Neurology/brief research reportCovert Brain Infarction in Emergency Department Patients: Prevalence, Clinical Correlates, and Treatment Opportunities
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.
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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)
- et al.
Covert brain infarction: towards precision medicine in research, diagnosis, and therapy for a silent pandemic
Stroke
(2020) - 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)
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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.
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