internists and stroke

[IMGforNeuro]

I wanted to ask all guys in internal med about the extent to which they deal with acute stroke?
Do you refer to the neurologist/stroke team immediately or manage it on your own.
Secondly, do you also follow up or manage chronic strokes or refer them to neurologists?

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[Kalel]

Acute CVA's should be sent to the ER for w/u and possible intervention. In the ER, you neuro guys are called, and I've found that at my school, after someone with a CVA is d/ced, they are typically instructed to f/u with the neuro stroke clinic. I worked in the neuro stroke clinic for a short while, and it seems to me that all they do there is order MRI's, carotid dopplers, get PT and OT consults, and keep patients on ASA. So in an outpatient setting, if a patient was already "plugged" into the system, and had an old CVA with no new neuro findings, I think that most IM docs would be comfortable keeping them on ASA and following them as needed for their CVA. I haven't had too much experience seeing CVA patients in IM private practices though, so I don't know how the community docs are handling it.

 

[RuralMedicine]

Neurology does not have ICU privileges for any of the ICUs in our system. Therefore acute stroke pts that are hemodynamically unstable, requiring airway control, or requiring antihypertensive drips are admitted to a medicine team (in our hospitals with open ICUs) or to the ICU team (in our hospitals with closed ICUs). Neurology then follows as consultants (and may subsequently take the patient on their service when they transfer out of the ICU).

 

[sanfilippo]

Rural is dead on here. Having just finished an MICU elective at a community hospital, I had my fair share of exposure to IC bleeds and ischemic strokes. MICU attending and residents are the primary, but neuro w/ or w/o neurosurgery is always placed on consult. neuro pretty much dictates care. there is quite much variability among the neuro folks regarding BP control in these patients but 160/100 is a good goal as lowering the bp to "normal" may just augment infarction. steroid use in this setting is very controversial and there is not much evidence in treating cerebral edema in hemorrhagic or ischemic contexts (malignancy is another context altogether) but some attendings will order it. Serial CT/MRI exams and neuro checks seem to be the general theme in all cases as well as PT/OT and speech/swallow evals. Rehab and ASA tx when stable remain hallmarks of chronic mgt. Kalel touched on work-up of thrombotic vs. embolic etiology (carotid a. disease, a fib, vasculitis/CVDs, endocarditis, hypercoaguable state, etc.)

Bottom line: neuro will handle acute strokes. Thrombolytics are generally given in the ER after the NIH criteria are applied. We had 2 candidates, one successful, the other developed a basal ganglial bleed.

however, among neuro topics, IMHO, stroke is the most high-yield for students/residents in general medicine.

-s.

 

[IMGforNeuro]

I also forgot to ask . Were those neurologists fellowships traines in stroke or were they general neurologists?
The reason i am asking is that vascular neuro is a subspeciality now and has some other aspects which these people learn during fellowships, like carotid and trans cranial doppler for example.

 

[Kalel]

Originally posted by IMGforNeuro
I also forgot to ask . Were those neurologists fellowships traines in stroke or were they general neurologists?
The reason i am asking is that vascular neuro is a subspeciality now and has some other aspects which these people learn during fellowships, like carotid and trans cranial doppler for example.

CVA's are bread and butter of neuro, so at my school, it was always general neuro residents and attendings who handled them. The doppler thing is probably institution dependent, most places probably still have vascular surgery do those tests which makes sense to me, since they are the ones who will have to decide when to do the surgery.

At my main university, we have a neuro intensive care unit where the neurologists and neurosurgeons attend on those critical stroke patients. I have heard many neuro residents say that many of these patients would be better suited for the micu under the care of internists though, particularly for BP management issues. At some of our affiliated hospitals, neuro doesn't have enough patients to have their own service, so medicine admits and neuro just consults. The neuro residents like it this way, although both sides have been known to complain about each other (med: neuro telling us what to do; neuro: med not doing what we ask).