Endovascular Therapy in Stroke: Who Should Do What?

Pauline Anderson

February 16, 2017

As endovascular therapy (EVT) becomes the standard of care for stroke patients with a large-vessel occlusion, it's important to outline the roles of physicians involved in the procedure, according to a group of experts in the field.

Stroke neurologist Alexandre Y. Poppe, MD, clinical associate professor, Department of Neurosciences, Université de Montréal, Quebec, Canada, and colleagues believe that stroke physicians should actively participate alongside their interventionist colleagues before, during, and after the EVT procedure to optimize swift, safe, and effective reperfusion.

There are typically two physicians involved in the EVT procedure: a stroke doctor, usually a neurologist, and an interventionalist, most often a radiologist but sometimes a neurosurgeon or a neurologist.

In a commentary published online January 31 in Stroke, the authors propose a division of labor between the stroke physician and neurointerventionalist that emphasizes "parallel rather than serial workflow."

"The bottom line is that EVT is now the standard of care for certain types of stroke and it's a complex, multidisciplinary procedure that requires team work and cooperation," Dr Poppe told Medscape Medical News.

"This goes beyond just an intervention; there is a whole continuum of care that we have to provide and that requires a partnership."

Authors of the commentary represent stroke physicians and radiologists from Canada, the United States, and Ireland. Some contributed to the ESCAPE trial, which demonstrated benefits of EVT using available thrombectomy devices compared with conventional treatment for patients with acute ischemic stroke. 

Although ESCAPE and other recent landmark trials, including MR CLEAN, SWIFT-PRIME, EXTEND-IA, and REVASCAT, showed that EVT is superior to medical therapy in acute stroke care, "there were no details in those studies about how the actual procedures were done or the roles of each of the participating physicians," said Dr Poppe.

Professional guidelines also don't provide much direction, he said.

Clinical Evaluation

The stroke physician is normally the initial point of contact in the emergency department. "Stroke physicians evaluate the patient clinically; they take the history, they examine the patient, and they make the diagnosis of stroke," said Dr Poppe.

In the 80% or so of patients eligible for intravenous alteplase (tissue plasminogen activator), this procedure is ideally administered under the guidance of a stroke physician with specialized training in stroke care.

About 20% of patients with ischemic stroke might be eligible for EVT If, on the basis of examination and results of neurovascular imaging, the stroke physician recommends EVT, he or she will contact an endovascular colleague.

Rapid identification of patients with large-vessel occlusion stroke but a clear contraindication to intravenous alteplase is "critical" to rapid mobilization, the authors write.

The endovascular expert oversees the technical side of things, the authors propose. These experts are the ones actually performing the procedure in the angiography suite, but they also carry out other tasks, such as preparing an EVT plan based on arterial anatomy and determining the potential need for anesthesia. The goal, of course, is rapidly achieving reperfusion.

During the procedure, the patient's medical care — including, among other things, monitoring blood pressure and maintaining appropriate hemodynamics — should be managed by the stroke physician along with a dedicated nurse, said the authors.

"It is fundamental to good care that the stroke physician or their delegate is present and involved before, during, and after the EVT procedure," they write.

As stroke was becoming an interventional procedure, "there was initially some fear that the stroke physician might be kind of excluded, or put on the sidelines, and the role would be less clear," said Dr Poppe. "We felt that it was important to restate how important that physician was in the whole procedure."

While procedures vary from hospital to hospital, the aim of the commentary was to "help streamline" the process and "make things go more smoothly," said Dr Poppe. "We can't force anyone to follow this, and it's true that people have their own approaches, but our idea was to kind of standardize the approach."

Dr Poppe noted that a growing number of neurologists are doing their own interventions. "The field is like cardiology was maybe 15 or 20 years ago, when cardiologists started to do their own procedures, such as coronary angiograms."

Double Role

Randall C. Edgell, associate professor, interventional and vascular neurology, Departments of Surgery and Neurology, Saint Louis University, Missouri, is one such expert playing two roles. He's an interventionalist who also does clinical stroke care.

While the "vast majority" of institutions now follow the division-of-labor model described in the article, there are a "growing but still small" number of successful programs where the roles are combined, said Dr Edgell.

He sees pros and cons to both approaches.

The plus side to having two experts with separately defined roles is that the stroke doctor "can focus on collecting the clinical information only and the interventionist can focus on the procedural aspects only."

The downside of this approach, however, is that "those two people have to really be on the same page," and physicians are often uncomfortable with the concept of working in parallel, said Dr Edgell.

"Clinical instincts may be different at times between those two people, and, human nature being what it is, it takes a long time to develop a really streamlined and mutual understanding in that kind of tense, time-sensitive situation."

It's too early to say which approach will prevail. "I don't know that you can say that the pendulum is swinging at this point," said Dr Edgell. "It's going to take time to sort out which ends up being the best and most successful model for patient care."

Dr Poppe is the site principal investigator for the ESCAPE trial and receives speaker's honoraria from Medtronic, which is a modest compensation. Dr Edgell is a consultant to Penumbra Inc.

Stroke. Published online January 31, 2017. Abstract

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