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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.

Background and Purpose: Research suggests that women and men may present with different transient ischemic attack (TIA) and stroke symptoms. We aimed to explore symptoms and features associated with a definite TIA/stroke diagnosis and whether those associations differed by sex. Methods: We completed a retrospective cohort study of patients referred to The Ottawa Hospital Stroke Prevention Clinic in 2015. Exploratory multinomial logistic regression was used to evaluate candidate variables associated with diagnosis and patient sex. Backwards elimination of the interaction terms with a significance level for staying in the model of 0.25 was used to arrive at a more parsimonious model. Results: Based on 1770 complete patient records, sex-specific differences were noted in TIA/stroke diagnosis based on features such as duration of event, suddenness of symptom onset, unilateral sensory loss, and pain. Conclusions: This preliminary work identified sex-specific differences in the final diagnosis of TIA/stroke based on common presenting symptoms/features. More research is needed to understand if there are biases or sex-based differences in TIA/stroke manifestations and diagnosis.

International guidelines recommend carotid revascularization within 14 days for patients with a symptomatic transient ischemic attack (TIA) or stroke event. However, significant delays in care persist, with only 9% of outpatients and 36% of inpatients in Ontario meeting this target. The study objective was to explore the influence of health system factors on carotid revascularization timelines.We conducted a retrospective chart review of all symptomatic TIA/stroke patients undergoing carotid endarterectomy or stenting at The Ottawa Hospital (2015-2016). The primary outcome was time from TIA/stroke to carotid revascularization. Health system variables of interest included location and timing of patient presentation, timelines to vascular imaging, and same-day collaboration between key services such as emergency, neurology, and surgery. Descriptive statistics and univariate analysis were used to determine statistically significant differences between groups.A total of 228 records met the inclusion criteria. The median time from TIA/stroke to carotid revascularization was 10 days, with 58% of patients meeting the 14-day guideline. Prompt patient presentation to emergency demonstrated significantly shorter timelines to surgery (7 days; P .001). Early vascular imaging was strongly correlated with early revascularization (4-5 days; P .001). In addition, collaboration from two or more care services enhanced timelines to surgery ranging from 2.0 to 6.5 days (P .001-.008).Early/emergency response to stroke symptoms was pivotal in achieving best practice recommendations for rapid carotid revascularization, emphasizing the need for ongoing public awareness. Emergency and ambulatory strategies to facilitate urgent vascular imaging, as well as mechanisms for same-day communication between teams require optimization to promote early revascularization.

We reviewed stroke care delivery during the COVID-19 pandemic at our stroke center and provincial telestroke system. We counted referrals to our prevention clinic, code strokes, thrombolysis, endovascular thrombectomies, and activations of a provincial telestroke system from February to April of 2017–2020. In April 2020, there was 28% reduction in prevention clinic referrals, 32% reduction in code strokes, and 26% reduction in telestroke activations compared to prior years. Thrombolysis and endovascular thrombectomy rates remained constant. Fewer patients received stroke services across the spectrum from prevention, acute care to telestroke care in Ontario, Canada, during the COVID-19 pandemic.

Background and Purpose: The diagnosis of transient ischemic attack (TIA) is largely dependent on a process of clinical decision-making that remains poorly characterized in the absence of a validated and accessible biomarker or imaging test. We performed a retrospective chart review to identify variables associated with a final neurologist diagnosis of TIA/stroke. Methods: Records for all patients seen in The Ottawa Hospital’s Stroke Prevention Clinic in 2015 were analyzed for patient and referral characteristics, features of the presenting neurological event, and final diagnosis by a stroke neurologist (classified as definite, possible, or definite not TIA/stroke). Multinomial logistic regression analysis with backward elimination was used to identify variables associated with the final diagnosis. Results: Our inclusion criteria were met by 1894 patients. After backward elimination, 23 potentially important variables were identified, including monocular vision loss (odds ratio [OR]: 30.4, 95% confidence interval [CI]: 14.6-63.3), symptoms of sudden onset (OR: 28.3, 95% CI: 14.2-56.2), unilateral weakness affecting 2 or 3 of face, arm, or leg (OR: 17.7, 95% CI: 9.8-31.7), and homonymous hemianopia (OR: 16.6, 95% CI: 8.1-34.0). Conclusions: Accurate diagnosis of TIA is essential to initiating appropriate secondary stroke prevention therapies. A focus on elements of the patient history most commonly associated with a final diagnosis of TIA/stroke may help to identify patients in greatest need of urgent SPC assessment and allow for the provision of effective and efficient stroke prevention services.

Background Identifying and treating patients with transient ischemic attack is an effective means of preventing stroke. However, making this diagnosis can be challenging, and over a third of patients referred to stroke prevention clinic are ultimately found to have alternate diagnoses. Aims We performed a systematic review to determine how neurologists diagnose transient ischemic attack. Summary of review A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using MEDLINE, Embase, and the Cochrane Library databases. Publications eligible for inclusion were those that included information on the demographic or clinical features neurologists use to diagnose transient ischemic attacks or transient ischemic attack–mimics. Of 1666 citations, 210 abstracts were selected for full-text screening and 80 publications were ultimately deemed eligible for inclusion. Neurologists were more likely to diagnose transient ischemic attack based on clinical features including negative symptoms or speech deficits. Patients with positive symptoms, altered level of consciousness, or the presence of nonfocal symptoms such as confusion or amnesia were more likely to be diagnosed with transient ischemic attack–mimic. Neurologists commonly include mode of onset (i.e. sudden versus gradual), recurrence of attacks, and localizability of symptoms to a distinct vascular territory in the diagnostic decision-making process. Transient ischemic attack diagnosis was more commonly associated with advanced age, preexisting hypertension, atrial fibrillation, and other vascular risk factors. Conclusions Neurologists rely on certain clinical and demographic features to distinguish transient ischemic attacks from mimics, which are not currently reflected in widely used risk scores. Clarifying how neurologists diagnose transient ischemic attack may help frontline clinicians to better select patients for referral to stroke prevention clinics.

Background Transient ischemic attack (TIA) is a strong predictor of subsequent stroke. Measures to decrease stroke incidence following TIA include medical management, risk factor optimization, and lifestyle modification. Best practice recommendations for stroke care promote individualized education on self-management across transitions from hospital to community settings. In the study region, patients with TIA are referred to the stroke prevention clinic where they receive rapid stroke assessment, risk factor management, education, and referral to risk reduction programs. Long-term management is typically the responsibility of primary care providers who may have limited resources for self-management support. Promotion of existing chronic disease self-management (CDSM) programs can complement this support. Objective The objective of our project was to examine the feasibility and acceptability of an electronic referral system to an existing CDSM program to facilitate self-management support for persons with TIA. Methods We performed a descriptive evaluation of a quality improvement project that involved development and implementation of a new electronic referral (eReferral) process. A partnership between the stroke prevention clinic and the regional Living Healthy CDSM program was developed alongside a clinical information system redesign implementing an eReferral system. Results Referral to the Living Healthy CDSM program was offered to each patient at the stroke prevention clinic. Of 912 patients seen over a 6-month period, 62 (7%) agreed to be referred. Of these, 23 (37%) were registered or waitlisted. Conclusion Formation of a partnership and implementation of the eReferral system facilitated referral to the Living Healthy CDSM program. Despite low referral and enrollment rates, the eReferral system provides one option to enhance self-management support for persons with TIA.

Background: For optimal stroke prevention, best practices guidelines recommend carotid endarterectomy (CEA) for symptomatic patients within two weeks; however, 2013 Ontario data indicated that only 9% of eligible patients from outpatient Stroke Prevention Clinics (SPCs) achieved this target. The goal of our study was to identify modifiable system factors that could enhance the quality and timeliness of care among patients needing urgent CEA. Methods: We conducted a retrospective chart review of transient ischemic attack/stroke patients assessed in Champlain Local Health Integrated Network SPCs between 2011 and 2014 who subsequently underwent CEA. Descriptive statistics were used to define patient characteristics, timelines from symptom onset to CEA, and system factors that contributed to delays or improvements in care. Multivariate analysis was used to determine statistically significant variations between groups. Results: Seventy-five records were eligible for study inclusion. Median time from initial symptoms to CEA was 31 days, with 21.3% of patients undergoing surgery within 2 weeks. Significant delays were common in patient presentation and assessment following symptom onset, wait times for vascular imaging and neurological assessment, and time from surgical assessment to CEA completion. Rapid testing and triage, coupled with collaborative initiatives among SPC, surgical, and radiology teams were associated with significantly improved timelines. Conclusions: Success factors for rapid CEA are multifaceted, including system changes that address public awareness of stroke and 911 response, improvements in vascular imaging access, and redesign of clinical services to promote collaboration and fast-tracking of care. Implementation of performance measures to monitor and guide clinical innovations is recommended.

Effective management of Transient Ischemic Attack (TIA) and stroke hinges on accurate diagnosis. Research suggests that women and men present with different TIA/stroke symptoms, and those more commonly reported by women are often considered atypical, or benign. For this reason, TIA or stroke in women may be underdiagnosed and undertreated. Growing evidence that women are disproportionately affected by stroke underpins this study focused on neurologist diagnosis of stroke/TIA in association with presenting symptoms. A retrospective chart review was performed using data from the charts of all patients referred to The Ottawa Hospital Stroke Prevention Clinic in 2015 with a provisional diagnosis of TIA/stroke. Demographics, event characteristics, and final diagnosis were extracted from each chart. Multinomial logistic regression analysis with backwards elimination and a significance level staying in the model of α=0.15 was used to identify variables associated with a final diagnosis of definite TIA/stroke. A sub-analysis was completed for the final model by sex. Of the 1864 included patients, 932 (50%) were women. There were no significant differences in age or final diagnosis of definite TIA/stroke based on sex. Among patients reporting classic stroke symptoms such as unilateral weakness, aphasia, and amaurosis fugax both sexes demonstrated significantly higher odds of a final diagnosis of TIA/stroke; however the odds were higher for men than women. For example, men with unilateral weakness, aphasia or amaurosis fugax had an odds ratio (OR) of 32.7, 7.7, and 27.8 respectively of having a final diagnosis of TIA/stroke, whereas the OR for women was 10.9, 5.4, and 22.2 respectively, although the 95% confidence intervals overlapped. In contrast, women reporting homonymous hemianopsia or any combination of ataxia, diplopia, or vertigo had a higher odds than men of being diagnosed with TIA/stroke (OR 21 and 8.5 respectively for women and OR 11.4 and 5.1 respectively for men). The trend in differences noted for the odds of definite TIA/stroke diagnosis among men and women may imply that women are less likely to be diagnosed with TIA even when reporting classical symptoms. More research is needed to understand sex-based differences in the diagnosis of TIA/stroke.

The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.

For optimal stroke prevention following transient ischemic attack or minor stroke, international best practice guidelines recommend carotid endarterectomy for appropriate candidates as soon possible, with a target of less than two weeks. Research has demonstrated however, that delays to surgery occur frequently, in part due to complex clinical care processes. The goal of our study was to identify modifiable factors which could improve timely access to urgent carotid endarterectomy. A retrospective chart review was competed, examining transient ischemic attack /stroke patients assessed in four regional Stroke Prevention Clinics between 2011 and 2014, who subsequently underwent carotid endarterectomy. Descriptive statistics were used to examine patient characteristics and time points to carotid surgery. A thematic analysis was performed to identify key factors which enhanced or delayed timelines to carotid endarterectomy. These themes were further analyzed to determine avoidable delays and key success factors. Seventy-five records were eligible for study inclusion. Completion of carotid endarterectomy within two weeks was achieved for 21% of patients. Six key themes were identified including patient response to stroke, first health care contact, surgical fitness, resource capacity and physician availability (neurology or surgery). Forty four percent of patients did not present to medical attention the day of symptom onset contributing substantially to avoidable delays in care. Furthermore, 79% of patients experienced delays in access to vascular imaging, neurologist assessment and surgical bookings. Success was influenced by distinct triage, rapid diagnostic testing, and physician accessibility strategies. This often required divergence from standard clinical practices and interdepartmental collaboration. Delayed patient presentation was the most common reason for delayed carotid endarterectomy which highlights the importance of ongoing public awareness strategies. Significant clinical delays were also noted at each step where patients required imaging or consultation. In order to reach carotid endarterectomy benchmarks, quality enhancement approaches will require coordinated, multifaceted care innovations.

Stroke prevention clinics were established in Ontario to provide comprehensive, equitable, evidence-based care for patients at high risk of stroke. However, depending on where patients present with their stroke symptoms there are differences in access to diagnostic services. Patients presenting to a primary care office or small hospital, have limited or no access to diagnostic services compared to those presenting to large academic hospitals. To overcome this inequitable access to stroke expertise and diagnostics, we developed a standard referral protocol, a centralized approach to triage and dedicated diagnostic imaging services in regional stroke prevention clinics. The objective of our research was to evaluate the degree to which these system supports have resulted in comprehensive stroke prevention best practice care. Retrospective data analysis was completed using the FY 2011/12 Ontario Stroke Audit of Secondary Stroke Prevention Clinics database. We examined differences in secondary stroke prevention best practices across the five stroke prevention clinics and if there were differences in practice by referral source (Emergency vs. Primary Care). A total of 1853 patients were seen at the five Champlain stroke prevention clinics in 2011/12. The majority of referrals were initiated from Emergency Departments 58.7%, followed by primary care 29.2%, specialists 9.2% and inpatient units 2.8%. Overall, high rates of neuroimaging (97.6%), and vascular imaging (97.6 %) were achieved with little variation across stroke prevention clinics. There was no variation in imaging rates by referral source. The stroke prevention clinics facilitated neuroimaging and vascular imaging for almost 30% of patients, as they did not have these tests completed at the site of initial presentation. Implementing a centralized stroke prevention clinic referral and triage system has enabled equitable access to essential diagnostic testing in the Champlain region. Rapid diagnostic imaging plays a vital role of in identifying stroke etiology, and influences patient prioritization, treatments and management in the stroke prevention clinic setting. Future research should include evaluation of patient outcomes relative to the timing of diagnostic testing.

Background: Prompt assessment in a stroke prevention clinic (SPC) reduces the risk of recurrent stroke after transient ischemic attack (TIA) or minor stroke. However, not all patients are seen rapidly, even in high-risk TIAs with speech deficits or unilateral weakness. The effects of delays on patient outcomes are not clear. We examined the records of patients referred after TIA/minor stroke to determine frequency, degree and reasons for delays in evaluation and carotid revascularization, as well as the effect of delays on patient outcomes. Methods: Records were obtained for all referrals to a regional SPC over 3 years. Target times were based upon triage symptoms, with highest-risk patients (unilateral weakness/speech deficits) being seen 2 days from receipt of referral, moderate-to-high risk within 7 days, and others within 30 days. Data regarding presentation, triage/referral, appointment, investigations and carotid revascularization were obtained. Delays between time points were calculated, and delay reasons were adjudicated. 90-day outcomes including death, recurrent stroke/TIA, and hospital readmission were determined, and comparisons made between patients with and without assessment delays. Results: Between 2009-11, 3492 patients were referred. 1420 (35.8%) were seen beyond suggested dates; the most common reason was scheduling issues (74.2%) followed by patient cancellation (7.9%) and hospitalization (6.0%). The average delay was 2.63 days (SD 7.48), increasing to 3.75 days (SD 5.35) in highest-risk patients. 79 (2.26%) patients had carotid revascularization; of these, 71 (90%) had surgery more than two weeks after onset. Delays were most often due to logistical issues (42.3%). Overall, assessment delays were associated with an absolute increase of 3.7% in 90-day hospitalization (p=0.001), 2.0% in recurrent stroke/TIA (p=0.013) and 0.8% in mortality (p=0.013). Conclusions: Delays in assessment after TIA/minor stroke are common and often due to potentially preventable system factors. These delays are associated with an increased absolute risk of recurrent stroke/TIA, hospitalization, and death. Avoiding delays between referral and assessment may provide opportunities to reduce adverse outcomes in this population.