RESUMEN
OBJECTIVES: The aim of the study was to prospectively compare the prognostic value of ABCD score, urgent carotid ultrasound (CUS), and unenhanced head computed tomography (UHCT) in patients presenting to the emergency department with transient ischemic attack (TIA). PATIENTS AND METHODS: We carried out a prospective observational study including consecutive adult patients with TIA. Each patient underwent ABCD score assessment, urgent CUS, and UHCT within 24 h from presentation. The primary outcome was the occurrence of ischemic stroke within 30 days. RESULTS: We included 186 patients with a median age of 75 years and a prevalent male sex (57.5%). During follow-up, 12 ischemic strokes (6.5%) occurred, four (7.1%) in patients with ABCD score less than 4 and 8 (6.2%) in those with a score of at least 4. An internal carotid stenosis of at least 50% consistent with the neurological deficit was found in 15 patients (8.1%), and it was associated with a high risk for stroke (odds ratio 4.5, 95% confidence interval 1.1-18.8). An acute ischemic lesion consistent with the neurological deficit was revealed by UHCT in 15 patients (8.1%), and it was associated with a trend of increasing stroke risk (odds ratio 2.5, 95% confidence interval 0.5-12.5). Patients without, with at least one, or with both positive imaging tests showed incremental stroke risk at both 7 (2.5, 12.5, and 33%) and 30 days (5, 12.5, and 33%) (P<0.05 for both). CONCLUSION: Simple imaging tests showed added prognostic value to ABCD score in TIA patients. Urgent CUS together with UHCT should be performed in all TIA patients regardless of ABCD score.
Asunto(s)
Arterias Carótidas/diagnóstico por imagen , Servicio de Urgencia en Hospital , Neuroimagen Funcional/métodos , Ataque Isquémico Transitorio/diagnóstico por imagen , Índice de Severidad de la Enfermedad , Factores de Edad , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Intervalos de Confianza , Urgencias Médicas , Femenino , Humanos , Ataque Isquémico Transitorio/mortalidad , Masculino , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Factores Sexuales , Tasa de Supervivencia , Tomografía Computarizada por Rayos X/métodos , Ultrasonografía Doppler Dúplex/métodosRESUMEN
OBJECTIVES: The diagnostic performance of transthoracic focused cardiac ultrasound (FoCUS) performed by emergency physicians (EP) to estimate ascending aorta dimensions in the acute setting has not been prospectively studied. The diagnostic accuracy and the interobserver variability of EP-performed FoCUS were investigated to estimate thoracic aortic dilation and aneurysm compared with the results of computed tomography angiography (CTA). METHODS: This was a prospective single-center cohort study of a convenience sample of patients who underwent CTA in the emergency department for suspected aortic pathology. FoCUS was performed before CTA, and the maximum ascending aorta diameter evaluated in parasternal long-axis view. Aorta diameter < 40 mm by visual estimation or by diameter measurement was considered normal. Measurements were recorded in all patients with aorta diameter ≥ 40 mm. Diagnostic accuracy of FoCUS for detection of aortic dilation (diameter ≥ 40 mm) and aneurysm (diameter ≥ 45 mm) were calculated considering the CTA result as reference standard. In a subgroup of patients, a second EP-sonographer performed FoCUS to evaluate interobserver agreement for the diagnosis of ascending aorta dilation. RESULTS: A total of 140 patients were enrolled in the study. Ascending aorta dilation and aneurysm were detected with FoCUS in 50 (35.7%) and in 27 (17.8%) patients, respectively. Sensitivity and specificity of FoCUS were 78.6% (95% confidence interval [CI] = 65.6% to 88.4%) and 92.9% (95% CI = 85.1% to 97.3%), respectively, for ascending aorta dilation and 64.7% (95% CI = 46.5% to 80.2%) and 95.3% (95% CI = 89.3% to 98.4%), respectively, for ascending aorta aneurysm. Interobserver agreement of FoCUS was k = 0.82. CONCLUSIONS: FoCUS performed by EP is specific for ascending aorta dilation and aneurysm when compared to CTA and appears a reproducible technique.
Asunto(s)
Aorta/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Ecocardiografía Transesofágica/métodos , Servicios Médicos de Urgencia/métodos , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Dilatación Patológica/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVE: To validate a clinical diagnostic tool, used by emergency physicians (EPs), to diagnose the central cause of patients presenting with vertigo, and to determine interrater reliability of this tool. METHODS: A convenience sample of adult patients presenting to a single academic ED with isolated vertigo (i.e. vertigo without other neurological deficits) was prospectively evaluated with STANDING (SponTAneousNystagmus, Direction, head Impulse test, standiNG) by five trained EPs. The first step focused on the presence of spontaneous nystagmus, the second on the direction of nystagmus, the third on head impulse test and the fourth on gait. The local standard practice, senior audiologist evaluation corroborated by neuroimaging when deemed appropriate, was considered the reference standard. Sensitivity and specificity of STANDING were calculated. On the first 30 patients, inter-observer agreement among EPs was also assessed. RESULTS: Five EPs with limited experience in nystagmus assessment volunteered to participate in the present study enrolling 98 patients. Their average evaluation time was 9.9 ± 2.8 min (range 6-17). Central acute vertigo was suspected in 16 (16.3%) patients. There were 13 true positives, three false positives, 81 true negatives and one false negative, with a high sensitivity (92.9%, 95% CI 70-100%) and specificity (96.4%, 95% CI 93-38%) for central acute vertigo according to senior audiologist evaluation. The Cohen's kappas of the first, second, third and fourth steps of the STANDING were 0.86, 0.93, 0.73 and 0.78, respectively. The whole test showed a good inter-observer agreement (k = 0.76, 95% CI 0.45-1). CONCLUSIONS: In the hands of EPs, STANDING showed a good inter-observer agreement and accuracy validated against the local standard of care.