Retinal photos taken in the emergency department helped differentiate transient ischemic attack from stroke mimics in the FOTO-TIA study

You better hope your emergency room doctors are trained in this, especially for young adult strokes.  Or you will need to demand an eye scan in the ER. Hope you are coherent enough to know how to challenge ER doctors on their expertise. Personally I'd prefer these much faster and objective ways of stroke determination, but then I know nothing, I'm not medically trained.

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The latest here:  

Retinal photos taken in the emergency department helped differentiate transient ischemic attack from stroke mimics in the FOTO-TIA study

Laurel N. Vuong, MD, Praneetha Thulasi, MD, Valérie Biousse, MD, Philip Garza, BS, David W. Wright, MD, Nancy J. Newman, MD, and Beau B. Bruce, MD, PhD

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Abstract

Objectives:

We evaluated the frequency and predictive value of ocular fundus abnormalities among patients who presented to the emergency department (ED) with focal neurologic deficits to determine the utility of these findings in the evaluation of patients with suspected TIA and stroke.

Methods:

In this cross-sectional pilot study, ocular fundus photographs were obtained using a nonmydriatic fundus camera. Demographic, neuroimaging, and ABCD² score components were collected. Photographs were reviewed for retinal microvascular abnormalities. The results were analyzed using univariate statistics and logistic regression modeling.

Results:

Two hundred fifty-seven patients presented to the ED with focal neurologic deficits, of whom 81 patients (32%) had cerebrovascular disease (CVD) and 144 (56%; 95% confidence interval: 50%–62%) had retinal microvascular abnormalities. Focal and general arteriolar narrowing increased the odds of clinically diagnosed CVD by 5.5 and 2.6 times, respectively, after controlling for the ABCD² score and diffusion-weighted imaging. These fundus findings also significantly differentiated TIA from non-CVD, even after controlling for the ABCD² score.

Conclusions:

Focal and general arteriolar narrowing were independent predictors of CVD overall, and TIA alone, even after controlling for the ABCD² score and diffusion-weighted imaging lesions. The inclusion of nonmydriatic ocular fundus photographs in the evaluation of patients presenting to the ED with focal neurologic deficits may assist in the differentiation of stroke and TIA from other causes of focal neurologic deficits.

Annually in the United States, 200,000 to 500,000 patients experience TIA,¹ with 7% to 14% subsequently having a stroke within 90 days.² A number of scores, particularly the widely used ABCD² score, were developed to determine which patients with TIA have the highest risk of stroke.² However, these scores have serious limitations.^3,–7 Diffusion-weighted imaging (DWI) has revolutionized the differentiation of stroke from TIA.¹ However, a negative DWI does not assist with the difficult, and arguably more important, task of differentiating TIA from non–cerebrovascular diseases, and TIA diagnosis remains very challenging. About 30% to 50% of patients diagnosed with suspected TIA by non neurologists are ultimately determined not to have a TIA by a stroke neurologist.^8,9 Even among non stroke neurologists, agreement about TIA is only moderate to good.¹⁰

Epidemiologic investigations have shown an association between ocular fundus abnormalities and diabetes, cardiovascular disease, and stroke,^11,–17 suggesting that ocular funduscopic findings may be useful in the diagnosis of TIA and stroke in patients who present to the emergency department (ED) with focal neurologic deficits. Nonmydriatic fundus cameras can be used to assess for abnormalities of the ocular fundus, and the cameras are compact, easy to use, and do not require pupillary dilation, making them an ideal tool for non ophthalmologists. We undertook a pilot investigation to evaluate the role of ocular fundus abnormalities in TIA and stroke diagnosis using patients who presented to our ED with focal neurologic deficits during the Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) Study.