To the Editor: "Timely and
appropriate treatment of acute stroke" will not be delivered to
patients until neurologists, the stroke specialists, receive adequate
training in neuroimaging during residency or through fellowships. This
is what is really "missing from this picture," in answer to the
question asked in the Editorial in THE JOURNAL
issue devoted to stroke.1
Most neurologists on both sides of the Atlantic have relinquished their
responsibility to interpret images of the brain to neuroradiologists
and even to general radiologists. The ominous consequences of this
behavior are already felt in the new thrombolytic therapies for stroke,
which requires simple but accurate interpretation of a brain CT scan to
rule out hemorrhage and early infarction. The Food and Drug
Administration has approved the general use of recombinant tissue-type
plasminogen activator (rtPA) in stroke in the United States even in
hospitals without a neuroradiologist. Because only 1800
neuroradiologists serve 6000 US hospitals, most "emergency" head CT
scans will be interpreted by neurologists or general radiologists. Yet,
the results of 2 recent consecutive surveys of American Academy of
Neurology members indicate that most US neurologists do not feel
qualified to interpret neuroimaging studies (40% for CT and 55% for
MRI) and most believe that currently neurology residents received
insufficient training in neuroimaging (76% in the first survey and
80% in the second) (unpublished data, J. Masdeu, MD, 1996). The report
by Dr Schriger and colleagues2 provides statistical
confirmation of the inaccuracy of CT interpretation by neurologists (as
well as radiologists and emergency physicians); only 40% of
neurologists and 52% of radiologists achieved 100% sensitivity for
identification of hemorrhage.