Stroke/Vascular pathologies and treatments

[Groy]

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I'm curious about the scope of practice and some of the procedures performed by vascular neurologists.

From what I understand, their role in stroke management is to consult on stroke cases, assess and examine acute stroke cases, read and interpret stroke imaging, initiate/guide the decision-making process (tPA, thrombectomy, etc.), and council on long-term stroke care.

Is this a good summary or are there things that I am missing here?

Additionally, a vascular fellowship allows you to specialize in other cerebrovascular diseases such as CADASIL, cavernous malformation, cerebral dissections, venous thrombosis, etc.

Since many of these pathologies (stroke included) can be treated by surgical procedures (neurosurg or interventional), what, besides diagnosis and medical management of these diseases falls within the scope of a Vascular/Stroke trained neurologist? Are there many procedures involved? Thanks!

 

[Thama]

The vast majority of strokes, both ischemic and hemorrhagic, are not treated surgically - I would estimate that I consulted a proceduralist for less than 1 in 20 stroke patients I cared for in residency. Exceptions include aneurysmal subarachnoid hemorrhage, vascular malformations amenable to clipping or coiling, and hemicraniectomy as an adjunctive measure for malignant edema in particularly large infarcts. A stroke neurologist is trained to manage the patient from the time they present (guiding administration of thrombolysis and thrombectomy when applicable), to evaluate etiologies and complications requiring inpatient management (e.g. intracardiac thrombus, malignant edema, etc), prepare patients for rehabilitation, and then follow up for secondary prevention. Interventional neuroradiologists and vascular neurosurgeons are occasionally consulted but rarely take the lead in these patients except for in cases of hemorrhage due to particular vascular malformations.

 

[Groy]

The vast majority of strokes, both ischemic and hemorrhagic, are not treated surgically - I would estimate that I consulted a proceduralist for less than 1 in 20 stroke patients I cared for in residency. Exceptions include aneurysmal subarachnoid hemorrhage, vascular malformations amenable to clipping or coiling, and hemicraniectomy as an adjunctive measure for malignant edema in particularly large infarcts. A stroke neurologist is trained to manage the patient from the time they present (guiding administration of thrombolysis and thrombectomy when applicable), to evaluate etiologies and complications requiring inpatient management (e.g. intracardiac thrombus, malignant edema, etc), prepare patients for rehabilitation, and then follow up for secondary prevention. Interventional neuroradiologists and vascular neurosurgeons are occasionally consulted but rarely take the lead in these patients except for in cases of hemorrhage due to particular vascular malformations.

I see, that's surprising, I thought the ratio for interventions would be much bigger!

As a follow-up, what are some specific sorts of cases or complications that vascular neurology specifically would be called in on? In other words, what are the situations in which it is more advantageous to call in a vascular/stroke neurologist vs. a general neurologist who works stroke? Is it just dependent upon whether the facility employs a vascular/stroke physician, or are there cases in which general neurologists doing stroke work will consult vascular neurologists or transfer their patients to other facilities to see a vascular neurologist?

 

[Thama]

Whether a vascular or general neurologist or even a general internist admits a stroke depends largely on the institution. At small hospitals without neurologists on staff, generalists will occasionally admit strokes but usually will punt to somewhere with a neurologist. At mid-sized hospitals with a couple of neurologists on staff, a general neurologist with or without vascular training will admit routine strokes, though cases likely to require thrombectomy, hemicraniectomy or osmotic therapy are often referred to a tertiary center. At academic and other tertiary centers, typically all strokes will be admitted under a vascular neurologist. At my med school the ratio of stroke admissions to other stuff was so high that only vascular neurologists attend on the inpatient service. At my residency program there are separate stroke and general services and stroke is always attended by a vascular neurologist.