As the global burden of cerebrovascular disease reaches near-epidemic levels, according to a recent World Health Organization report, management of patients at risk for stroke or with a history of stroke is an ever more pressing concern among vascular neurologists and primary care physicians alike. This is why the AAN Stroke and Vascular Neurology Section, at approximately 1,300 members, is one of the Academy's largest sections.
Section chair Antonio Culebras, MD, FAAN, FAHA, a professor of neurology at SUNY Upstate Medical University in Syracuse, NY, and vice chair Seemant Chaturvedi, MD, FAAN, FAHA, a professor of clinical neurology and vice chair for veterans affairs programs at the University of Miami Miller School of Medicine, spoke to Neurology Today recently about the challenges and controversies facing the field, and what to expect from the section in the coming months.
One of the primary challenges in vascular neurology, they said, is a shortage of trained and certified specialists. This problem is hardly unique to stroke specialists — indeed, many neurologic subspecialties, as well as a number of other medical specialties, are seeing dwin-dling numbers of new practitioners — but it appears to be especially critical in vascular neurology, where, as Harold P. Adams Jr., MD, and José Biller, MD, noted in a December 2014 editorial in the journal Stroke, “delays [in treatment] are inherently life-threatening.”
“There are only 1,100 certified vascular neurologists in the nation right now,” Dr. Culebras told Neurology Today. “Many of them are over the age of 50. There are 1,000 primary care stroke centers and 60 comprehensive centers in the nation, and that's definitely insufficient. On the other side of the coin, 30 percent of stroke fellowships go unfilled. People are not rushing to become vascular neurologists.”
Conversely, “a lot of older neurologists are no longer interested in taking call and covering the emergency room, and some of them are retiring. This is putting strain on the systems of care,” Dr. Chaturvedi said.
The shortage of stroke neurologists is no doubt due to a complex array of factors, Dr. Culebras said, but one contributing factor is that compensation is not commensurate with the workload. Vascular neurologists typically take calls and make emergency room visits on nights and weekends on top of their office hours and scheduled hospital visits, and are not reimbursed or otherwise compensated for these extra hours. Some may also be on call for teleneurology, Dr. Culebras noted, which is likewise not compensated appropriately in many states.
“All of these are additional burdens that remain without compensation, and that lessens the attractiveness of the specialty,” he said.
These unpaid hospital visits and emergency calls “can be taxing work,” Dr. Chaturvedi said. “If I'm on call tonight and I have a patient scheduled in the office tomorrow, and if I'm getting six to eight calls at all hours of the night, you can imagine I might be pretty exhausted tomorrow. So there will be very little incentive for doing that if it's going to affect [physicians'] performance the next day, especially if they're not getting compensated.”
The Stroke section's Fair Compensation Workgroup has drafted a position document on this topic, which it hopes will encourage policymakers to correct these deficits. The document, which is currently being reviewed by several AAN committees, will also compare different payment models gleaned from other subspecialties, in order to offer guidelines for compensating vascular neurologists in the future.
The section also recently formed another working group to “identify challenges to the recruitment and retention of vascular neurologists,” Dr. Culebras said. This newly formed group will “investigate what other challenges are preventing neurologists from entering vascular neurology, and make recommendations to address the problems.” Discussions have not yet begun, but Dr. Culebras anticipates that one of the group's key goals will be to address physician burnout [see the Neurology Today article, “Why Are Neurologists Burned Out?” http://bit.ly/NT-burnout].
Compensating stroke and vascular neurologists for currently unpaid services will have the added benefit of helping to expand teleneurology, which Drs. Culebras and Chaturvedi said is a crucial service that provides much-needed care to stroke victims in rural and urban areas alike. Expanding teleneurology is currently one of the section's chief objectives, Dr. Culebras said.
“With teleneurology, we could provide quality care that is not available in the absence of a stroke center,” he said.
Currently, teleneurology's main utility has been in “bringing stroke expertise to small community hospitals or rural areas where they ordinarily wouldn't have it,” said Dr. Chaturvedi. “Some of these areas may not have a neurologist at all, so if you can provide them with somebody with stroke expertise, that could be very valuable.”
But teleneurology can likewise provide valuable care in urban areas. “For example, if you're in a congested place like New York or Los Angeles, it could take a long time to get from one hospital to another to see an urgent patient. If we can shave off, say, 20 or 30 minutes in time to treatment, there's definitely the potential for more neurologic improvement and even lower mortality,” Dr. Chaturvedi said.
ADVANCES IN PRACTICE
As the section grapples with these practice objectives, stroke and vascular neurologists have also welcomed the arrival of four novel oral anticoagulants (NOACs) — dabigatran, rivaroxaban, apixaban, and edoxaban — that have expanded the arsenal of available therapies for managing patients with conditions that require long-term anticoagulation, such as atrial fibrillation (AF) — which, Dr. Culebras noted, is increasing in incidence around the globe.
In February 2014, Drs. Culebras and Chaturvedi, along with several other members of the Stroke and Vascular Neurology Section, published a guideline for the prevention of cardioembolic stroke in patients with non-valvular AF, which included a review of three of the four NOACs (the fourth, edoxaban, was approved after the paper was published).
“All these NOACs are excellent additions to the armamentarium, but neurologists should not throw away warfarin,” Dr. Culebras said. While NOACs are easier for patients to use and are associated with a lower risk for intracranial hemorrhage than warfarin, they are more expensive, which has limited their use in many developing nations, Dr. Culebras noted. Plus, their effects cannot be reversed, meaning that “if a patient comes to the emergency room with a stroke, we cannot administer tissue plasminogen activator (tPA), or stop the bleeding if the stroke is hemorrhagic, whereas with warfarin, we can hopefully reverse the effects.”
In addition, there are currently no tests to detect the levels of the drug in the blood. “So if a patient comes into the emergency room with bleeding in the head, we cannot tell whether the patient has overdosed on one of these NOACs or whether it was just a spontaneous bleed,” Dr. Culebras said. “The same thing happens with ischemic stroke.”
The section's recommendations emphasized that the NOACs represent a “wonderful addition to the armamentarium,” Dr. Culebras said, but that these drugs may not be for everyone. Neurologists should inform their patients of the advantages and disadvantages of each treatment and involve them in the decision-making process when starting a new anticoagulant drug, the guideline proposed.
New studies are just starting to look at other promising uses for the NOACs, such as treating patients with hypercoagulable states and cryptogenic stroke, Dr. Chaturvedi added.
More papers and guidelines on a variety of topics of interest to vascular neurologists will be forthcoming, and the section plans to host several sessions at the AAN Annual Meeting in Washington, DC, in April, including a “Controversies in Neurology” session on antiplatelets, anticoagulants, or stenting for acute treatment of carotid dissection, Dr. Culebras said.
“We're finally expecting some better data regarding this condition, based on some studies that our colleagues in Europe are doing,” Dr. Chaturvedi said, which will hopefully provide some much-needed guidance into managing this condition.