Is carotid imaging underused in patients with transient ischemic attack or ischemic stroke? A Swedish Stroke Register (Riksstroke) study

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Large‐vessel disease including carotid artery stenosis is a major pathophysiological mechanism of transient ischemic attack (TIA) and acute ischemic stroke (IS).1 Carotid surgery or stenting is used to reduce the risk of ipsilateral IS.2 Current guidelines for TIA and IS recommend the use of carotid imaging to identify potential candidates for carotid stenosis interventions.3 Standard modalities are carotid Doppler ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA). Varying proportions of carotid imaging have been reported in clinical practice. In studies performed at specialized single or multiple centers, proportions of any carotid imaging procedure could be as high as >95% in patients with TIA6 and IS.6 In population‐based studies, reported proportions of carotid imaging were lower; in a TIA study performed at all 13 public hospitals in Hong Kong, carotid Doppler ultrasound was done in 45% and MRA in 8%,9 and in an Israeli study based on a national registry, any vascular investigation was performed in 47% of patients with TIA and 48% of minor IS.10
Reported factors associated with lack of any carotid imaging in mixed TIA and IS cohorts were older age, female sex,11 and a higher Charlson score, which reflects comorbidity.11 In TIA, direct discharge from emergency department,13 and in IS, posterior circulation stroke, worse stroke severity,11 and no stroke unit care14 were associated with not being investigated for carotid disease.
There are only few studies assessing adherence to recommendation on carotid imaging and factors associated with not undergoing carotid imaging in a population‐based perspective.
We therefore aimed to assess the proportion of carotid imaging and determinants for its non‐use in patients with TIA and IS with respect to baseline demographics, risk factors, hospital characteristics, and geographical region, based on the Swedish Stroke Register for TIA (Riksstroke‐TIA, RS‐TIA) and stroke (Riksstroke, RS).

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