Quick recognition, treatment essential in stroke management
|Aisha T. Liferidge, M.D.
Even though the official title of her Aug. 3 presentation was "Essentials for Stroke Management," the subtitle of the lecture by Aisha T. Liferidge, M.D., was even more descriptive: "Brain Attack 101: How to Maintain Your Stroke of Genius."
In applying this "stroke of genius" to everyday practice, Dr. Liferidge made recommendations in adhering to the fundamentals of stroke management in the emergency department, and addressed the role of primary stroke centers.
"Stroke is particularly applicable to us as emergency physicians who belong to the National Medical Association because significant racial disparities exist in terms of mortality, morbidity and associated risk factors associated with stroke," said Dr. Liferidge, M.D., assistant professor and attending emergency physician at the University of Maryland Medical Center, Baltimore.
Stroke has taken a high toll as the chief perpetrator of death and illness in the U.S., with more than 800,000 strokes occurring each year, she noted. Stroke is the No. 1 source of serious long-term disability, and the No. 3 cause of death.
The essentials in stroke management, Dr. Liferidge said, basically come down to competently and quickly recognizing the five most common presentations of ischemic stroke — anterior cerebral artery, middle cerebral artery, posterior cerebral artery, vertebrobasilar system and lacunar.
"There is overlap, regardless of the type, so it's important to remember the most common symptom for acute stroke is edema, which can be clearly visualized as a darkened area on a head CT scan," Dr. Liferidge said. "The most common location to find an acute stroke on a head CT is the internal capsule and the basal ganglia."
In terms of medical therapy for the treatment of stroke, tissue plasminogen activator (tPA) is the only FDA-approved thrombolytic for stroke, she said. Excellent neurologic recovery is expected if tPA is administered in a timely manner after a patient presents with stroke. It has been proven to affect outcomes positively when given within a set window of time and when given within the context of specified guidelines.
In managing the stroke patient in an acute care setting, effective communication is essential between emergency physicians and neurologists, Dr. Liferidge said. To that end, it's important for emergency physicians to be proficient in using the National Institutes of Health Stroke Scale because it represents a common language that emergency physicians and neurologists can use in discussing specific cases of stroke. Another tool emergency physicians can use to assist them with their day-to-day management of stroke is the American College of Emergency Physician's policy paper.
"There are countless tools available to emergency physicians to optimize their management of stroke," she said. "Stroke represents a significant public health concern and offers the opportunity for effective medical management in the emergency department."
Dr. Liferidge also addressed the Primary Stroke Center initiative, which is gaining momentum throughout the country.
"The role of the primary stroke center in optimizing the management of stroke is a fairly new concept and essentially has been shown to improve patient outcomes," she said.
Eleven key components are required for a stroke center to earn a Joint Commission Certificate of Distinction, officially designating it as a primary stroke center, Dr. Liferidge said. The top attribute of a primary stroke center is highly organized multidisciplinary care involving a team of emergency physicians, neurologists, stroke team nurses, radiologists, ancillary departments and administration.
Dr. Liferidge encouraged emergency physicians to play an instrumental role on multidisciplinary teams in stroke care. If their hospitals are primary stroke centers, she encouraged emergency physicians to participate actively. If their hospitals are not, she advised emergency physicians to keep abreast about what is going on with this initiative and to consider transferring patients to a primary stroke center.
"Primary stroke centers are a good idea, and it's something we are moving toward as an emergency delivery system," she said. "Get involved and increase your knowledge and participation in these centers and this initiative, which has been shown to improve patient outcomes. Stroke remains a very common and important condition that every emergency physician should be confident in managing acutely."