Current Patterns in the Management of Adult Stroke by Filipino Neurologists: A Nationwide Cross-Sectional Survey among Fellows of the Philippine Neurological Association

 Artemio A. Roxas Jr,1,2 and Ralph Louie P. Bautista2
for the Stroke Council of the Philippine Neurological Association

1Department of Neurosciences, College of Medicine and
Philippine General Hospital, University of the Philippines Manila
2Stroke Council of the Philippine Neurological Association

Background. Despite the availability of clinical guidelines for stroke, variation exists in the management patterns of stroke among neurologists.

Objective. To determine the current practice patterns of Filipino adult neurologists in stroke and their adherence to the current clinical guidelines of the Stroke Society of the Philippines (SSP).

Methods. Cross-sectional survey using a 3-page, 17-item questionnaire reviewed by the Stroke Council of the Philippine Neurological Association (PNA).

Results and Observations. From November 2013 to July 2014, 136 of 277 (49%) locally practicing board certified adult neurologists of the PNA were surveyed. Some important findings from the survey include: (1) 70% of respondents underestimated the benefit of warfarin in stroke prevention in nonvalvular atrial fibrillation (NVAF); (2) for acute ischemic stroke, although the recommended systolic blood pressure (SBP) threshold is >220 mm Hg, 43% would initiate antihypertensive therapy at SBP >180 mm Hg; (3) for acute primary intracerebral hemorrhage (ICH), 42% would start antihypertensives at SBP >140 mm Hg; (4) despite the absence of guidelines recommending the use of neuroprotectant drugs for acute stroke, 75% and 56% of neurologists have prescribed it to >80% of their patients with infarcts and ICH respectively; (5) 46% of neurologists have not experienced giving thrombolytic therapy to any of their patients with acute ischemic stroke; (6) among patients with clinically stable hemorrhagic strokes, 77% of neurologists would give antithrombotics, while 28% of them would start it 30 days after the onset of stroke; (7) only 21% of respondents have ordered carotid studies as part of their work up in >80% of their patients with ischemic strokes; and (8) 64% of respondents have requested carotid revascularization procedures for patients with significant carotid stenosis, and about 38% of these patients underwent the procedure.

Conclusion. The management patterns in stroke remain varied among Filipino neurologists, although the patterns show increasing adherence toward guideline recommendations. The following practices are noted: underestimation of the benefits of oral anticoagulation for stroke prevention among patients with NVAF; use of pharmacologic control of blood pressure below the recommended threshold for acute ischemic stroke; widespread use of neuroprotectant drugs despite lack of definite evidence for its use; low utilization of carotid studies in the work-up of patients with ischemic stroke and the low rate of revascularization procedures in confirmed cases of carotid stenosis; and a relative increase in experience with thrombolysis.

Key Words: clinical guidelines, adherence, survey, Filipino neurologist, stroke