The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention,1 the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7th edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

We examined to what extent clinical assessment alone can predict subtle acute cerebral infarction on magnetic resonance imaging (MRI). Of the 72 patients presented to the emergency department (ED) with transient neurological deficits, 26 (36.1%) were predicted to be “positive” and 46 (63.9%) “negative” for transient ischemic attack/minor stroke by two independent neurologists. Twenty patients (27.8%) had acute restricted diffusion on MRI. Clinical assessment showed substantial agreement with MRI findings (Kappa = 0.75), sensitivity (95.0%), specificity (86.5%), positive-likelihood ratio 7.06, and negative-likelihood ratio 0.06. Neurological assessment has an excellent predicting value for MRI-confirmed acute cerebral infarction and a key role in the facilitation of effective patient care in the ED.

Introduction: Individualizing risk for stroke following a transient ischemic attack (TIA) is a topic of intense research, as existing scores are context-dependent or have not been well validated. The Canadian TIA Score stratifies risk of subsequent stroke into low, moderate and high risk. Our objective was to prospectively validate the Canadian TIA Score in a new cohort of emergency department (ED) patients. Methods: We conducted a prospective cohort study in 14 Canadian EDs over 4 years. We enrolled consecutive adult patients with an ED visit for TIA or nondisabling stroke. Treating physicians recorded standardized clinical variables onto data collection forms. Given the ability of prompt emergency carotid endarterectomy (CEA) to prevent stroke (NNT = 3) in high risk patients, our primary outcome was the composite of subsequent stroke or CEA ≤7 days. We conducted telephone follow-up using the validated Questionnaire for Verifying Stroke Free Status at 7 and 90 days. Outcomes were adjudicated by panels of 3 local stroke experts, blinded to the index ED data collection form. Based on prior work, we estimated a sample size of 5,004 patients including 93 subsequent strokes, would yield 95% confidence bands of +/− 10% for sensitivity and likelihood ratio (LR). Our analyses assessed interval LRs (iLR) with 95% CIs. Results: We prospectively enrolled 7,569 patients with mean 68.4 +/−14.7 years and 52.4% female, of whom 107 (1.4%) had a subsequent stroke and 74 (1.0%) CEA ≤7 days (total outcomes = 181). We enrolled 81.2% of eligible patients; missed patients were similar to enrolled. The Canadian TIA Score stratified the stroke/CEA ≤7days risk as: Low (probability <0.2%, iLR 0.20 [95%CI 0.091-0.44]; Moderate (probability 1.3%, iLR 0.79 [0.68-0.92]; High (probability 2.6%, iLR 2.2 [1.9-2.6]. Sensitivity analysis for just stroke ≤7 days yielded similar results: Low iLR 0.17 [95%CI 0.056-0.52], Medium iLR 0.89 [0.75-1.1], High iLR 2.0 [1.6-2.4]. Conclusion: The Canadian TIA Score accurately identifies TIA patients risk for stroke/CEA ≤7 days. Patients classified as low risk can be safely discharged following a careful ED assessment with elective follow-up. Patients at moderate risk can undergo additional testing in the ED, have antithrombotic therapy optimized, and be offered early stroke specialist follow-up. Patients at high risk should in most cases be fully investigated and managed ideally in consultation with a stroke specialist during their index ED visit.

Background: Canadian Stroke Guidelines recommend that Transient Ischemic Attack (TIA) patients at highest risk of stroke recurrence should undergo immediate vascular imaging. Computed tomography angiography (CTA) of the head and neck is recommended over carotid doppler because it allows for enhanced visualization of the intracranial and posterior circulation vasculature. Imaging while patients are in the emergency department (ED) is optimal for high-risk patients because the risk of stroke recurrence is highest in the first 48 hours. Aim Statement: At our hospital, a designated stroke centre, less than 5% of TIA patients meet national recommendations by undergoing CTA in the ED. We sought to increase the rate of CTA in high risk ED TIA patients from less than 5% to at least 80% in 10 months. Measures & Design: We used a multi-faceted approach to improve our adherence to guidelines including: 1) education for staff ED physicians; 2) agreements between ED and radiology to facilitate rapid access to CTA; 3) agreements between ED and neurology for consultations regarding patients with abnormal CTA; and 4) the creation of an electronic decision support tool to guide ED physicians as to which patients require CTA. We measured the rate of CTA in high risk patients biweekly using retrospective chart review of patients referred to the TIA clinic from the ED on a biweekly basis. As a balancing measure, we also measured the rate of CTA in non-high risk patients. Evaluation/Results: Data collection is ongoing. An interim run chart at 19 weeks shows a complete shift above the median after implementation, with CTA rates between 70 and 100%. At the time of submission, we had no downward trends below 80%, showing sustained improvement. The CTA rate in non-high risk patients did also increase. Disucssion/Impact: After 19 weeks of our intervention, 112 (78.9%) of high risk TIA patients had a CTA, compared to 10 (9.8%) in the 19 weeks prior to our intervention. On average, 10-15% of high risk patients will have an identifiable lesion on CTA, leading to immediate change in management (at minimum, an inpatient consultation with neurology). Our multi-faceted approach could be replicated in any ED with the engagement and availability of the same multi-disciplinary team (ED, radiology, and neurology), access to CTA, and electronic orders.

Introduction: Our principal aim was to document the feasibility of the systematic measurement of the inter-arm blood pressure difference (IABPD) during an episode of transient ischemic attack (TIA) or mild stroke diagnosed in the Emergency Department (ED). As secondary goal was to compare the systolic blood pressure (BP) at triage with the systolic BPs measured during the IABPD. Methods: This is a single center pilot study. Patients presenting in the ED for a diagnosis of TIA were recruited. Once patient has been triaged and diagnosed of TIA, a research assistant made sure that the patient lay on a stretcher for at least 5 minutes. Two automated sphygmomanometers were applied, on each arm. No specific device or device calibration were required. Three consecutive simultaneous BP readings were performed, inverting cuffs arm to arm between each reading. Only the last two set of readings were used to calculate the mean IABPD. This method enables to minimize the error coming from the potential sphygmomanometers’ inaccuracies. Results: 32 patients were recruited from June to September 2017 and all had a successful IABPD measurement. Four patients had an IABPD >10 mmHg, varying from 1.5 to 13 mmHg when the left arm was higher and from 1 to 61 mmHg when the right arm was higher. Of the 22 patients where the triage BP arm side selection was recorded, only 11 were congruent with the arm presenting the highest BP during the IABPD measurement. Selecting of the arm with the highest BP value may better reflect cerebrovascular risk exposition. The mean systolic BP at triage was 159.3 mmHg (95%CI: 144.9-173.7) compared to144.8 mmHg (95%CI: 132.9-156.7) if the arm with the highest value during the IABPD measurement is selected and 142.4 mmHg (95%CI: 130.8-154.0) if the same arm as triage is selected. The p-value for these differences were 0.003 and 0.001 respectively. The patient which presented the IABPD of 61 mmHg, had a stroke 3 days after its ED visit which subsequently led to her death 10 days later. Conclusion: Our results show that the systematic IABPD measurement using a pragmatic approach in the ED is feasible and is ready to investigate its use in the context of a new TIA or mild stroke. This information may contribute to a better discrimination of the short-term risk of stroke and may help to diagnose acute aortic dissection, monitor more accurately BP during hyperacute stroke or estimate intracerebral hemorrhage risk if systemic thrombolysis is considered.

Introduction: Studies suggest that there is a significant discrepancy between emergency physicians diagnosis of TIA and confirmation by neurologists. The objectives of our study were to identify factors associated with neurologists confirmation of TIA in patients referred from the emergency department. Methods: Data were obtained from a prospective cohort study across more than 8 university-affiliated Canadian hospitals from 2006-2017 of adult patients diagnosed with a TIA or non-disabling stroke in the ED. Patients presenting after 1 week of symptom onset, receiving TPA as part of a stroke code, with a GCS<15 at baseline, and without a neurology assessment within 90 days were excluded. Univariate analyses were performed with t-tests or chi-square tests as indicated. Multivariate analysis with backward elimination was performed to identify unique predictors of TIA confirmation. Results: Of 8,669 patients diagnosed with TIA in the ED, 7,836 (90%) were assessed by neurology. The mean age of patients was 68.2 years and 71.1% presented with their first ever TIA. The rate of confirmation of TIA by neurology was 56%. The most common alternate diagnoses included migraines (26%), peripheral vertigo (10%), syncope (6%), and seizure (4%). The 3 strongest predictors of confirmation of TIA were infarct on imaging (OR 2.31, 2.03-2.63), history of weakness (OR 2.19, 1.95-2.48), and history of language disturbance (OR 2.05, 1.79-2.34). The 3 strongest predictors of an alternate diagnosis were syncope (OR 0.51, 0.39-0.67), history of bilateral weakness (or 0.51, 0.31-0.84), and confusion (OR 0.57, 0.48-0.67). Conclusion: The rate of TIA confirmation by neurology in our study was 56%. Emergency physicians should have a high index of suspicion of TIA in patients with history of weakness and language disturbance, and should resist referring to a stroke prevention clinic, patients with syncope, bilateral findings, or confusion.