Mechanical thrombectomy for ischemic stroke: a role for cardiology!

Abstract

The classic (6 hours) 2 window would have been borderline at the CSC 1 while rich collaterals 1 indicated , in fact, an extended window. 2 He was ineligible for thrombolysis (whose efficacy is significantly limited in LVO), was refused MT in the CSC, and unsurprisingly, had a very bad outcome (Modified Rankin Scale score, 4) and will be a burden to his family and the health system. This all could likely have been avoided by rapid MT at a local facility. The story 1 illustrates several issues fundamental to understanding current problems with MT adoption, including a rapid and effective access to MT as the first-line consideration. Indeed, with the current very poor access to MT in some countries including Poland, 3 stroke interventions must be rapidly expanded geographically and with a dramatic increase in the number of willing and trained interventionists to meet the enormous public health need. The "gold standard" treatment of AIS (rapid mechanical revascularization) mirrors the last 2 decades of acute myocardial infarction care. In contrast to acute myocardial infarction, however , we now face an overwhelming shortage of neurointerventionists to support the shift in AIS treatment. Therefore, interventionists from other training backgrounds must now fill this gap in AIS, and a collaborative ST-segment elevation myocardial infarction (STEMI) model for care needs to be instituted to ensure rapid re-vascularization, particularly as the brain cells are far more sensitive to ischemia than the myo-cardium. 4 If the case is very complex, the time to transfer the patient from a thrombectomy-capable centre to CSC is after the blocked artery has been opened and the brain reperfused. Otherwise, local treatment will suffice. Training many more neuroradiologists does not appear to be a practical solution. The volume of elective intracranial work does not provide enough cases to support the many more providers needed to treat AIS. The only practical solution is to recruit and train other practicing interventionists, such as cardiologists and interventional radiologists (neurologists A role for cardiology! To the editor Acute ischemic stroke (AIS) is a major cause of death and disability. Up to approximately 35% strokes are caused by potentially reversible large-vessel occlusion (LVO). The recent stroke thrombectomy clinical vignette in Kardi-ologia Polska (Kardiol Pol, Polish Heart Journal) 1 presents a major stroke patient who, in all likelihood , would have been a routine candidate for guideline-mandated 2 mechanical thrombectomy (MT) to improve his lifelong prognosis by reducing the discharge disability level. 2 Although a full functional recovery can never be guaranteed, imaging studies portended a significant opportunity for major improvement with MT which could have restored functionality and saved the long-term care burden and health system costs. Time to intervention is critical in LVO-AIS, with patients revascularized in 2 hours or less achieving approximately 90% good functional clinical recovery. 2 The recovery associated with a delay of more than 6 hours is considerably poorer , yielding approximately 20% good functional outcome. 2 Despite the on-site availability of a staffed primary percutaneous coronary intervention catheterization laboratory used for elec-tive neuroradiology procedures, a certified AIS-MT operator (cardiologist / angiologist) and what appears to be an upstanding stroke unit (catch-ment area of approximately 500 000 inhabitants , stroke thrombolysis leading implementation), MT was regrettably not performed on site. 1 Referral was mandated to the single "desig-nated" MT center (comprehensive stroke centre , CSC) in the region (province) inhabited by a large population (3.8 million) with transfer times of up to approximately 3 hours. Stroke epidemiology data suggest this region needs up to 1500 MTs per year. No routine CSC is able to process more than 250 to 300 MT cases per year. The data-driven goal is revascularization within 2 hours for best results. 2 No avoidable trans-portations can be accepted in AIS. This patient was rejected by CSC citing "nega-tive effect of transportation on MT eligibility." 1