# National survey of clinical practices and perspectives in the management of ischaemic stroke patients with minor neurological deficits

## TL;DR

This study surveyed Dutch neurologists about admitting ischaemic stroke patients with minor symptoms, finding varied practices and willingness to discharge some patients from the emergency department.

## Contribution

The study reveals significant variation in clinical practices and risk thresholds for discharging ischaemic stroke patients with minor deficits.

## Key findings

- Admission rates for ischaemic stroke patients with minor deficits varied from 21% to 89% across clinical scenarios.
- 89% of respondents accepted a risk threshold of up to 5% for secondary deterioration to justify direct ED discharge.
- Most respondents (90%) were open to randomizing patients into trials comparing admission versus ED discharge.

## Abstract

Patients with ischaemic stroke are increasingly encountered in neurological practice. Current guidelines recommend hospital admission for monitoring and coordination of appropriate aftercare, regardless of stroke severity. However, the clinical necessity of admitting all such patients remains uncertain. Some neurologists argue that selected low-risk patients can be discharged directly from the emergency department (ED). Given the ongoing debate and lack of high-quality evidence, we aimed to explore current practices and attitudes toward the management of patients with ischaemic stroke with minor neurological deficits in the Netherlands.

A national online survey was conducted to explore current variations in clinical practice regarding admission strategies for patients with ischaemic stroke. The survey included five clinical cases and was distributed to neurologists and neurology trainees. We assessed which patient and stroke characteristics influenced the decision to admit a patient.

A total of 107 respondents completed the survey, comprising 72 neurologists (67%) and 36 neurology trainees (33%). Admission rates for ischaemic stroke with minor neurological deficits varied considerably across the five clinical vignettes, ranging from 21% to 89%. Willingness to randomise patients into a trial evaluating admission versus ED discharge was high, with rates between 77% and 94% across cases. The majority of respondents (89%) considered a risk threshold of up to 5% for secondary deterioration acceptable to justify direct discharge from the ED. Of these, 44% would accept a risk of 1–2%, while 45% would accept a risk of 3–5%. Only 10% indicated that all ischaemic stroke patients should be admitted regardless of risk.

Current guideline-driven practice in the Netherlands leads to hospital admission for nearly all patients with ischaemic stroke. However, our survey reveals substantial heterogeneity among neurologists and trainees regarding the willingness to consider direct ED discharge under specific conditions. If certain criteria are met, a majority would opt for ED discharge, with 89% accepting a risk of up to 5% for early neurological deterioration. These findings underscore the need for evidence-based admission strategies, potentially enabling safe ED discharge for selected patients and more efficient use of hospital resources.