The state of neurointerventional care
By Martin Geza Radvany, MD, FSIR, and Venu Vadlamudi, MD, RPVI, FSIR Summer 2021
During the June Stroke Case Conference, Venu Vadlamudi, MD, RPVI, FSIR, Martin Geza Radvany, MD, FSIR, Joseph Gemmete, MD, FSIR, David Sacks, MD, FSIR, and Paul S. Brady, MD, served on the panel, both presenting cases and asking questions of the other presenters. While the SIR Stroke Case Conference fosters discussion on topics such as the critical role of timing in stroke care or difficult technical scenarios, the series also highlights the differences between institutions and the challenges facing IRs involved in stroke care.
Education update: Accessible stroke education
The transition to virtual meetings in the COVID-19 era affected planned in-person stroke education activities such the SIR Stroke Course at the Annual Scientific Meeting and the second iteration of the SIR Stroke Imaging Boot Camp. The Interventional Neuroradiology Service Line and the Stroke Advisory Group, with strong support from SIR leadership, have been able to make the transition and continue to provide stroke education to SIR members.
With the closing of the ACR Learning Center last fall, the SIR Stroke Imaging Boot Camp needed to be restructured into an online-only activity. To this end, the SIR Stroke Series was developed as a four-module webinar mini course covering topics ranging from the diagnostic workup of acute stroke, advanced stroke imaging and AI, COVID-19 and stroke, and optimization of case selection. IR stroke experts were joined by other neurovascular experts including Ashutosh Jadhav, MD, PhD, of Barrow Neurological Institute; Waleed Brijinkji, MD, of the Mayo Clinic; and Lori Jordan MD, PhD, with Vanderbilt University Medical Center.
The series culminated in the inaugural SIR Stroke Case Conference in which faculty present challenging cases followed by a panel discussion. With the success of the inaugural case conference, a quarterly SIR Stroke Case Conference was launched to provide a forum in which IR attendings and trainees have the opportunity to present challenging stroke interventions and discuss the cases with a panel of experienced stroke specialists.
Planning is currently underway for another fall SIR Stroke Series which will include a variety of lecture webinars. This will again be a virtual meeting in which we plan to leverage the virtual meeting platform to invite presenters who might not otherwise be able to participate in an in-person format.
With the resumption of “in-person” meetings on the horizon, we hope to expand the educational offerings to include hands-on device and simulator training and we look forward to seeing everyone in person next spring at the SIR Annual Scientific Meeting and SIR Stroke Course.
IRQ spoke with Drs. Vadlamudi, Radvany, Gemmete and Sacks on the structure of their response teams, the challenges of the specialty and the need for training pathways.
Does your institution have a stroke response team? At what point are you brought into the pathway for treating a stroke patient?
Venu Vadlamudi, MD, RPVI, FSIR: Our institution does have a stroke response team, comprised of the stroke response nurse, neurologist and IR. The IR is brought into the case when either the neurologist has a high pre-test suspicion of large vessel occlusion (LVO) stroke or following advanced imaging for LVO evaluation.
David Sacks, MD, FSIR: The interventional physician is contacted when the stroke neurologist is evaluating a patient with clinical findings suspicious for an LVO. Since it can take time to set up the room, or have the interventional team arrive from home for an after-hours case, we want to be called based on clinical suspicion rather than waiting for positive imaging. If imaging is negative, the team goes home. My estimate is that we cancel no more than 10–20% of call-ins. This approach also works well for cases being transferred from satellite hospitals. If imaging at the satellite hospital is sufficient and the transfer time is short, the patient can go directly from the helipad to the IR suite.
Martin Geza Radvany, MD, FSIR: We have two stroke pathways. The first pathway consists of transfers comprehensive stroke center (CSC) and the other focuses on patients that present directly to the hospital. Arkansas has only two CSCs, but there is a network of over 50 stroke-ready hospitals that have tele-stroke coverage, can perform a head CT and administer TPA. Patients are evaluated by the stroke neurologist using a telemedicine platform and make the decision to transfer a patient with a possible LVO. A stroke alert page goes out to the on-call stroke team to alert the team and provide an estimated ETA. This allows allocation of resources during working hours when a possible thrombectomy case is being transferred. After hours, the team is waiting at the hospital when the patient arrives. Another alert goes out when the patient arrives and the neurology residents or attending evaluate the patient. The transfers can take 2 or more hours, so repeat imaging is performed when the patients arrive. The on-call stroke interventionalist is alerted when a transfer patient arrives to be prepared to review the imaging. Approximately 50% of the interventions are from transfers.
For patients who present directly to the institution, the stroke neurology team evaluates the patient and orders imaging studies. The on-call stroke interventionalist is contacted to review the imaging. If the imaging study is positive, a stroke alert is activated and the on-call team comes in.
Joseph Gemmete, MD, FSIR: We are brought into the pathway when a patient has an NIH stroke scale score greater or equal to 8, or with an LVO determined on imaging. Our hospital has a stroke response team called the Brain Injury Group that includes an ER physician, stroke neurologist, endovascular specialist and anesthesiologist on the paging alerts.
What does training and credentialing for stroke care look like at your institution? Are there policies for certain procedures, such as who can place an intracranial stent?
VV: We follow the most recent SIR stroke training guideline document for stroke credentialing and training requirements. Intracranial stenting is performed by formally trained neurointerventionalists in our system. These are quite rare cases in the acute setting but do occasionally come up.
DS: Our hospital uses both IR and endovascular neurosurgeons to provide stroke interventions. The neurosurgeons are considered qualified based on their fellowship training. The IR physicians have been performing stroke interventions for 20 years and had a training requirement of 10 cases, which would not be the training requirement today. We do not have separate privileging for intracranial stents.
MR: Our institution currently has four fellowship-trained NIR attendings with radiology backgrounds. The NIR physicians perform intracranial stenting procedures.
JG: At our tertiary academic hospital we require an endovascular neurosurgery or interventional neuroradiology (INR) fellowship with CAST certification. Only endovascular neurosurgery or INR fellowship trained physicians can place intracranial stents.
There are informal pathways for IRs-in-training to pursue neuro IR, but what is your advice for established IRs who may be trying to break into stroke care?
VV: For established IRs looking to get into stroke care, the key steps are clinical evaluation and ability to co-manage these patients (depending on local neurology expertise), understanding of neuroimaging beyond the automated output from some of the commercially available software programs, and, of course, technical performance of thrombectomy including carotid stenting and recognition/management of complications. Stroke is truly a very complex disease state and LVO thrombectomy needs to be performed by physicians fluent and comfortable in all the different aspects of stroke care. And paramount to all this is a robust quality assurance and improvement program.
DS: An IR looking to provide stroke care needs to understand that the intracranial circulation is not simply another vascular bed. The end organ and physiology and the blood vessels are unique. Certainly, wire and catheter skills are complementary, but not identical.
MR: As with other procedures, an IR looking to provide stroke care needs to become educated about stroke so that they can speak the same language as other specialists involved in the care of this patient population. The catheter skills needed for stroke intervention can be learned, ideally from someone who is experienced in endovascular treatment of patients with ischemic stroke.
JG: You’ll need to get proper training and mentorship with someone in INR, in addition to attending stroke conferences and INR meetings while and reading about the subject. Make sure you have experience performing cerebral angiography with good microcatheter skills.
What do you think is the next challenge for IR stroke care?
VV: I think the next challenge is really the next opportunity for IRs in stroke care—establishing formal training pathways into neurointerventional radiology from IR. Though there will be a lag period in this evolutionary step, it will be an important one to allow IRs to continue their involvement in stroke care in the future.
DS: The future of training is an interesting challenge. The adoption of online learning and webinars has made education more accessible, and electronic communication may also allow case observation and even remote proctoring. However, novel means of training will need to maintain favorable outcomes. Otherwise, local availability of stroke interventions will be inferior to transport to a centralized facility, despite the time cost.
MR: I agree. The imaging and clinical evaluation can be learned via a course, but the hands-on training and proctoring remain a challenge. Simulators and remote proctoring may be able help alleviate some of this challenge, but at this time, performing procedures under the guidance of an experienced operator remains essential for those starting out.
JG: I feel our next challenge is for IRs to be recognized as players in the stroke field. This will only be possible by showing outcomes similar or better than those of the other specialties performing these procedures.
Stroke care guidelines
SIR’s Standard’s Division has published multiple guidelines on stroke care, such as:
- Position statements
- Research reporting standards
- Training and credentialling
- Quality improvement
- Collaboration and endorsements
These statements cover everything from training for endovascular stroke to guidelines for carotid stenting, stroke prevention and cervicocerebral angiography.
The SIR Guidelines app is free to use and allows health care workers to quickly access evidence-based recommendations in an easy-to-use, point-of-care format that simplifies clinical decision-making.
The initial release includes an interactive periprocedural recommendation calculator that generates scenario-specific anticoagulation and antibiotic recommendations based on the SIR consensus guidelines. Users can input medications and patient factors to generate recommendations tailored for the patient’s and procedural bleeding risk.
The app will be continually updated to include new Clinical Practice Guidelines and tools to assist in clinical decision-making.
View the stroke guidelines on bit.ly/stroke-guidelines, jvir.org/content/reporting or download the new SIR Guidelines app from the Apple app store at bit.ly/SIR-guidelines.