Availability of endovascular therapies for cerebrovascular disease at primary stroke centers

Abstract

<jats:sec><jats:title>Background</jats:title><jats:p> Endovascular therapies (EVTs) are useful for treating cerebrovascular disease. There are few data about the availability of such services at primary stroke centers (PSCs). Our hypothesis was that some of these services may be available at some PSCs. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> We conducted an internet-based survey of hospitals certified as PSCs by the Joint Commission. The survey inquired about EVTs such as intra-arterial (IA) lytics, IA mechanical clot removal, coiling of aneurysms, and cervical arterial stenting, physician training, coverage models, hospital type, and outcomes. Chi-square analyses were used to detect differences between academic and community PSCs. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Data were available from 352 PSCs, of which 75% were community hospitals, 23% academic medical centers, and 80% were non-profit; almost half (48%) see 300 or more patients annually with ischemic stroke. A majority (60%) provided some or all EVTs on site, while 29% had none on site and no plans to add them. Among the respondents offering EVTs, 95% offered stenting of neck vessels, 86% IA lytics, 80% IA mechanical, and 74% aneurysm coiling. The majority (&gt;55%) that did offer such services provided them 24/7/365. Most endovascular coverage was provided by interventional neuroradiologists (60%), fellowship trained endovascular neurosurgeons (42%), and interventional radiologists (41%). The majority of hospitals (81%) did not participate in an audited national registry. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> A variety of EVT services are offered at many PSCs by interventionalists with diverse types of training. The availability of such services is clinically relevant now with the proven efficacy of mechanical thrombectomy for ischemic stroke. </jats:p></jats:sec>

Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy

“…Current evidence from randomized controlled trials supports endovascular therapy (EVT) for patients with large vessel occlusion (LVO) 1 . Whilst the procedure is now standard of care, it is hampered by its overall limited availability 2,3 . Among strategies to improve EVT availability for stroke patients are telemedical stroke networks which have been shown to effectively facilitate early initiation of treatment 4,5 .…”

Society of Interventional Radiology Training Guidelines for Endovascular Stroke Treatment

“…Vascular/IR physicians who were not trained in formal neurointerventional fellowships have historically provided and continue to provide EVT in substantial numbers with good outcomes, comparable to those achieved by neurointerventional physicians during similar years (29)(30)(31)(32)(33)(34)(35). A recent survey of the Joint Commission (JC) PSCs found that 60% of the responding PSCs performed EVT, and, of these, 41% relied on IR physicians to provide this care (26). Similarly, analysis of the Medicare database found that 34% of EVT cases were performed by physicians who were not trained in dedicated neurointerventional fellowships (36).…”

“…Benchmarks for quality outcomes have been established (25), along with higher-level stroke center designation by accrediting bodies including comprehensive stroke centers and, more recently, thrombectomy-capable stroke centers. EVT is also being performed in many primary stroke centers (PSCs) (26). Given the extensive changes since 2009 in endovascular stroke care, revision of the 2009 SIR training guidelines is timely and necessary.…”

Endovascular Stroke Therapy

“…In comparison, there are more than 1,000 primary stroke centers (PSCs) in the United States, but less than half of these facilities offer around-the-clock mechanical thrombectomy. 36 Given the time-sensitive efficacy of endovascular therapy, there may be a role in the future for EMS to bypass PSCs and transport patients directly to CSCs. 37 Currently, this concept is controversial and not recommended due to concerns regarding inappropriate prehospital triage and potential delays in administration of IV rtPA.…”