SPECIAL ARTICLE Treating Stroke as a Medical Emergency: A Survey of Resident Physicians’ Attitudes toward “Brain Attack” and Carotid Endarterectomy Michael Y. Wang, M.D., Sean D. Lavine, M.D., Harmik Soukiasian, M.D., Robert Tabrizi, B.S., Michael L. Levy, M.D., Steven L. Giannotta, M.D. Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California OBJECTIVE: A major impetus of the “brain attack” campaign is the early recognition and treatment of acute stroke. Critical to this goal is the education of physicians during their residency training. METHODS: Resident physicians in Los Angeles who were in family practice (18%), internal medicine (51%), emergency medicine (20%), and neurology (11%) and had already completed their first year of training responded to a questionnaire on stroke and the treatment of carotid stenosis. RESULTS: Of the 266 respondents, 76% had heard of the “brain attack” campaign, 22% did not identify dysarthria as a symptom of stroke, and 21% did not identify obtundation as a presentation of stroke. Twenty-eight percent chose not to use tissue plasminogen activator for acute ischemic stroke, and 60% recognized the need to begin treatment within 3 hours. More than 90% of respondents were able to identify correct screening tests for patients with suspected carotid stenosis. However, 56% responded that they would not advocate operating on patients with asymptomatic severe stenosis (>70%) until stenosis reached a critical value (85%). Conversely, 45% would recommend operative treatment for symptomatic patients who had less than 60% stenosis. Sixty-eight percent would refer patients to vascular surgeons, 14% to neurosurgeons, and 17% to both for carotid endarterectomy. CONCLUSION: Recognition of stroke as a medical emergency is improving. However, significant progress can still be made in the recognition of stroke symptoms. Primary care and neurology residents remain skeptical about carotid endarterectomy for asymptomatic patients, whereas there is enthusiasm for treating stroke survivors. Education by members of the surgical community could promote the aggressive treatment of asymptomatic patients to prevent stroke. (Neurosurgery 48:1109–1117, 2001) Key words: Brain attack, Carotid endarterectomy, Stroke T he 1990s were designated “The Decade of the Brain” to signify an impetus toward advancements in neuroscience. One of the major goals of the campaign was to reduce the morbidity and mortality associated with cerebrovascular dis- ease. Stroke is the third leading cause of death as well as the leading cause of disability in the United States. In early August 2000, former United States President Gerald R. Ford had two strokes. Of concern was that his symptoms were initially misdi- agnosed as a sinus infection. The American Association of Neu- rological Surgeons has recognized that patient and physician education with regard to the concept of stroke, or “brain attack,” is lacking. Although directed efforts at education in the form of educational exhibits and materials have been developed, the educational process is only in its early stages. Thus, a major effort has been directed toward the early recognition and prompt treatment of stroke (2, 4, 21, 25). This effort has been coined “brain attack,” borrowing the common terminology for myocardial infarction to convey the urgency associated with stroke (10, 29). A second effort has been directed at the prevention of stroke by identifying and treating cerebrovascular disease before symp- toms and permanent neurological deficits ensue. This effort has largely been a public health campaign designed to decrease stroke risk factors such as hypertension and tobacco use. Neu- rosurgeons, vascular surgeons, and neurointerventionalists can play a more aggressive role in stroke prevention by treating extracranial carotid disease with either carotid endarterectomy (CEA) or carotid angioplasty with stenting (24, 26, 27). 1109 Neurosurgery, Vol. 48, No. 5, May 2001