Cost Effective Strategies:
1. Use some form of risk stratification. The short-term risk of stroke after TIA is much higher than previously recognized. If you are not admitting all your TIA patients, then it is cost effective to admit those who are at highest risk. There are at least 3 specific risk stratification
tools (California rule, ABCD rule, ABCD2 rule) that are all easy to use in the ED and seem to be indicative of stroke outcome.
2. Perform carotid ultrasound in the ED on your TIA patients. Finding the underlying vascular cause of a TIA is an important step in fixing that underlying lesion. Carotid ultrasound is quick and very sensitive to high grade stenosis. It is much cheaper than CT or MR angiography and does not expose the patient to radiation or iodinated dye. Patients with high grade stenosis benefit from rapid revascularization.
3. Give all TIA patients aspirin (or some other AHA-recommended antiplatelet medication). You wouldn’t think of not giving aspirin to an active chest pain patient, and the same applies to TIA patients. Unless there is a specific and absolute contraindication, all TIA patients should receive an antiplatelet medication. Aspirin is the cheapest and reduces stroke by approximately 20% to 25% over placebo.
4. Arrange for your TIA patients to have immediate evaluations. It’s become very clear in recent years that rapid evaluation of TIA patients can decrease the high early stroke rate. Studies suggest that ED-based observation units can be implemented with similarly good results.
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