Stroke Is Best Managed by Neurologists
Stroke care is now managed in and out of dedicated stroke units. All agree that stroke units are worthwhile. But who should run them and who participate? Choice of physician personnel should depend on the type of unit, what participants need to know and to do, and who is available.
The most advanced stroke units provide cutting edge care from arrival in the emergency room until rehabilitation. They have ready access to advanced diagnostic and therapeutic technologies and treatments and have physician coverage 24 hour a day, 7 days a week. These units require the following:
(A) One or more physicians with intimate knowledge of brain anatomy, function, and cervicocranial blood supply. These physicians know the symptoms and signs found in stroke patients and the detailed differential diagnosis of stroke subtypes. They are very familiar with the symptoms, signs, and diagnosis of other neurological disorders. They are knowledgeable about stroke recovery and rehabilitation.
(B) One or more physicians who are competent and experienced in monitoring and treating acute and chronic cardiovascular and cardiopulmonary abnormalities and are familiar with the medical complications found in stroke patients and how to prevent and manage them if they occur.
The great majority of A-type physicians are neurologists, but some internists are interested and some are potentially educable. With training and experience they could fulfill the A-type job description. Similarly, neurologists, especially those with intensive care unit training, can become competent as B-type physicians, and many now are. Most guidelines emphasize that physician eligibility to perform given tasks depends on training, experience, and competence and not the union card that a physician carries (that is his or her original residency department). These stroke units also need nurses with experience in caring for stroke patients. Psychosocial and economic guidance personnel are also useful. Physical therapists are available early in the course of stroke. Clearly these units should also have readily available access to neurosurgery, vascular surgery, endovascular, cardiology, hematology, and pulmonary specialists.
Less-advanced units take excellent medical care of patients and have CT scan availability and experienced nurses and therapists but do not have advanced diagnostic and therapeutic capabilities always available during the acute period. B-type physicians (usually internists) are quite capable of managing these units. Some stroke units are mostly geared to rehabilitation and can be manned by any physician trained and experienced in facilitating stroke recovery. Some rehabilitation units are managed by geriatricians, internists, and physical medicine specialists as well as by neurologists. Physical therapists are essential. Physicians manning these units should be very familiar with the causes, treatments, and time courses of recovery of the various stroke subtypes. All too often the stroke patients in these units are assumed to be stable and all energy is focused on facilitating recovery. They are considered to have “graduated” from acuteness. The medical details of the acute stroke are all too often out of sight and out of mind.
Unfortunately, stroke care is often divided among 3 different locales and physicians: (1) the generalist who has treated the patient in the community and who, it is hoped, applies preventive measures before and after the stroke, (2) the physician who cares for the patient while hospitalized for the acute stroke, optimally in a dedicated stroke unit, and (3) rehabilitation specialists who care for the patient during recovery, often at a rehabilitation facility separate from the acute hospital. After rehabilitation the baton is then passed back to the general physician, who all too often has not been brought up-to-date on the details of the patient’s diagnosis and treatment. It would be wonderful if these 3 sites were well integrated, with all physicians and personnel working closely together.
Of course, most strokes are not now managed in dedicated stroke units. Physicians caring for these patients in the hospital or in the community should possess as many as possible of the capabilities enumerated in the A type and B type job descriptions. Among all potential specialists, neurologists with interest, training, and experience caring for stroke patients are most likely to possess all of these attributes. The brain is complex and is the major domain of the neurologist. The brain is the Rolls Royce of the human body. Would you want your Rolls Royce to be serviced by any ordinary mechanic, who takes care of all kinds of automobiles?
Section Editors: Geoffrey A. Donnan, MD, FRACP and Stephen M. Davis, MD, FRACP
The opinions expressed in this editorial are not necessarily those of the editors or of the American Stroke Association.