How Twin Cities neurologists treat ischemic stroke. Policies and trends
D. C. Anderson
Department of Neurology, Hennepin County Medical Center, Minneapolis 55415.
OBJECTIVE--To examine community practices. DESIGN--Physician practice
policies were surveyed using case vignettes in which evaluation for carotid
endarterectomy or use of anticoagulation therapy was at issue. Virtually
the same group was surveyed in 1988 and again in 1991, after publication of
carotid endarterectomy trials in symptomatic patients. SETTING--Greater
Metropolitan Minneapolis-St. Paul, Minnesota. PARTICIPANTS--Community and
academic neurologists in practice of general adult neurology.
MEASUREMENT--Percentage of respondents who would recommend the management
option in question for each vignette. RESULTS--Ninety-eight percent favored
evaluation for carotid endarterectomy in appropriately symptomatic "good
risk" patients in 1988 before proof of efficacy became available. Proof
increased the percentage (from 67% to 92%) favoring evaluation in older,
sicker, symptomatic patients but not the percentage of those favoring
evaluation of bruit patients (1988: 33%; 1991: 24%). In 1991, a lower
percentage recommended warfarin therapy after noncardioembolic transient
ischemic attack; this was especially apparent in the vertebrobasilar case
(1988: 59%; 1991: 37%). Both years, nine of 10 neurologists recommended
heparin therapy for progressing stroke, while half to three-fourths used it
after partial stroke or transient ischemic attack. Almost all would use
anticoagulants for secondary prophylaxis after suspected cardioembolic
stroke. CONCLUSION--The results reflect a treatment-oriented empirical
approach in this community and document quick clinical application of
scientific evidence when it became available.
