Neurology/brief research report
Covert Brain Infarction in Emergency Department Patients: Prevalence, Clinical Correlates, and Treatment Opportunities

https://doi.org/10.1016/j.annemergmed.2021.10.011Get rights and content

Study objective

Covert brain infarctions are focal lesions detected on brain imaging consistent with ischemia in the absence of a history of overt stroke or neurologic dysfunction. Covert brain infarctions are associated with an increased risk of future stroke. We evaluated the prevalence of covert brain infarctions in patients undergoing computed tomography (CT) in the emergency department (ED), as well as clinician response to the findings.

Methods

Patients aged more than 50 years who underwent CT of the head and were seen and discharged from our ED from January to September 2018 were identified. Patients with a history of stroke, or prior brain imaging with ischemia, were excluded. Patient data and clinician response (patient notification, neurology referral, and risk factor modification) were collected.

Results

We included 832 patients, with an average age of 62 years, and 50% of the patients were women. Covert brain infarctions were present in 11% of patients (n=95). Only 9% of patients with covert brain infarctions were clearly made aware of the finding. Of the patients with covert brain infarctions, 27% were already on aspirin and 28% on a statin. Aspirin was added for 2 patients, and statin medication was not started on any patient. The blood pressure medication was added or adjusted for 2 patients with covert brain infarctions. The neurology department was consulted for 9% of the patients with covert brain infarctions.

Conclusion

The prevalence of covert brain infarctions in patients older than 50 years presenting to the ED who underwent CT of the head and were subsequently discharged from the ED was 11%. Only 9% of these patients were made aware of the finding, with minimal intervention for stroke prevention at the time of their visit. Interventions targeting this population should be considered.

Introduction

Covert brain infarctions are focal lesions detected on brain imaging consistent with ischemia in the absence of a history of overt stroke or neurologic dysfunction. They are the most common incidental finding on brain imaging, with a prevalence of 10% to 30% in elderly populations.1 Covert brain infarctions are associated with an increased risk of future stroke.1,2 Stroke prevention interventions such as further diagnostic testing and risk factor modification are indicated in these patients according to the current guidelines.2 Evidence regarding covert brain infarction in emergency department (ED) patients is limited. The goal of this study was to determine the prevalence of covert brain infarction in patients undergoing computed tomography (CT) in the ED who were subsequently discharged and to determine how often clinicians act on these findings or make patients aware of them.

Section snippets

Study Design and Setting

We conducted a retrospective chart review of patients presenting to the ED of an urban academic medical center. The study was approved by the institutional review board of Virginia Commonwealth University.

Selection of Participants

The TriNetX database (TriNetX) was used to query patients presenting from January 1 to September 30, 2018, who were aged more than 50 years and underwent a non–contrast-enhanced CT of the head in the ED and were subsequently discharged without inpatient or observation admission. Patients with

Characteristics of Study Subjects

A total of 1,144 patients were identified in our initial data query. We excluded 166 patients with previous brain imaging with ischemia, 98 patients with a known history of stroke, and 48 patients with both a known history of stroke and previous imaging with ischemia. Thus, a total of 832 patients remained and were included in our analysis. Patient characteristics are shown in the Table. The average age was 62 years, and 50% of the patients were women. When interrater reliability was calculated

Limitations

The primary limitation of our study is its retrospective single-center design. Findings in other populations and practice settings may be different. As with any retrospective study, there is potential confounding due to errors in documentation or coding. It is possible that patients were made aware of the covert brain infarctions (or counseled regarding the risk factors we evaluated) but that this was not documented in their clinical notes or discharge instructions. As all data were collected

Discussion

The goal of this study was to determine how often the covert brain infarctions are diagnosed in patients aged more than 50 years undergoing CT of the head in the ED who were subsequently discharged, as well as the clinical response to the findings. In prior studies, the prevalence of covert brain infarctions has been 10% to 30% in older populations and 30% to 50% in populations with elevated cardiovascular risk.1 The prevalence in our population was on the lower end of this range at 11%. Given

References (5)

  • T.R. Meinel et al.

    Covert brain infarction: towards precision medicine in research, diagnosis, and therapy for a silent pandemic

    Stroke

    (2020)
  • E.E. Smith et al.

    Prevention of stroke in patients with silent cerebrovascular disease: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association

    Stroke

    (2017)
There are more references available in the full text version of this article.

Cited by (1)

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Please see page 266 for the Editor’s Capsule Summary of this article.

Supervising editor: Clifton Callaway, MD, PhD. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

Author contributions: JRB, VRF, and ZMG conceived and designed the study, and JRB obtained the institutional review board approval. JRB and CKB undertook screening for patients and collected data. JRB and ZMG performed the statistical analysis. JRB, ZMG, and VRF drafted the manuscript, and all authors contributed to its revision. JRB had full access to all of the data in this study and takes responsibility for the integrity of the data and the accuracy of the data analysis. JRB takes responsibility for the paper as a whole.

Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The authors report that this article did not receive any outside funding or support.

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