Attitudes of Canadian and U.S. neurologists regarding carotid endarterectomy for asymptomatic stenosis.

BACKGROUND: The American Heart Association carotid endarterectomy (CE) guidelines endorse CE for asymptomatic carotid stenosis if the procedure can be performed with low morbidity. However, the Canadian Stroke Consortium has published a consensus against CE for asymptomatic stenosis. The views of practicing neurologists in the two countries on this subject are unclear. METHODS: A survey was undertaken of 270 neurologists from either Florida or Indiana and 180 neurologists from either Ontario or Quebec. RESULTS: The survey was returned by 36% of neurologists. Both Florida (65%) and Indiana neurologists (35%) were significantly more likely than Canadian neurologists (11%) to sometimes/often refer patients for surgery(p<0.001). Neurologists from Florida relied more on noninvasive methods of carotid stenosis assessment (36%) than Canadian neurologists (12%, p=0.003), who preferred angiography. Neurologists from Florida more often cited medicolegal concerns as a reason for referring patients for surgery (27%), compared to Canadian neurologists (3%, p=0.0001). CONCLUSIONS: Practices pertaining to carotid stenosis evaluation and management differ both regionally and by country. Canadian neurologists refer fewer asymptomatic patients for CE and rely more on angiography as a preoperative diagnostic tool. The potential of medicolegal liability is a greater force in clinical decision-making for certain U.S. neurologists, compared to their Canadian counterparts. These differences may partly explain the variations in CE utilization in the two countries.

Cerebral angioplasty practice at major medical centers in the United States.

Concern has been expressed recently regarding the proliferation of angioplasty and/or stenting of cerebral vessels. However, little is known about the volume of angioplasties being performed or the number of experienced interventionalists. A questionnaire was mailed to directors of accredited radiology residency programs in the United States, to define the level of expertise available at teaching hospitals in terms of angioplasty and/or stenting. Of 200 programs surveyed, 111 responded (56 %). Of 111 program directors 47 (42%) indicated that cerebral angioplasty was being performed at their center. The greatest experience is currently for angioplasty of post-subarachnoid hemorrhage vasospasm (mean 16 procedures performed) and the least experience for dilation of basilar artery atherosclerosis (mean five procedures performed). The reported stroke and/or death rate in centers performing angioplasty of the extracranial carotid system is 1.5 %. Comparisons with other medical specialties (e.g., cardiologists, neurologists, neurosurgeons) are necessary to determine the full scope of extracranial neurovascular procedures being performed and the corresponding complication rates.

Emergency physician attitudes toward thrombolytic therapy in acute stroke.

BACKGROUND: Intravenous use of tissue plasminogen activator (TPA) is the only currently approved treatment for acute ischemic stroke. METHODS: To determine emergency physician attitudes and practices with regard to thrombolysis for ischemic stroke, a questionnaire was sent to program directors of accredited emergency medicine residencies in the United States. RESULTS: There were 73 program directors who responded to the survey; 71% of medical centers have used TPA for treatment of stroke. The reported major complication rate for cerebral hemorrhage and death averaged 7%. For nontreating centers, two major factors cited were lack of appropriate patients and concerns regarding the safety of TPA; 48% of the facilities do not have an acute stroke team. Delayed patient arrival and the perceived narrow risk/benefit ratio of TPA were identified as the two greatest obstacles to more widespread use of TPA. CONCLUSION: Although the majority of medical centers that responded in this study have some experience with thrombolytic therapy for acute ischemic stroke, almost one half do not have an acute stroke team and considerable uncertainty exists regarding the safety of intravenous TPA. More uniform national treatment of acute stroke will require greater consensus among emergency physicians and further analysis of the risk/benefit ratio of thrombolytic treatment.