Training Guidelines for Endovascular Ischemic Stroke Intervention: An International Multi-Society Consensus Document

Lavine, S. D.; Cockroft, Kevin M.; Hoh, Brian L.; Bambakidis, Nicholas C.; Khalessi, Alexander A.; Woo, Hyeon-Jun; Riina, Howard A.; Siddiqui, Adnan H.; Hirsch, Joshua A; Chong, Winston; Rice, Henry E.; Wenderoth, Jason; Mitchell, Peter; Coulthard, Alan; Signh, T.J.; Phatorous, C.; Khangure, Makhan S.; Klurfan, Paula; Iancu, Daniela; Gunnarsson, Þorsteinn; Jansen, Olav; Muto, Mario; Szikora, I; Piérot, Laurent; Brouwer, Patrick A.; Gralla, Jan; Renowden, Shelley; Andersson, Tommy; Fiehler, Jens; Turjman, Francis; White, Phil; Januel, Anne-Christine; Kulcsár, Zsolt; Chapot, René; Spelle, Laurent; Dima, Sofia; Taschner, Christian; Szajner, Maciej; Krajina, Antonı́n; Sakai, Nobuyuki; Matsumaru, Yuji; Yoshimura, Shinichi; Ezura, Masayuki; Fujinaka, Toshiyuki; Iihara, K.; Ishii, Akira; Higashi, Toshio; Hirohata, Masaru; Hyodo, Akio; Ito, Yuhei; Kawanishi, Masahiko; Kiyosue, Hiro; Kobayashi, Eiichi; Kobayashi, Sei; Kuwayama, Naoya; Matsumoto, Yoshihisa; Miyachi, Shigeru; Murayama, Yuichi; Nagata, Izumi; Nakahara, Ichirō; Nemoto, Shigeru; Niimi, Y.; Oishi, Hidenori; Satomi, Junichiro; Satow, Tetsu; Sugiu, Kenji; Terada, Tomoaki; Yamagami, Hiroshi; Vergara-Díaz, Omar; Lylyk, Pedro; Jayaraman, Mahesh; Patsalides, Athos; Gandhi, Chirag D.; Lee, S.K.; Abruzzo, Todd; Albani, Barbara; Ansari, Sameer A; Arthur, Adam S; Baxter, Blaise; Bulsara, Ketan R.; Chen, M.; Almandoz, Josser E Delgado; Fraser, Justin F.; Heck, Don; Hetts, Steven W.; Hussain, Muhammad Shazam; Klucznik, Richard P.; Leslie-Mawzi, Thabele; Mack, William J.; McTaggart, Ryan; Meyers, Philip M.; Mocco, J; Prestigiacomo, Charles J.; Pride, G. Lee; Rasmussen, Peter A.; Starke, Robert M.; Sunenshine, Peter; Tarr, Robert W.; Frei, Donald; Ribó, Marc; Nogueira, Raul G; Zaidat, Osama O.; Jovin, Tudor G; Linfante, Italo; Yavagal, Dileep R.; Liebeskind, David S; Novakovic, Robin; Pongpech, Sirintara; Rodesch, Georges; Söderman, Michael; terBrugge, Karel G.; Taylor, Allan; Krings, Timo; Orbach, Darren B.; Biondi, Alessandra; Picard, L; Suh, Dae Chul; Tanaka, Michihiro; Zhang, H.Q.

doi:10.3174/ajnr.a4766

Cited by 50 publications

(13 citation statements)

References 21 publications

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“…As EVT of acute ischemic stroke becomes a mainstream offering at many centers, an endovascular-specific multidisciplinary QI process should be established in all programs offering this treatment. 24,25 These endovascular cases, similar to trauma cases, require complex processes of care. These processes go beyond the clinical and technical skills of the operators themselves and should be monitored in a continuous and ongoing fashion.…”

Section: Ongoing Quality Improvementmentioning

confidence: 99%

“…As noted earlier in the section on data collection, all cases should be entered into a trial, data base, or registry with national participation. 24,25,76 In the United States, Medicare is functioning under the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015, 140 which seeks to align disparate quality programs through Qualified Clinical Data Registries. This approach is in keeping with our aforementioned recommendation for data collection and quality control.…”

Section: Review Processmentioning

confidence: 99%

“…Revision of this QI consensus statement remains focused on processes of care and patient outcomes. Other documents address standards for physician training 24,25 and recommendations for patient selection and treatment methods. 5,23 As in the previous guidelines, it is intended that these benchmarks be used in a quality-improvement program to assess and improve processes and outcomes in acute stroke revascularization.…”

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confidence: 99%

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Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke

Sacks

Baxter

Campbell

et al. 2018

AJNR Am J Neuroradiol

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192

179

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ABBREVIATIONS: ASPECTS ϭ Alberta Stroke Program Early Computed Tomography Score; EVT ϭ endovascular therapy; mRS ϭ modified Rankin Scale; mTICI ϭ modified thrombolysis in cerebral infarction; NIHSS ϭ National Institutes of Health Stroke Scale; QI ϭ quality improvement; SAH ϭ subarachnoid hemorrhage; SICH ϭ symptomatic intracranial hemorrhage; SITS-MOST ϭ Safe Implementation of Thrombolysis in Stroke Monitoring Study; TICI ϭ thrombolysis in cerebral infarction; TIMI ϭ thrombolysis in myocardial infarction; TPA ϭ tissue plasminogen activator E ndovascular therapy (EVT) for acute ischemic stroke in selected patients has recently been proved effective in several clinical trials, and the widespread adoption of thrombectomy into routine clinical practice has begun. However, these acute stroke services are resource-intensive, including advanced cerebral im-aging and highly trained multidisciplinary hospital teams rapidly responding to emergency activation. Despite the previous acceptance of intravenous fibrinolysis for acute ischemic stroke and the development of designated stroke centers, 1 ischemic stroke remains a leading cause of adult death and disability. 2 Many patients are not candidates for fibrinolysis, and intravenous therapy is relatively ineffective for severe strokes as a result of large cerebral artery occlusions. Moreover, it is uncertain if the benefits of endovascular stroke treatment in the trial setting can be generalized to clinical care provided by hospitals and teams of varying training, experience, and case volume. In other medical disciplines, rapid technologic advancement required guidelines to utilize these tools effectively and responsibly. 3 Quality-improvement (QI) metrics for the outcomes of endovascular ischemic stroke treatment were published by a multisociety, multispecialty, international consensus group in 2013. 4 These QI metrics have been accepted at a national level in Great Britain and Ireland 5 but have yet to be included into stroke center accreditation requirements in the United States. Subsequent to the publication of the prior QI guidelines, eight randomized trials and several meta-analyses of EVT have been published. 6-20 These randomized trials have established EVT as standard of care when available, 5,21-23 and provide additional data on which to update the metrics and bench-

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Section: Ongoing Quality Improvementmentioning

confidence: 99%

Section: Review Processmentioning

confidence: 99%

mentioning

confidence: 99%

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Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke

Sacks

Baxter

Campbell

et al. 2018

AJNR Am J Neuroradiol

Self Cite

192

179

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“…With reference to relevant literature [ 1 – 15 ], policy/guidelines [ 23 – 25 ] and discussions within the study team, a survey questionnaire was initially developed with 12 options (the propositions) for future organisation of thrombectomy services in England (see Table 1 ).…”

Section: Methodsmentioning

confidence: 99%

A Delphi study and ranking exercise to support commissioning services: future delivery of Thrombectomy services in England

Halvorsrud

Flynn

Ford

et al. 2018

BMC Health Serv Res

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BackgroundIntra-arterial thrombectomy is the gold standard treatment for large artery occlusive stroke. However, the evidence of its benefits is almost entirely based on trials delivered by experienced neurointerventionists working in established teams in neuroscience centres. Those responsible for the design and prospective reconfiguration of services need access to a comprehensive and complementary array of information on which to base their decisions. This will help to ensure the demonstrated effects from trials may be realised in practice and account for regional/local variations in resources and skill-sets. One approach to elucidate the implementation preferences and considerations of key experts is a Delphi survey. In order to support commissioning decisions, we aimed using an electronic Delphi survey to establish consensus on the options for future organisation of thrombectomy services among physicians with clinical experience in managing large artery occlusive stroke.MethodsA Delphi survey was developed with 12 options for future organisation of thrombectomy services in England. A purposive sampling strategy established an expert panel of stroke physicians from the British Association of Stroke Physicians (BASP) Clinical Standards and/or Executive Membership that deliver 24/7 intravenous thrombolysis. Options with aggregate scores falling within the lowest quartile were removed from the subsequent Delphi round. Options reaching consensus following the two Delphi rounds were then ranked in a final exercise by both the wider BASP membership and the British Society of Neuroradiologists (BSNR).ResultsEleven stroke physicians from BASP completed the initial two Delphi rounds. Three options achieved consensus, with subsequently wider BASP (97%, n = 43) and BSNR members (86%, n = 21) assigning the highest approval rankings in the final exercise for transferring large artery occlusive stroke patients to nearest neuroscience centre for thrombectomy based on local CT/CT Angiography.ConclusionsThe initial Delphi rounds ensured optimal reduction of options by an expert panel of stroke physicians, while subsequent ranking exercises allowed remaining options to be ranked by a wider group of experts within stroke to reach consensus. The preferred implementation option for thrombectomy is investigating suspected acute stroke patients by CT/CT Angiography and secondary transfer of large artery occlusive stroke patients to the nearest neuroscience (thrombectomy) centre.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-2922-3) contains supplementary material, which is available to authorized users.

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“…Formal neuroscience training, stringent peer review and quality assurance processes are critical to ensuring the best possible patient outcomes. (27) The key specifications are…”

Section: Additional Informationmentioning

confidence: 99%

European Recommendations on Organisation of Interventional Care in Acute Stroke (EROICAS)

Fiehler

Cognard

Gargiulo³

et al. 2016

International Journal of Stroke

112

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Training Guidelines for Endovascular Ischemic Stroke Intervention: An International Multi-Society Consensus Document

Cited by 50 publications

References 21 publications

Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke

Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke

A Delphi study and ranking exercise to support commissioning services: future delivery of Thrombectomy services in England

European Recommendations on Organisation of Interventional Care in Acute Stroke (EROICAS)

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