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In this issue, Werring et al 1 have set out the evidence, patient selection and technique of one of the most effective new treatments in stroke medicine, with a ‘number needed to treat’ of fewer than three for improved functional outcome. The UK’s National Institute for Health and Care Excellence (NICE) (February 2016)2 and the Royal College of Physicians of London (October 2016)3 have each issued guidelines on its uptake, but these are purely advisory. In April 2017, National Health Service (NHS) England announced that it will commission mechanical thrombectomy. This is likely to be one of the biggest funding commitments that NHS England specialised commissioning has ever made: over £100 million per year when fully implemented, but balanced by massive life-changing patient benefit. NHS England is now working to assess each of England’s 24 neuroscience centres to establish the degree of readiness to provide this service.
The challenge will be to deliver the service to our patients safely and effectively. It will be a very major undertaking to provide the additional doctors, nurses, radiographers and other staff to be able to treat the 8000 or so patients estimated to be eligible for this treatment.4 The only doctors trained currently in the UK to provide this treatment are interventional neuroradiologists, and we have only around 80 of these. We therefore need Health Education England to make a substantial investment to train interventional specialists. Appropriate training has been, and is being, discussed by the British Society of Neuroradiologists, the UK Neurointerventional Group, the British Society of Interventional Radiologists, and representatives of the Royal Colleges. Guidelines on training have been published and comments made.5 6 It is a matter of debate whether the neuroscience centres will be the only sites performing these procedures, and whether neurointerventionalists will be supported in some centres by general interventional radiologists, cardiology colleagues or even interventional stroke physicians and neurologists who have undergone appropriate training. The other option would be for some geographical areas to have regional thrombectomy centres staffed by trained non-neurointerventionalists. These logistics are currently being considered.
As Werring et al discuss, there are two ways to deliver thrombectomy: either ‘drip and ship’, or ‘mothership’ direct transfer to specialist centre. Both may be appropriate, depending on the geographical spread of the local population. However ‘drip and ship’ has its own challenges: the patient needs a RED category response for transfer from the triaging interventional centre/hyperacute stroke unit to the thrombectomy centre, and this will need to be commissioned. The other major challenge is the investment in training and resources to deliver the immediate imaging in district general hospitals triaging for ‘drip and ship’. Currently, there are too few radiographers trained to perform the CT cerebral angiography at the same time as the plain CT scans. Immediate interpretation is also not universally available, either by a radiologist in discussion with a stroke physician or by a stroke physician alone. We need resources to provide this. Several stroke centres in the UK are already providing training.
In addition, it is essential that clinicians submit data on all patients to the UK’s Sentinel Stroke National Audit Database (SSNAP audit) and, when appropriate, recruit them to ongoing clinical trials. Of particular interest are those trials using advanced imaging to assess the efficacy of thrombectomy, such as the proposed Pragmatic Ischaemic Thrombectomy Evaluation-Advanced Imaging (PISTE-AI) trial.
In conclusion, thrombectomy should be the standard of care for our patients and NHS England’s announcement that it is commissioning the service is most welcome. However, it will take a lot of hard work, cooperation, consultation and support from all staff groups and levels of management for this to succeed.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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