Richard Jackson, MD
This is an exciting time for the acute treatment of ischemic strokes with innovations in thrombectomy and advancements in imaging-based tissue evaluation for thrombolysis. Yet the percentage of patients being treated with these advancements remains low at around 15%. The treatment of ischemic cerebral disease is following in the footsteps of ischemic cardiac disease with the creation of hospital-led evidence-based programs and regional treatment programs involving primary and comprehensive stroke centers collaborating with local EMS providers.
However, as the director of a primary stroke center, I am continually surprised by the delays in presentation to the hospital for care. I remember, as an intern on the telemetry rotation, admitting what seemed like a never-ending amount of chest pain patients for evaluation. Every night on call for stroke, I, like all neurologists, face questions regarding the disposition of patients with resolved symptoms, patients with delayed presentation to the emergency room, patients not wanting to come into the hospital for treatment, and the questions surrounding acute treatment. These nights, I am always left wondering, what has cardiology done better than neurology? Why don’t people in the community present for evaluation at the slightest possible acute cerebral insult? Is it that our treatments and programs need time to create the system they have, or do we need to do more on the community education programs?
Maybe it’s both. A community primary stroke center has a duty to its community to create the primary stroke system, not just stroke care. To collaborate with primary care for prevention, to collaborate with surgeons to create clearance protocols for patient safety, to collaborate with the local nursing homes for rehabilitation, to lobby the government for screenings such as carotid duplex and intraoperative TCD, and to educate our patients and families. We have come a long way, but we have a long way to go — together.