The Neurosurgeon as a Stroke Specialist

Abstract

Stroke is one of the leading causes of adult long-term disability affecting a total of 795 000 people annually in the US. Stroke is also responsible for the death of 140 000 Americans each year. Its annual cost in health care expenditures and missed days of work is estimated at $34 billion.1 Therefore, successful stroke management has tremendous public health implications. The main goal of ischemic stroke management is rapid reperfusion because it has the highest chance of neurologic recovery. For a long time, administration of intravenous tissue plasminogen activator (IV-tPA) was the mainstay of re-establishing blood flow.2 However, advancements in endovascular devices have paved the way for mechanical thrombectomy and effectively revolutionized the management of ischemic stroke - making it a surgical disease (Figure 1). The efficacy of mechanical thrombectomy is irrefutable, with a number needed to treat of 3 for improved functional outcomes as shown in the nine landmark randomized controlled trials comparing endovascular therapy to standard medical care alone.3FIGURE 1.: A , Antero-posterior (AP) and B , lateral views of a left internal carotid angiogram in an acute ischemic stroke patient with an acute occlusion of the left middle cerebral artery (MCA) proximal to its bifurcation. Reperfusion was achieved using mechanical thrombectomy as demonstrated in the C , AP and D , lateral views of the left internal carotid angiogram with opacification of the MCA candelabra.Given the burden that stroke has on society and its economy, it is the vascular neurosurgeons' social responsibility to take the lead in stroke care and not limit themselves to the procedural skills they provide. Although stroke has shifted to become a surgical disease, neurosurgeons are unfortunately nowhere identified as ‘stroke specialists' in the vernacular of the current time. Because of their expertise and advanced training, there is a need for vascular neurosurgeons to take leadership in the management of acute ischemic stroke. Due to the high acuity nature of neurosurgical diseases and the risk of permanent neurologic deficits in case of delays, neurosurgeons are naturally trained to care for time-sensitive diseases and stand as experts in treating complex aspects of ischemic and hemorrhagic diseases of the central nervous system (bypass surgery, decompressive craniectomy, carotid endarterectomy, and so forth). Therefore, it is of utmost importance that neurosurgeons take on the role of ‘stroke specialists' with detailed and current knowledge of the disease, its management, complications, and follow-up. This requires the evolution of the cerebrovascular surgeon to a “neurovascular specialist” both in reality and perception. In addition to mastering mechanical revascularization, vascular neurosurgeons have to take stroke call and should be experts in the medical management of acute ischemic stroke to determine the eligibility for IV-tPA administration, the initiation of anti-platelet therapy, antihypertensives, and other pharmacotherapy. This holistic approach to stroke care that we have undertaken at Jefferson Hospital for Neurosciences is central to stroke patient ownership and will allow neurosurgeons to maintain and grow patient control. In addition, it helps us as vascular neurosurgeons to position ourselves more prominently in the treatment of extracranial carotid disease with endarterectomy and carotid stenting. The Jefferson Neuroscience Network includes 37 hospitals and 5 comprehensive stroke centers with telemedicine consultations that are delivered to community hospitals through robotic technology at the remote sites. The Neurosurgery Department was instrumental in the development of this telestroke network and remains the driver of the program. It allows vascular neurosurgeons along with stroke neurologists to act as “first responders” in the management of ischemic stroke by determining eligibility for IV-tPA and triage of these patients. Throu