Risk of Ischemic Stroke After Transient Ischemic Attack in Patients Receiving Comprehensive Versus Noncomprehensive Diagnostic Workup: A Systematic Review and Meta-Analysis

Abstract

Background: Although a timely comprehensive diagnostic workup is recommended for patients with transient ischemic attack (TIA), few studies have examined its impact on post-TIA ischemic stroke risk. In this study, we hypothesized that patients receiving more comprehensive diagnostic workup have better outcomes, regardless of their care setting.

Methods: Studies on the workup process of patients with TIA and the 90-day post-TIA ischemic stroke incidence were searched. Eligible studies were scored 1 to 4 based on the number of diagnostic workups (head computed tomography scan, brain magnetic resonance imaging, and cerebrovascular imaging) and the involvement of a neurology provider in the diagnosis process.

Results: Thirty-eight studies were included for meta-analysis. The overall 90-day post-TIA ischemic stroke risk was estimated to be 5% (95% CI, 4.9%-5.1%). Our meta-analysis showed that studies with higher scores-provided more comprehensive diagnostic workups by neurology providers-had a lower risk of 90-day post-TIA ischemic stroke (P<0.001). The post-TIA ischemic stroke risk was 8.4% (95% CI, 6.4%-10.8%) among studies with a score of "1, 5.3% (95% CI, 5.2%-5.5%) among studies with a score of 2, 2.9% (95% CI: 2.7%-3.2%) among studies with a score of 3, and 3.2% (95% CI, 2.5%-4%) among studies with a score of 4. The difference between studies with a score of 3 and "4 was not statistically significant (P=0.524). Moreover, studies with more comprehensive cardiac examinations had lower 90-day post-TIA ischemic stroke risk (P<0.001).

Conclusions: Our findings highlight that a more comprehensive diagnostic workup-neuroimaging, cerebrovascular studies, and cardiac examinations-of patients with TIA delivered by neurology providers might improve their outcomes by reducing the risk of 90-day post-TIA ischemic stroke, regardless of the care setting.

Keywords: care setting; diagnostic workup; risk of recurrent stroke; transient ischemic attack.