Rethinking Training and Distribution of Vascular Neurology Interventionists in the Era of Thrombectomy.

Abstract

See related article, p 2042 Vascular neurologists (VNs) now have 2 powerful tools to improve outcomes after stroke, intravenous tissue-type plasminogen activator (r-tPA) and endovascular thrombectomy (ET). Among the many common aspects of both treatments, the fastest possible intervention after stroke onset emerges to be paramount.1–3 With r-tPA, it has taken 20 years from approval to be accepted, the subspecialty of VN to be born and trained, and systems of care implemented to speed treatment by improving Emergency Department and pre-hospital management. In contrast, ET based on the 5 positive landmark randomized trials reported in the past 2 years4–8 has been accepted much more abruptly. Yet, the same sort of changes in streamlining systems of care and training and distribution of VN expertise are as necessary for ET as they were for r-tPA to deliver ET as rapidly as possible. The abruptness of this ET revolution, and the redirection of care and resources required, have found the VN community unprepared. Dramatic changes in VN training and distribution are necessary to accommodate the fastest possible ET intervention. Our 3-fold premise to be explored below is that (1) treatment of ET candidates is multifaceted and optimally should include the expertise of a VN, (2) the VN community needs to rethink and retool its workforce to accommodate the most rapid and widespread ET treatment possible, and (3) this should by necessity include training and more widely distributing substantially more VNs to carry out ET. The authors acknowledge that what we propose as a Comment and Opinion diverges from the current standard management, which is to concentrate ET expertise into a few hands at Comprehensive Stroke Centers (CSCs) and have the patient brought to Mecca. Initially, the same model was proposed for r-tPA, but the top 3 enrolling …