Challenges to stroke care 5 years after endovascular therapy became the standard.

Abstract

Endovascular therapy is a highly effective and safe treatment for patients with acute ischemic stroke with large vessel occlusion (LVO) and is now considered the standard of care. Complication rates of endovascular therapy are low, but its efficacy is highly time-dependent and declines rapidly as time from symptom onset to treatment increases. Thus, it seems logical that patients with acute stroke due to LVO should get treated with endovascular therapy, if indicated, as soon as possible. At the same time, providers of this highly specialised treatment should be well-trained and meet minimum quality standards. However, in the USA, the reality of endovascular therapy is different depending on the setting: in metropolitan regions, geographically close centres capable of delivery this therapy compete with each other and struggle to find enough patients to treat, while in some rural areas access to this specialised treatment is lacking. Establishing new thrombectomy-capable stroke centres has been suggested as a solution to close this gap, but whether the quality standards of these centres would be good enough has been questioned. To make matters worse, just as endovascular therapy centres are clustered in metropolitan areas, the same is true for primary stroke centres (ie, stroke centres that provide treatment with intravenous alteplase, but cannot provide endovascular therapy), but initial transfer of patients with LVO to primary stroke centres can lead to avoidable treatment delays.