Editorial
Organization of Endovascular Thrombectomy
The Need for a 2-Tier System
Mayank Goyal, MD; Kathinka D. Kurz, MD; Marc Fisher, MD
I n 2015, with the publication of 5 randomized controlled tri-
als in the New England Journal of Medicine, endovascular
thrombectomy (EVT) became the standard of care for acute is-
chemic stroke patients with a large vessel occlusion within 6
hours after stroke onset.1–5 This treatment is time sensitive and
faster treatment leads to better outcomes.6 Broadly speaking,
the onset of stroke to imaging decides the likelihood of favor-
able imaging and imaging to reperfusion decides the likelihood
of good outcome.7 The quality of reperfusion correlates to out-
come.8 Intravenous alteplase has limited effectiveness in this
population of acute stroke because of large vessel occlusion.
Given the effectiveness of the treatment (number needed to treat
of 2.5 for one-point improvement in modified Rankin Scale),
we have an obligation to create systems of care that can make
this treatment available to as many eligible patients as possible.
Stroke care is a multidisciplinary team effort. It is not just
about the procedure in the catheterization lab and pulling the
clot out. It starts from the identification of stroke symptoms
to the 911 call to organization of transport, assessment and
parallel processing in the emergency department, fast and
effective imaging, appropriate decision making, management
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of vital signs, airway and sedation, anesthesia as needed dur-
ing the procedure, providing postprocedure care in a stroke
unit and neurocritical care unit, and appropriate rehabilitation.
It is highly likely that higher volume centers will be better
at achieving this.9 At a societal level, organization of medical
therapeutics is going to be different from surgical therapeutics
especially for those that are time critical and require high lev-
els of training and specialization and appropriate equipment.
The distribution of the human population can be broadly
divided into cities, towns, and rural areas. Cities, by definition,
have a large collection of people and will usually have pre-
existing tertiary health care facilities that are experienced in
managing emergencies, such as acute myocardial infarction,
trauma, obstetric emergencies, etc. At the tertiary center, the
management of stroke typically includes a multidisciplinary
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
Department of Radiology, University of Calgary, AB, Canada (M.G.);
Department of Radiology, Stavanger University Hospital, Norway
(K.D.K.); Department of Electrical and Computer Engineering, University
of Stavanger, Norway (K.D.K.); and Department of Neurology, Beth
Israel Deaconess Medical Center, Boston, MA (M.F.).
Guest Editor for this article was Ralph L. Sacco, MD.
Correspondence to Mayank Goyal, MD, Seaman Family MR Research
Centre, Foothills Medical Centre, 1403 29th St NW, Calgary, AB T2N
2T9. Email mgoyal@ucalgary.ca
(Stroke. 2019;50:1325-1326.
DOI: 10.1161/STROKEAHA.118.024482.)
© 2019 American Heart Association, Inc.
Stroke is available at https://www.ahajournals.org/journal/str
DOI: 10.1161/STROKEAHA.118.024482
1325
team consisting of emergency physicians, stroke neurologists,
neurointerventionists, nurses, technologists, etc. In most cen-
ters, the service is run on a 24/7/365 basis. In addition, these
centers have a well-functioning and staffed stroke unit, reha-
bilitation specialists and necessary infrastructure such as bi-
plane neuroangiography suite stocked with all necessary tools,
neuroICU, etc. Towns may or may not be close to a city, will
generally have a medical facility that will be able to provide
some basic surgical procedures, but there will be a high de-
gree of variability between different hospital regarding what
procedures and services are available. The factors that will
influence the availability of services include as follows: the
size of the town, proximity to a city, economic considerations,
population demographics and possibly other random factors
such as local leadership, history of the town, etc. Rural areas
will, by definition, have a low population density and typically
patients will have to be transported to towns or cities for se-
rious/complex medical problems.
Thus, when we have to think of the organization of acute
stroke care, we cannot characterize the entire country/pop-
ulation with one approach. Cities have the opportunity for
maximizing specialization, teamwork, efficiency, and create
centers of excellence. We know that in general higher volume
centers have higher reperfusion rates and faster workflow.
Conversely, smaller places catering to a less dense population
(those that are not close to a large city) may require a differ-
ent solution that balances the potential loss of efficiency and
effectiveness by having reduced specialization and volume
versus the time spent in transporting the patient to a relatively
distant tertiary center.
We have no choice but to create measurement of perfor-
mance tools for these 2 scenarios that are distinctly different.
These performance tools should not be limited to just the pro-
cedure (eg, groin to reperfusion, quality of reperfusion, and
procedural complication) but should apply to the system as a
whole (stroke onset to 911 [in some ways a reflection of pa-
tient education], 911 to arrival on-site, on-site time, time to
get to the correct hospital, etc). The bar for workflow, volume
of cases, training of personnel, complications, and outcomes,
should be stricter for tertiary centers. This way patients with
stroke in cities which, by the way, is the majority of the people
in the developed world will have access to much higher quality
of care and have the highest potential for favorable outcomes.
Patients in less populated areas can still have access to the
treatment (as opposed to no access or significantly delayed
access) in a center that can provide EVT. The tertiary centers
can in many situations provide training, support, and other
services to these smaller centers. This support could be live
through video conference, teleradiology, etc or could be by
regular training courses, simulation workshops, and confer-
ences focused on complications and difficult cases.
 1326  Stroke  June 2019
By setting a universally lenient bar (which is being sug-
gested by some organizations), we do solve the problem of
allowing centers to be created and some level of service to be
provided in the less populated areas, but we risk (and this is
a major risk) of unnecessarily diluting the optimal outcomes
that can be achieved in cities by appropriate triage. This will
result in many centers having lower volumes, unable to sus-
tain the required level of infrastructure, teamwork and 24/7
service. To support a worthy cause and maintain the ability to
provide this highly effective treatment to the as much of the
population as possible, we risk making it less effective for the
majority because the majority of the population lives in cities.
The risk of setting the bar high, as is being recommended by
some societies,10 is that centers outside big cities will not have
a sufficient volume and may not be able to attract the nec-
essary talent. It also prevents/delays access to populations of
some jurisdictions/countries that are just starting to perform
EVT. Of course, more data would be needed to show that
treatment at a low-volume center is better than no treatment or
substantially delayed treatment.
Thus, what would make sense is to have 2 distinct
pathways:
1. Tertiary, high population density areas: here the bar
should be set high for the volume of cases, workflow
complications, etc. The number of centers of course will
have to be limited to allow centers to have a sufficient
volume and sustain 24/7 in-house availability.
2. Not-so-densely populated areas: here the bar should
be set such that individual hospitals and physicians are
encouraged to learn and provide EVT. The bar for the
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number of cases and workflow parameters could be
much lower. However, the bar for the hospital to allow
sufficient opportunity for the team to have continued
medical education, the opportunity to collaborate and
learn from high volume centers, keep up their skill set
using simulation tools, etc should remain reasonably
high. In addition, these centers will be expected to
maintain excellent records and be subject to audits to
demonstrate that the results of the randomized trials are
being replicated.
We have but one opportunity to set this up correctly. It
is much easier to make appropriate recommendations now as
EVT for stroke is starting to expand rather than let it devolve
into chaos and then restructure the system later on.
Disclosures
None.
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KEY WORDS: Editorials ◼ brain ischemia ◼ decision making ◼ reperfusion
◼ standard of care ◼ stroke ◼ thrombectomy