Duplication of Neurovascular Imaging in Stroke Work Up Protocol at an Academic Teaching Hospital

Purpose: Multiple imaging guidelines for acute ischemic stroke and transient ischemic attack (TIA) have been published to direct clinicians towards effective imaging modalities and concurrently decrease potential overutilization of ineffective imaging studies. Though compliance of these guidelines has increased in recent years, a substantial rise in image utilization still remains widespread within the past decade. Our study seeks to assess the prevalence of redundant imaging during emergency department work-up of patients presenting with stroke-like and/or TIA symptoms.

Methods/Materials: A retrospective review of all patients presenting to the ED with stroke-like and/or TIA symptoms was collected from January 2020 to December 2022. Redundant imaging was defined as any duplicate cross-sectional brain, brain-vascular, or neck-vascular imaging in an ED encounter. Patient demographics, as well as admission and hospital features, were recorded and analyzed.

Results: Of the 24 patients presenting with stroke-like and/or TIA symptoms in the ED recorded, 70.8% were female, and 29.2% were male. All patients recorded redundant imaging with CTA-MRI as the central combination followed by CTA-CT head/neck w/ and w/o contrast. Time-lapse between the redundant images was recorded, with 54.2% being within 0-6 hrs, 4.5% within 7-12 hrs, 16.7% within 13-24hrs, and 20.8% being >24hrs. Importantly, indications for post-admission secondary scans were mainly due to the uncertainty of the initial findings, with few due to technical artifacts and follow-up studies.

Conclusions: Through analysis of our study, we found that increased imagining utilization for patients with TIA and/or stroke-like symptoms is associated with redundant imaging. Such redundancy should be discouraged in the future. Duplicative neurological studies on the same patients occur frequently, often show similar results, and are an additional cost source. Identifying recommendations for initial ER stroke evaluation and management is pertinent to attenuate excess hospital expenditure.