Who Should Treat Stroke?
Who Should Treat Stroke?
There is no question that acute stroke is a major health problem, with about 800 000 strokes per year in the USA alone. Most stroke victims do not have a good recovery. US stroke healthcare costs are $41 billion a year. Dollar amounts do not capture the suffering of the patient, family and friends for the death, disability and loss of independence caused by strokes. There is again no question that strokes are best prevented, but 800 000 strokes a year creates a huge need for emergency stroke treatment, including by endovascular means.
Intravenous tissue plasminogen activator improves outcomes but the improvement is slight for those with large vessel occlusion (internal carotid, middle cerebral and vertebrobasilar) as documented by non-invasive vascular imaging or by the presence of the hyperdense middle cerebral artery sign on non-contrast head CT. Intra-arterial (IA) catheter directed techniques are more effective in restoring flow in patients with large vessel occlusions, and randomized trials have confirmed improved outcomes. Furthermore, newer methods of treatment such as mechanical revascularization devices now allow rapid successful revascularization and possibly open the door to additional patients with better clinical results.
Hospitals want interventional stroke services to be available in their community both as a critical patient service and also to avoid patient harm from a delay in care caused by a transfer of patients to other centers. Hospitals also have an economic incentive to treat patients locally. Intracranial endovascular procedures are typically performed by physicians who have trained in endovascular surgical neuroradiology (ESNR) fellowships. However, with the increasing demand to provide stroke rescue services quickly and locally, other endovascular trained interventional specialists such as interventional radiologists (IR) and interventional cardiologists (IC) are also providing this care.
Is this right? Is it reasonable? Is it good care? Or is it the height of arrogance and the product of a cavalier 'cowboy' ignorance that could lead these other specialists to believe that one vascular tree is little different from another and the only good occlusion is a reopened occlusion? Are IR and IC barbarians to be kept out of the head? I have been part of discussions about these issues for several years with the leadership of the Society of Neurointerventional Surgery (SNIS) and members of the NeuroVascular Coalition. In June 2011, Don Heck and I discussed these issues at the SNIS stroke practicum in Seattle. We found that our slides were practically interchangeable but we drew different conclusions. In the audience questions after the presentations it was clear that, to some, I represented the arrogant, cavalier, cowboy barbarian. SNIS has invited both me and Don to put our talks on paper and contribute our thoughts on this topic to a new controversies section in Journal of NeuroInterventional Surgery. As an IR, my comments will be specific to my specialty but my comments are also relevant to IC. It is my intention that this discussion leads to thoughtful communication between specialties, an improved working relationship and, bottom line, improved care.
The major objections to IR treating stroke are as follows:
Abstract and Introduction
Introduction
There is no question that acute stroke is a major health problem, with about 800 000 strokes per year in the USA alone. Most stroke victims do not have a good recovery. US stroke healthcare costs are $41 billion a year. Dollar amounts do not capture the suffering of the patient, family and friends for the death, disability and loss of independence caused by strokes. There is again no question that strokes are best prevented, but 800 000 strokes a year creates a huge need for emergency stroke treatment, including by endovascular means.
Intravenous tissue plasminogen activator improves outcomes but the improvement is slight for those with large vessel occlusion (internal carotid, middle cerebral and vertebrobasilar) as documented by non-invasive vascular imaging or by the presence of the hyperdense middle cerebral artery sign on non-contrast head CT. Intra-arterial (IA) catheter directed techniques are more effective in restoring flow in patients with large vessel occlusions, and randomized trials have confirmed improved outcomes. Furthermore, newer methods of treatment such as mechanical revascularization devices now allow rapid successful revascularization and possibly open the door to additional patients with better clinical results.
Hospitals want interventional stroke services to be available in their community both as a critical patient service and also to avoid patient harm from a delay in care caused by a transfer of patients to other centers. Hospitals also have an economic incentive to treat patients locally. Intracranial endovascular procedures are typically performed by physicians who have trained in endovascular surgical neuroradiology (ESNR) fellowships. However, with the increasing demand to provide stroke rescue services quickly and locally, other endovascular trained interventional specialists such as interventional radiologists (IR) and interventional cardiologists (IC) are also providing this care.
Is this right? Is it reasonable? Is it good care? Or is it the height of arrogance and the product of a cavalier 'cowboy' ignorance that could lead these other specialists to believe that one vascular tree is little different from another and the only good occlusion is a reopened occlusion? Are IR and IC barbarians to be kept out of the head? I have been part of discussions about these issues for several years with the leadership of the Society of Neurointerventional Surgery (SNIS) and members of the NeuroVascular Coalition. In June 2011, Don Heck and I discussed these issues at the SNIS stroke practicum in Seattle. We found that our slides were practically interchangeable but we drew different conclusions. In the audience questions after the presentations it was clear that, to some, I represented the arrogant, cavalier, cowboy barbarian. SNIS has invited both me and Don to put our talks on paper and contribute our thoughts on this topic to a new controversies section in Journal of NeuroInterventional Surgery. As an IR, my comments will be specific to my specialty but my comments are also relevant to IC. It is my intention that this discussion leads to thoughtful communication between specialties, an improved working relationship and, bottom line, improved care.
The major objections to IR treating stroke are as follows:
IA stroke treatment is investigational and therefore should only be performed by the best trained physicians in academic centers using research protocols.
There is no need for additional manpower. Even if IA treatment is offered in community hospitals, there are sufficient ESNR trained physicians to provide this care.
There should be no shortcuts in training.
IR training is not adequate. Emergency care by an inadequately trained physician will lead to worse outcomes than the natural history of the disease or outcomes from transfer to another hospital.
There is no future for IR treating stroke or, at minimum, the time is limited.
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