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How Twin Cities Neurologists Treat Ischemic Stroke: Policies and Trends

How Twin Cities Neurologists Treat Ischemic Stroke: Policies and Trends Abstract • 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. References 1. Hedenius P. The use of heparin in internal diseases . Acta Med Scand . 1941;107:170-177.Crossref 2. Wright IS, McDevitt E. Cerebral vascular diseases: their significance, diagnosis and present treatment, including the selective use of anticoagulant substances . Ann Intern Med . 1954;41:682-698.Crossref 3. Millikan CH, Siekert RG, Shick RM. Studies in cerebrovascular disease, III: the use of anticoagulant drugs in the treatment of insufficiency or thrombosis within the basilar arterial system . Proc Staff Meet Mayo Clin . 1955;30: 116-126. 4. Millikan CH, Siekert RG, Shick RM. Studies in cerebrovascular disease, V: the use of anticoagulant drugs in the treatment of intermittent insufficiency of the internal carotid arterial system . Proc Staff Meet Mayo Clin . 1955;30: 578-586. 5. Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia . Lancet . 1954;2:994-996.Crossref 6. Sage JI. Stroke: the use and overuse of heparin in therapeutic trials . Arch Neurol . 1985;42:315-317.Crossref 7. Phillips SJ. An alternative view of heparin anticoagulation in acute focal brain ischemia . Stroke . 1989;20:295-298.Crossref 8. Scheinberg P. Heparin anticoagulation . Stroke . 1989;20:173-174.Crossref 9. Warlow C. Carotid endarterectomy: does it work? Stroke . 1984;15: 1068-1076.Crossref 10. Jonas S. Can carotid endarterectomy be justified? No. Arch Neurol . 1987;44:652-654.Crossref 11. Jonas S. Anticoagulant therapy in cerebrovascular disease: review and meta-analysis . Stroke . 1988;19:1043-1048.Crossref 12. Putnam SF, Adams HP Jr. Usefulness of heparin in initial management of patients with recent transient ischemic attacks . Arch Neurol . 1985;42: 960-962.Crossref 13. Duke RJ, Bloch RF, Turpie AGG, Trebilcock R, Bayer N. Intravenous heparin for the prevention of stroke progression in acute partial stable stroke: a randomized controlled trial . Ann Intern Med . 1986;105:825-828.Crossref 14. Keith DS, Phillips SJ, Whisnant JP, Nishimaru K, O'Fallon WM. Heparin therapy for recent transient focal cerebral ischemia . Mayo Clin Proc . 1987;62:1101-1106.Crossref 15. Haley EC, Kassell NF, Torner JC. Failure of heparin to prevent progression in progressing ischemic infarction . Stroke . 1988;19:10-14.Crossref 16. Ramirez-Lassepas M, Quinones MR. Heparin therapy for stroke: hemorrhagic complications and risk factors for intracerebral hemorrhage . Neurology . 1984;34:114-117.Crossref 17. Ramirez-Lassepas M, Cipolle RJ, Rodvold KA, et al. Heparin-induced thrombocytopenia in patients with cerebrovascular disease . Neurology . 1984;34:736-740.Crossref 18. Marsh EE III, Adams HP Jr, Biller J, et al. Use of antithrombotic drugs in the treatment of acute ischemic stroke: a survey of neurologists in practice in the United States . Neurology . 1989;39:1631-1634.Crossref 19. Halperin JL, Hart RG. Atrial fibrillation and stroke: new ideas, persisting dilemmas . Stroke . 1988;19:937-941.Crossref 20. Pierce JMS, Gubay SS, Walton JN Long term anticoagulant therapy in transient cerebral ischemic attacks . Lancet . 1965;1:6-9.Crossref 21. Baker RN, Schwartz WS, Rose AS. Transient ischemic attacks: a report of a study (cooperative) of anticoagulant therapy . Neurology . 1966;16:841-847.Crossref 22. Bradshaw P, Brennan S. Trial of long-term anticoagulant therapy in the treatment of small stroke associated with normal cerebral arteriogram . J Neurol Neurosurg Psychiatry . 1975;38:642-647.Crossref 23. Brust JCM. Transient ischemic attacks: natural history and anticoagulation . Neurology . 1977;27:701-707.Crossref 24. Kuller LH. The transient ischemic attack: a critical review of anticoagulant and surgical therapy . Stroke . 1974;9:23-26. 25. Cervantes FD, Schneiderman LJ. Anticoagulants in cerebrovascular disease: a critical review of studies . Arch Intern Med . 1975;135:875-877.Crossref 26. Ramirez-Lassepas M, Cipolle RJ. Medical treatment of transient ischemic attacks: does it influence mortality? Stroke . 1988;19:397-400.Crossref 27. Fields WS, Lemak NA, Frankowski RF, Hardy RJ. Controlled trial of aspirin in cerebral ischemia . Stroke . 1977;8:301-314.Crossref 28. Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke . N Engl J Med . 1978;299:53-59.Crossref 29. Bousser MG, Eschwege E, Haguenau M, et al. 'AICLA' controlled trial of aspirin and dipyridimole in the secondary prevention of athero-thrombotic cerebral ischemia . Stroke . 1983;14:5-14.Crossref 30. UK-TIA Study Group. United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: interim results . BMJ . 1988;296:316-320.Crossref 31. Antiplatelet-Trialists' Collaboration. Secondary prevention of vascular disease by prolonged antiplatelet treatment . BMJ . 1988;296:320-331.Crossref 32. The EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke: results of an international randomized trial . N Engl J Med . 1985;313:1191-1200.Crossref 33. Dyken ML. Carotid endarterectomy studies: a glimmering of science . Stroke . 1986;17:355-357.Crossref 34. European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis . Lancet . 1991;337: 1235-1243.Crossref 35. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis . N Engl J Med . 1991;325:445-453.Crossref 36. Veterans Administration Cooperative Study. Role of carotid endarterectomy in asymptomatic carotid stenosis . Stroke . 1986;17:534-539.Crossref 37. The Asymptomatic Carotid Atherosclerosis Study Group. Study design for randomized prospective trial of carotid endarterectomy for asymptomatic atherosclerosis . Stroke . 1989;20:844-849.Crossref 38. Wiebers DO. Effectiveness of carotid endarterectomy for asymptomatic carotid stenosis: design of a clinical trial . Mayo Clin Proc . 1989;64:897-904. 39. The CASANOVA Study Group. Carotid surgery versus medical therapy in asymptomatic carotid stenosis . Stroke . 1991;22:1229-1235.Crossref 40. Whisnant JP, Cartlidge NEF, Elveback LR. Carotid and vertebral-basilar transient ischemic attacks: effect of anticoagulants, hypertension, and cardiac disorders on survival and stroke occurrence—a population study . Ann Neurol . 1978;3:107-115.Crossref 41. Estol CJ, Pessin MS. Anticoagulation: is there still a role in atherosclerotic stroke? Stroke . 1990;21:820-824.Crossref 42. Caplan LR. Diagnosis and treatment of ischemic stroke . JAMA . 1991; 266:2413-2418.Crossref 43. Jones HR Jr, Millikan CH, Sandok BA. Temporal profile (clinical course) of acute vertebrobasilar system cerebral infarction . Stroke . 1980;11: 173-177.Crossref 44. Jones HR Jr, Millikan CH. Temporal profile (clinical course) of acute carotid system cerebral ischemia . Stroke . 1976;7:64-71.Crossref 45. Patrick BK, Ramirez-Lassepas M, Snyder BD. Temporal profile of vertebrobasilar territory infarction: prognostic implications . Stroke . 1980;11: 643-648.Crossref 46. Petersen P, Godtfredsen J. Embolic complications in paroxysmal atrial fibrillation . Stroke . 1986;17:622-626.Crossref 47. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation . N Engl J Med . 1990;323:1505-1511.Crossref 48. Stroke Prevention in Atrial Fibrillation Investigators. Stroke prevention in atrial fibrillation study: final results . Circulation . 1991;84:527-539.Crossref 49. Cerebral Embolism Task Force. Cardiogenic brain embolism: the second report of the cerebral embolism task force . Arch Neurol . 1989;46:727-743.Crossref 50. UK-TIA Study Group. Variation in the use of angiography and carotid endarterectomy by neurologists in the UK-TIA aspirin trial . BMJ . 1983;286: 514-517.Crossref 51. Swanson PD, Calanchini PR, Dyken ML, et al. A cooperative study of hospital frequency and character of transient ischemic attacks, II: performance of angiography among six centers . JAMA . 1977;237:2202-2206.Crossref 52. Chassin MR, Brook RH, Park RE, et al. Variations in the use of medical and surgical services by the Medicare population . N Engl J Med . 1986; 314:285-290.Crossref 53. Haerer AF, Gotshall RA, Conneally PM, et al. Cooperative study of hospital frequency and character of transient ischemic attacks, III: variations in treatment . JAMA . 1977;238:142-146.Crossref 54. Till JS, Toole JF, Howard VJ. Physicians' attitudes: management of carotid artery plaques, murmurs, and transient ischemic attacks . Arch Neurol . 1985;42:1198-1201.Crossref 55. Pokras R, Dyken ML. Dramatic changes in the performance of endarterectomy for diseases of the extracranial arteries of the head . Stroke . 1988; 19:1289-1290.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Neurology American Medical Association

How Twin Cities Neurologists Treat Ischemic Stroke: Policies and Trends

Archives of Neurology , Volume 50 (10) – Oct 1, 1993

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References (64)

Publisher
American Medical Association
Copyright
Copyright © 1993 American Medical Association. All Rights Reserved.
ISSN
0003-9942
eISSN
1538-3687
DOI
10.1001/archneur.1993.00540100083023
Publisher site
See Article on Publisher Site

Abstract

Abstract • 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. References 1. Hedenius P. The use of heparin in internal diseases . Acta Med Scand . 1941;107:170-177.Crossref 2. Wright IS, McDevitt E. Cerebral vascular diseases: their significance, diagnosis and present treatment, including the selective use of anticoagulant substances . Ann Intern Med . 1954;41:682-698.Crossref 3. Millikan CH, Siekert RG, Shick RM. Studies in cerebrovascular disease, III: the use of anticoagulant drugs in the treatment of insufficiency or thrombosis within the basilar arterial system . Proc Staff Meet Mayo Clin . 1955;30: 116-126. 4. Millikan CH, Siekert RG, Shick RM. Studies in cerebrovascular disease, V: the use of anticoagulant drugs in the treatment of intermittent insufficiency of the internal carotid arterial system . Proc Staff Meet Mayo Clin . 1955;30: 578-586. 5. Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia . Lancet . 1954;2:994-996.Crossref 6. Sage JI. Stroke: the use and overuse of heparin in therapeutic trials . Arch Neurol . 1985;42:315-317.Crossref 7. Phillips SJ. An alternative view of heparin anticoagulation in acute focal brain ischemia . Stroke . 1989;20:295-298.Crossref 8. Scheinberg P. Heparin anticoagulation . Stroke . 1989;20:173-174.Crossref 9. Warlow C. Carotid endarterectomy: does it work? Stroke . 1984;15: 1068-1076.Crossref 10. Jonas S. Can carotid endarterectomy be justified? No. Arch Neurol . 1987;44:652-654.Crossref 11. Jonas S. Anticoagulant therapy in cerebrovascular disease: review and meta-analysis . Stroke . 1988;19:1043-1048.Crossref 12. Putnam SF, Adams HP Jr. Usefulness of heparin in initial management of patients with recent transient ischemic attacks . Arch Neurol . 1985;42: 960-962.Crossref 13. Duke RJ, Bloch RF, Turpie AGG, Trebilcock R, Bayer N. Intravenous heparin for the prevention of stroke progression in acute partial stable stroke: a randomized controlled trial . Ann Intern Med . 1986;105:825-828.Crossref 14. Keith DS, Phillips SJ, Whisnant JP, Nishimaru K, O'Fallon WM. Heparin therapy for recent transient focal cerebral ischemia . Mayo Clin Proc . 1987;62:1101-1106.Crossref 15. Haley EC, Kassell NF, Torner JC. Failure of heparin to prevent progression in progressing ischemic infarction . Stroke . 1988;19:10-14.Crossref 16. Ramirez-Lassepas M, Quinones MR. Heparin therapy for stroke: hemorrhagic complications and risk factors for intracerebral hemorrhage . Neurology . 1984;34:114-117.Crossref 17. Ramirez-Lassepas M, Cipolle RJ, Rodvold KA, et al. Heparin-induced thrombocytopenia in patients with cerebrovascular disease . Neurology . 1984;34:736-740.Crossref 18. Marsh EE III, Adams HP Jr, Biller J, et al. Use of antithrombotic drugs in the treatment of acute ischemic stroke: a survey of neurologists in practice in the United States . Neurology . 1989;39:1631-1634.Crossref 19. Halperin JL, Hart RG. Atrial fibrillation and stroke: new ideas, persisting dilemmas . Stroke . 1988;19:937-941.Crossref 20. Pierce JMS, Gubay SS, Walton JN Long term anticoagulant therapy in transient cerebral ischemic attacks . Lancet . 1965;1:6-9.Crossref 21. Baker RN, Schwartz WS, Rose AS. Transient ischemic attacks: a report of a study (cooperative) of anticoagulant therapy . Neurology . 1966;16:841-847.Crossref 22. Bradshaw P, Brennan S. Trial of long-term anticoagulant therapy in the treatment of small stroke associated with normal cerebral arteriogram . J Neurol Neurosurg Psychiatry . 1975;38:642-647.Crossref 23. Brust JCM. Transient ischemic attacks: natural history and anticoagulation . Neurology . 1977;27:701-707.Crossref 24. Kuller LH. The transient ischemic attack: a critical review of anticoagulant and surgical therapy . Stroke . 1974;9:23-26. 25. Cervantes FD, Schneiderman LJ. Anticoagulants in cerebrovascular disease: a critical review of studies . Arch Intern Med . 1975;135:875-877.Crossref 26. Ramirez-Lassepas M, Cipolle RJ. Medical treatment of transient ischemic attacks: does it influence mortality? Stroke . 1988;19:397-400.Crossref 27. Fields WS, Lemak NA, Frankowski RF, Hardy RJ. Controlled trial of aspirin in cerebral ischemia . Stroke . 1977;8:301-314.Crossref 28. Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke . N Engl J Med . 1978;299:53-59.Crossref 29. Bousser MG, Eschwege E, Haguenau M, et al. 'AICLA' controlled trial of aspirin and dipyridimole in the secondary prevention of athero-thrombotic cerebral ischemia . Stroke . 1983;14:5-14.Crossref 30. UK-TIA Study Group. United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: interim results . BMJ . 1988;296:316-320.Crossref 31. Antiplatelet-Trialists' Collaboration. Secondary prevention of vascular disease by prolonged antiplatelet treatment . BMJ . 1988;296:320-331.Crossref 32. The EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke: results of an international randomized trial . N Engl J Med . 1985;313:1191-1200.Crossref 33. Dyken ML. Carotid endarterectomy studies: a glimmering of science . Stroke . 1986;17:355-357.Crossref 34. European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis . Lancet . 1991;337: 1235-1243.Crossref 35. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis . N Engl J Med . 1991;325:445-453.Crossref 36. Veterans Administration Cooperative Study. Role of carotid endarterectomy in asymptomatic carotid stenosis . Stroke . 1986;17:534-539.Crossref 37. The Asymptomatic Carotid Atherosclerosis Study Group. Study design for randomized prospective trial of carotid endarterectomy for asymptomatic atherosclerosis . Stroke . 1989;20:844-849.Crossref 38. Wiebers DO. Effectiveness of carotid endarterectomy for asymptomatic carotid stenosis: design of a clinical trial . Mayo Clin Proc . 1989;64:897-904. 39. The CASANOVA Study Group. Carotid surgery versus medical therapy in asymptomatic carotid stenosis . Stroke . 1991;22:1229-1235.Crossref 40. Whisnant JP, Cartlidge NEF, Elveback LR. Carotid and vertebral-basilar transient ischemic attacks: effect of anticoagulants, hypertension, and cardiac disorders on survival and stroke occurrence—a population study . Ann Neurol . 1978;3:107-115.Crossref 41. Estol CJ, Pessin MS. Anticoagulation: is there still a role in atherosclerotic stroke? Stroke . 1990;21:820-824.Crossref 42. Caplan LR. Diagnosis and treatment of ischemic stroke . JAMA . 1991; 266:2413-2418.Crossref 43. Jones HR Jr, Millikan CH, Sandok BA. Temporal profile (clinical course) of acute vertebrobasilar system cerebral infarction . Stroke . 1980;11: 173-177.Crossref 44. Jones HR Jr, Millikan CH. Temporal profile (clinical course) of acute carotid system cerebral ischemia . Stroke . 1976;7:64-71.Crossref 45. Patrick BK, Ramirez-Lassepas M, Snyder BD. Temporal profile of vertebrobasilar territory infarction: prognostic implications . Stroke . 1980;11: 643-648.Crossref 46. Petersen P, Godtfredsen J. Embolic complications in paroxysmal atrial fibrillation . Stroke . 1986;17:622-626.Crossref 47. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation . N Engl J Med . 1990;323:1505-1511.Crossref 48. Stroke Prevention in Atrial Fibrillation Investigators. Stroke prevention in atrial fibrillation study: final results . Circulation . 1991;84:527-539.Crossref 49. Cerebral Embolism Task Force. Cardiogenic brain embolism: the second report of the cerebral embolism task force . Arch Neurol . 1989;46:727-743.Crossref 50. UK-TIA Study Group. Variation in the use of angiography and carotid endarterectomy by neurologists in the UK-TIA aspirin trial . BMJ . 1983;286: 514-517.Crossref 51. Swanson PD, Calanchini PR, Dyken ML, et al. A cooperative study of hospital frequency and character of transient ischemic attacks, II: performance of angiography among six centers . JAMA . 1977;237:2202-2206.Crossref 52. Chassin MR, Brook RH, Park RE, et al. Variations in the use of medical and surgical services by the Medicare population . N Engl J Med . 1986; 314:285-290.Crossref 53. Haerer AF, Gotshall RA, Conneally PM, et al. Cooperative study of hospital frequency and character of transient ischemic attacks, III: variations in treatment . JAMA . 1977;238:142-146.Crossref 54. Till JS, Toole JF, Howard VJ. Physicians' attitudes: management of carotid artery plaques, murmurs, and transient ischemic attacks . Arch Neurol . 1985;42:1198-1201.Crossref 55. Pokras R, Dyken ML. Dramatic changes in the performance of endarterectomy for diseases of the extracranial arteries of the head . Stroke . 1988; 19:1289-1290.Crossref

Journal

Archives of NeurologyAmerican Medical Association

Published: Oct 1, 1993

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