Stroke physician curriculum
A Curriculum for Australasian Stroke Physicians
Introduction
Australasian Stroke Physicians work in the speciality field of stroke (both ischaemic and haemorrhagic) to manage patients in the public and private sector and in the hospital, clinic and community. Australasian Stroke Physicians manage acute stroke including revascularisation strategies, institute strategies for stroke prevention and optimise stroke recovery.
The practice requires an interdisciplinary approach that incorporates a working knowledge of relevant aspects of cerebrovascular disease epidemiology, clinical neurology, stroke related neurovascular anatomy and physiology, diagnostic neuroimaging and interventional neuroradiology, and neurorehabilitation. The requisite body of knowledge which provides the foundation for the provision of expert stroke care is complex and necessitates specific training in medical school and hospital residency followed by supplementation through a focused fellowship.
The purpose of this document is:
- To provide a framework for physicians and trainees for further training in the specialty field of stroke
- To provide a framework for training organisations e.g. hospitals to develop training programs for stroke physicians
- To provide clarity for other clinicians to understand the scope of practice of a Stroke Physician, for example to facilitate multidisciplinary care.
After achieving these learning and training objectives a Stroke Physician would be competent in the management of acute stroke presentations, the coordination of the acute admission of a patient with stroke including leadership of a multidisciplinary team, and liaison with subacute services required to optimse stroke recovery. This will enable the Stroke Physician to be an advocate to improve health systems for local, State and National stroke care. The stroke physician should also have a key role in the implementation of secondary prevention strategies including both pharmacological and non-pharmacological approaches.
Scope
This document describes the skills and knowledge a Stroke Physician would require to provide expert care for stroke patients especially in the acute phase. It is written from the perspective of the learning and training goals rather than the content required to achieve these.
Australasian Stroke Physicians manage intracerebral haemorrhage and acute ischaemic infarction of focal parts of the brain, the retina, and the spinal cord. Other cerebrovascular conditions are also included e.g. cerebral venous sinus thrombosis.
Stroke Physicians manage adults with stroke and the older paediatric population who may have similar management issues to their adult counterparts.
Contents
- Neuroanatomy and vascular supply
- Stroke pathophysiology
- Hyperacute Stroke Care
- Acute Stroke Care
- Neuroimaging and other investigations
- Acute management of non-stroke cerebrovascular diseases
- Assessment for the cause of stroke or TIA and secondary prevention of stroke
- Communication with patients and families in stroke units
- Restorative care and interfaces with subacute care
- The Stroke patient with comorbidities
- Other issues in the field of Stroke (teaching, research, administration, quality improvement, advocacy)
Neuroanatomy and vascular supply
A Stroke Physician can explain the anatomy of the normal brain and its blood supply. Stroke Physicians also manage acute vascular events involving the eye and spinal cord, and therefore a knowledge of the functional anatomy of these regions is also required.
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Explain neuroanatomy as it relates to function e.g. frontal lobe functions
- Use symptom analysis and bedside clinical neurological assessment skills to determine the likely topography of a stroke lesion in either the brain, spinal cord or retina
- Understand vascular anatomy as it relates to stroke causation e.g. middle cerebral artery, anterior cerebral artery, posterior cerebral artery and vertebrobasilar system territory stroke
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Understand the anatomy and functional importance of the collateral circulation to the anterior and posterior circulations
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Understand the vascular anatomy of the spinal cord
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Explain normal variants and their impact on stroke pathophysiology e.g. persistent foetal origin of posterior cerebral artery
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Identify and describe these features on neuroimaging investigations.
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Understand cardiac anatomy and physiology pertinent to stroke care
Stroke pathophysiology
A Stroke Physician can explain stroke presentations within the framework of stroke pathophysiology impacting on anatomy and function.
One of the most important skills of a Stroke Physician is to assimilate history, examination and neuroimaging (both parenchymal and vessel, and from multiple modalities). A Stroke Physician uses this knowledge to understand an individual person’s stroke pathophysiology, how this is evolving at the time of the initial consultation, the natural history of how this is likely to evolve in future and the therapeutic considerations that may influence this outcome.
- Explain the vascular diseases that lead to stroke e.g. atherosclerosis, cardiac thromboembolism, dissection, amyloid angiopathy
- Explain the temporal course of the evolution of an acute stroke, especially with respect to imaging (but also histopathologically) e.g. penumbral conversion to core, haematoma expansion, timing of oedema, impact of time on the neuroimaging appearance of a stroke
- Understand cerebrovascular reserve and the relationships between autoregulation, intracranial pressure and cerebral blood flow
- Explain the neurophysiology of stroke presentations both in terms of vascular supply and brain localization e.g. dysphasia, hemianopia
Hyperacute stroke care
A Stroke Physician coordinates care for emergency presentations of patients with stroke both in the community and when the stroke occurs in hospital. This may include understanding and development of systems for prehospital stroke identification and triage and contributing to the emergency management of these patients in the Emergency Department.
- Understand the clinical presentations of stroke and how they and how other clinicians (e.g. paramedics) recognise these presentations.
- Be competent with commonly used stroke scales e.g. NIHSS (National Institutes of Health Stroke Scale), mRS (Modified Rankin Scale)
- Diagnose and manage stroke mimics (see list in Acute stroke care, Diagnosis section) whilst not undertreating patients with possible stroke diagnoses
- Understand retrieval systems to hospital services including bypass of facilities that cannot deliver thrombolysis or endovascular clot retrieval
- Develop and use escalation procedures for strokes occurring in inpatient settings
- Understand and rapidly arrange neuroimaging and other methods for diagnosing stroke type without delaying time-critical treatment and assessing the stroke-in-evolution e.g. multimodal CT
- Recognise early CT changes in hyperacute stroke
- Understand CT angiography and CT perfusion studies
- Assess patients for suitability for intravenously administered reperfusion therapies e.g. thrombolysis
- Understand the pharmacology of thrombolytic therapies and the principles of management of the patient treated with them.
- Arrange subsequent inpatient care for patients who have received thrombolytic therapy particularly in the following 24 hour period.
- Assess patients for suitability for endovascular therapies e.g. endovascular clot retrieval and refer as necessary
- Manage patients with intracerebral haemorrhage and their specific issues e.g. anticoagulation reversal, blood pressure management, detection and management of obstructive hydrocephalus and indications for neurosurgical decompression
- Appropriately use systems of care that optimise early assessment and intervention for stroke patients
Acute stroke care
A Stroke Physician coordinates a multidisciplinary care team that can clarify stroke and non-stroke diagnoses, manage these diagnoses such that the patient remains stable or recovers from early complications, and plans the next phase of care.
One of the principal roles of a Stroke Physician is to lead and coordinate the collaborative efforts of the medical, nursing and allied health staff to achieve the best outcome for a stroke patient. These collaborations extend to staff from other disciplines e.g. Emergency Medicine, Radiology, Intensive Care Physicians, General Physicians, Geriatricians, Rehabilitation Physicians and General Practitioners.
Diagnosis
- Understand and appropriately arrange neuroimaging and other methods for diagnosing stroke type and assessing the acute evolution of imaging changes after ischaemic and haemorrhagic stroke.
- e.g. Understand MRI sequences and how they inform stroke type (see Neuroimaging and other investigations section)
- Diagnose stroke mimics clinically and through appropriate use of investigations (also see hyperacute stroke care section)
- Somatic Symptom Disorder
- Seizures and Todd’s paresis
- Hypoglycaemia
- Subdural haematoma
- Encephalitis (infective and autoimmune)
- Migraine
Management principles during admission with acute stroke
- Understand the role of nutrition in acute stroke patients
- Recognise the issue of nasogastric feeding as a prompt to consider discussing palliation and end of life care in appropriate patients and situations
- Balance the need for nutrition with the goal of restoring swallowing
- Understand the natural history of change in physiological variables in acute stroke, and the potential impact of manipulating these in an acute stroke patient.
- Especially to understand the impact of acute blood pressure management in an acute ischaemic or haemorrhagic stroke patient
- Assess a deteriorating stroke patient and determine if the deterioration is due to a change in neurology or a non-neurological process
- Particularly to understand the presentations of failure of the ischaemic penumbra in ischaemic stroke patients
- Recognise when Neurosurgical intervention may become appropriate and institute measures to identify this pre-emptively e.g. malignant MCA (middle cerebral artery) territory infarction requiring decompressive hemicraniectomy
- Understand the role of early mobilisation in acute stroke patients.
- Understand how this may benefit stroke recovery and DVT prevention, and how it may impact on the ischaemic penumbra
- Understand the impact of the stroke on cognition and communication, and how these issues affect assessment of the impact of the stroke on the patient, and all of the other aspects of care (see Communication section for more detail)
Prevention and management of complications
- Manage patients with suspected or diagnosed aspiration and nosocomial pneumonia, applying relevant local hospital protocols for antibiotic usage.
- Employ strategies to prevent catheter and cannula related infection
- Assess the need for DVT (Deep Venous Thrombosis) prophylaxis and tailor these to the type of stroke (e.g. heparin in a patient with haemorrhagic stroke) and changes in need as DVT risk changes with alterations in mobility or the goals of rehabilitation.
- Manage DVT and PE (Pulmonary Embolism) acutely after ischaemic or haemorrhagic stroke
- Manage post-stroke seizures and post-stroke epilepsy as a specific consequence of stroke
- Recognise and manage other sequelae of stroke that may occur in the inpatient setting but may only manifest after discharge (see also the Restorative Care section)
- Mood disorders
- Pain
- Fatigue
- Sleep disorders
- Sexuality issues
- Cognitive dysfunction
- Epilepsy
Stroke imaging
Although referred to frequently in other sections of this document, a Stroke Physician judiciously uses imaging and other investigations to evaluate acute stroke presentations and to assess the progress of stroke pathophysiology in the following days and weeks. Other investigations are covered elsewhere, but an expert understanding of stroke imaging is one of the principal skills of a Stroke Physician.
- Adeptly interpret of CT and MR imaging of the brain and the extracranial and intracranial vasculature
- Adeptly interpret extracranial duplex ultrasonography and understand how this relates to other modalities of carotid imaging.
- Understand the diagnostic value (and limitations) of plain CT scans
- Understand the additional value of multimodal CT scanning including CT angiography and CT perfusion scanning
- Understand MRI scanning including the information obtainable from specialised sequences that need to be specifically requested (e.g. dissection sequences, MR venography)
Acute management of non-stroke cerebrovascular diseases
A Stroke Physician also manages other vascular diseases which affect the central nervous system such as:
- Reversible cerebral vasoconstriction syndrome
- Posterior reversible encephalopathy syndrome
- Large vessel occlusion or stenosis with haemodynamic compromise. For example occlusion or stenosis of the internal carotid artery, middle cerebral artery, basilar artery or vertebral artery.
- As a specific situation, Moyomoya syndrome.
- Cerebral venous thrombosis
Assessment for the cause of stroke or TIA and secondary prevention of stroke
A Stroke Physician assesses stroke patients to determine the cause of stroke especially as this relates to advising secondary prevention strategies. This requires a clear understanding of pharmacological principles.
- Recognise presentations of TIA and TIA mimics
- Recognise TIA as an opportunity to optimise stroke prevention
- Assess for the specific causes of stroke that may indicate specific secondary prevention measures in appropriate patients, and coordinate access to these as necessary
- Carotid imaging for stenosis and referral for carotid revascularisation e.g. carotid endarterectomy or stenting
- Arterial imaging for dissection and RCVS (Reversible Cerebral Vasoconstriction Syndrome)
- Venous imaging for CVT (Cerebral Venous Thrombosis) and anticoagulation as appropriate
- Cardiac imaging for structural abnormalities e.g. PFO (Patent Foramen Ovale), endocarditis, atrial myxoma
- Cardiac assessment for AF and anticoagulation as appropriate
- Principles of cigarette smoking cessation
- Institute secondary prevention therapy, understanding specific situations when these therapies may not be indicated.
- Different choices of antiplatelets
- Intravenous, subcutaneous and oral anticoagulants
- Lipid lowering therapy (and prescribing decisions after haemorrhagic stroke)
- Blood pressure lowering therapy
- Understand and manage rare causes of stroke
- Genetic disorders e.g. CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarction and Leucoencephalopathy), MELAS (Mitochondrial Encephalopathy with Lactic Acidosis and Stroke-like episodes), Fabry disease
- Vascular disorders e.g. Amyloid angiopathy, Moyamoya and when to refer for superficial temporal artery to middle cerebral artery bypass
- Autoimmune disorders (antiphospholipid antibody syndrome, cerebral vasculitis)
- Advise women regarding the use of oestrogen-containing therapies after stroke.
Communication with patients and families in stroke units
Although all physicians require highly developed communication skills (see the RACP Professional Qualities Curriculum, https://www.racp.edu.au/docs/default-source/default-document-library/professional-qualities-curriculum.pdf), this is of particular importance in the field of stroke because many stroke patients become unable to communicate by themselves. Because of this unexpected inability to communicate, often there is no pre-determined alternative mechanism for communicating with substitute decision makers and the rest of the patients’ social network.
- Understand the importance of clear and regular communication with the stroke patient and their relative others
- Recognise the relevant issues pertaining to privacy and confidentiality, especially in the context of impaired competency related to stroke deficits.
- Facilitate expertise in dealing with distressed relatives in an emotion-charged stressful environment
- Provide a framework for discussing common stroke scenarios; e.g. ineligibility for stroke interventions, complications of stroke treatments, predictable stroke deterioration in small vessel syndromes and after large MCA stroke, consent for hemicraniectomy, palliative issues, need for residential care, stroke prognosis.
- Obtain expertise in communicating stroke related issues to other clinicians, the public and the media.
