common clinical scenario that we face every day. And we think the approach could be adapted for other acute medical conditions.”