Should patients with stroke see a neurologist?

Stroke program for India

India is silently witnessing a stroke epidemic. There is an urgent need to develop a national program towards "Fighting Stroke". This program should be specific to our national needs. In order to recommend on who should lead an Indian fight-stroke program, we examined the published opinions of stroke clinicians and the official documents on stroke care training abroad. We identified the resources that already exist in India and can be utilized to develop a national fight-stroke program. Through a review of published literature, we noted different opinions that exist on who would best manage stroke. We found that because stroke is a cardiovascular disorder of the central nervous system, its management requires a multi-disciplinary approach involving clinicians with background not limited to neurology. India has very few neurologists trained in stroke medicine and they cannot care for all stroke patients of the country. We propose a mechanism that would quickly put in place a stroke care model relevant in Indian context. We recommend for tapping the clinical expertise available from existing pool of non-neurologist physicians who can be trained and certified in stroke medicine (Strokology). We have discussed an approach towards developing a national network for training and research in Strokology hoping that our recommendations would initiate discussion amongst stroke academicians and motivate the national policy makers to quickly develop an "Indian Fight Stroke Program."

Early management and outcome of acute stroke in Auckland

BACKGROUND

Studies of acute stroke management in stroke units and tertiary referral hospitals may not accurately reflect practice within the population. Reliable information on the management of stroke within a population is sparse.

AIMS

To compare clinical practice in acute stroke management in Auckland with guidelines for the management and treatment of stroke in other countries; to provide a baseline measure against which future changes in management can be evaluated.

METHODS

All new stroke events in Auckland residents in 12 months were traced through multiple case finding sources. For each patient, a record of investigations and treatment during the first week of hospital admission was kept.

RESULTS

One thousand eight hundred and three stroke events (including subarachnoid haemorrhages) occurred in 1761 patients in one year. Twenty-seven per cent of all events were managed outside hospital and 73% of the stroke events were treated in an acute hospital. Of the 1242 stroke events admitted to an acute hospital in the first week, only 6% were managed on the neurology and neurosurgery ward, 83% were managed by a general physician or geriatrician and 42% had computed tomography (CT). Of 376 validated ischaemic strokes, 44% were treated with aspirin and 12% with intravenous heparin. Of the 690 unspecified strokes (no CT or autopsy), 38% received aspirin and 0.5% heparin. The 28 day in-hospital case fatality for all stroke events admitted to an acute hospital during the first week was 25%.

CONCLUSIONS

In Auckland, management of acute stroke differed from clinical guidelines in the high proportion of patients managed in the community, the low rate of neurological consultation, and the low frequency of CT scanning. Despite these deficiencies in management, the 28 day hospital case fatality in Auckland was similar to other comparable studies which had a high proportion of cases evaluated by a neurologist and CT.

Physician attitudes toward treatment options for cerebrovascular disease

One-hundred physicians older than 50 and 100 physicians younger than 50 were surveyed concerning treatment preferences for patients with transient ischemic attacks (TIAs) or completed stroke. These attitudes were compared to cardiovascular disease prevention strategies for patients with angina pectoris and myocardial infarction. Physicians younger than 50 were therapeutically aggressive for cerebrovascular and cardiovascular disease; physicians older than 50 were aggressive for cardiovascular disease but therapeutically nihilistic for cerebrovascular disease. Physicians younger than 50 were more likely to be aggressive for TIA than for completed stroke patients, and these physicians were more likely to utilize ticlopidine and oral anticoagulants for both TIA and completed stroke patients.

Transient ischemic attack and minor ischemic stroke: an algorithm for evaluation and treatment. Mayo Clinic Division of Cerebrovascular Diseases

OBJECTIVE

To report a cost-effective and scientifically based algorithm for the clinical assessment and treatment of patients with transient ischemic attack (TIA) or minor ischemic stroke.

DESIGN

We comprehensively reviewed the literature on the epidemiologic features, assessment approaches, and treatment recommendations for ischemic cerebrovascular disease and developed an algorithm by using the available clinical and research data to support all decision-making steps.

MATERIAL AND METHODS

For patients with TIA or minor ischemic stroke, the appropriate setting for investigation (inpatient or outpatient), suggested diagnostic tests, use of anticoagulants and antiplatelet agents, and indications for surgical treatment are reviewed.

RESULTS

Although stroke is a common cause of death and lost productivity in the United States, the clinical assessment of patients with TIA or minor ischemic stroke has lacked consistency. The simplified algorithm clarifies patients who may be candidates for hospitalization and possible anticoagulation therapy. Initial diagnostic studies should include computed tomography of the head without use of a contrast agent, which quickly distinguishes nonhemorrhagic from hemorrhagic cerebrovascular disease. Evolving noninvasive studies of the cerebral vasculature are providing increasingly sensitive means of detecting stenoses, yet cerebral angiography remains the "gold standard." Treatment options depend on the pathophysiologic findings on diagnostic evaluation.

CONCLUSION

The assessment of patients with ischemic cerebrovascular disease is complex. The simplified algorithmic approach reported herein necessitates entry of appropriate patients into the algorithm. Because of clinical heterogeneity, an algorithm may apply to a wide spectrum of patients but will not cover every situation; hence, evaluation must be guided by a patient's unique history and findings on examination and by the physician's clinical experience.