o Critical care anaesthetists & nursing staff. Vilela P, Rowley H. Brain ischemia: CT and MRI techniques in acute ischemic stroke. Training a non-radiologist to perform an INR procedure such as coiling a brain aneurysm, or mechanical thrombectomy (MT) for stroke is possible in the UK (a very small number of neurosurgeons from the UK and overseas have been trained to coil aneurysms in UK centres), but as yet there is no GMC approved INR training process for a non-radiologist. This article aims to summarise important aspects of MT for primary care physicians and to discuss its implications for the NHS and commissioners. Mechanical thrombectomy for acute ischaemic stroke during the COVID-19 pandemic: changes to UK practice and lessons learned D. McConachie, N. McConachie, P. White, R. Crossley, W. Izzath Nottingham University Hospitals NHS Trust But just Imaging for stroke thrombectomy and resource implications 28 Alexander Mortimer 6. Research and Markets Logo. In the cohort of 275 patients presenting with severe strokes treated with mechanical thrombectomy, 3-month follow-up data are available for 240 patients. 10 Peter McMeekin and Martin James 3. Institute of Translational and Clinical Medicine, Newcastle University, Newcastle upon-Tyne, UK . Saver J, Goyal M, van der Lugt A et al. Thrombectomy is more effective than the current standard treatment of thrombolysis (clot-busting drugs) however only a very small minority of patients are currently able to access thrombectomy. Khoury N, Darsaut T, Ghostine J et al, for the EASI trial collaborators. Nogueira R, Jadhav A, Haussen D et al for the DAWN Trial Investigators. The expected value of perfect information per patient eligible for mechanical thrombectomy in the UK is estimated at £3178. Despite the impact of COVID-19 on most medical device markets, global sales of mechanical thrombectomy devices for the emergency treatment of acute ischemic stroke (AIS) - which includes both stent retrievers and aspiration devices and associated products - is expected to increase at a healthy CAGR of approximately 5.7%, from nearly $677m in … Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. Currently very few UK centres have the critical mass of specialists and support teams to enable them to provide thrombectomy on a 24/7 basis. Where ‘drip and ship’ is the only possible model, staff such as radiographers (with the training to perform CT angiograms) in the receiving hospitals may be found to be in short supply and there may be capacity issues within local radiology services. Read about our cookies.. By Dr Dipankar Dutta2018-11-30T08:44:00+00:00, Dr Dipankar Dutta discusses some important aspects of mechanical thrombectomy and implications for the NHS and primary care clinicians and commissioners. suggests the resource impact in the UK is higher because of the cost of the mechanical thrombectomy procedure. Organising ambulance services for effective implementation of mechanical thrombectomy 23 Chris Price and John Black 5. The use of advanced imaging (CT perfusion or MR diffusion and perfusion scans) can demonstrate salvageable brain tissue regardless of the time of onset of the stroke.32 The DAWN trial treated patients who were last known to be well 6 to 24 hours earlier and had a mismatch between the severity of the clinical deficit and the infarct volume (assessed by diffusion-weighted MRI or perfusion CT). Mechanical thrombectomy for acute ischaemic stroke during the COVID-19 pandemic: changes to UK practice and lessons learned D. McConachie, N. McConachie, P. White, R. Crossley, W. Izzath Nottingham University Hospitals NHS Trust The Royal Stoke University Hospital (RSUH) was the first UK centre to perform mechanical thrombectomy for ischaemic stroke on a regular basis and the first to deliver this 24/7. Safety and efficacy of solitaire stent thrombectomy. A clot-retrieval device attached to a guidewire is introduced through the delivery catheter to the site of the occlusion, to remove the clot and re-establish blood flow. Andrew Clifton In this issue, Werring et al1 have set out the evidence, patient selection and tech- nique 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 HERMES collaboration presented patient level data for 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to usual treatment that included intravenous tPa in 87%).23 Endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted common odds ratio [cOR] 2.49, 95% confidence interval [CI] 1.76–3.53; p<0.0001).23 The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on mRS for one patient was 2.6.23 The benefits of mechanical thrombectomy over usual care were present in patients aged 80 years or older, those randomised more than 300 min after symptom onset, and those not eligible for intravenous alteplase.23 Mortality at 90 days and risk of symptomatic intracranial haemorrhage did not differ between groups.23 Other meta-analyses have presented very similar conclusions; number needed to treat (NNT) to reduce disability of 2.5, and NNT for an extra patient to achieve independent outcome of 4.25 (3.29–5.99).24,25, The overall complications rate of mechanical thrombectomy is about 4 to 29%, based on recent trial data.6,26 However, many complications are minor and do not affect the eventual outcomes for patients.6 Serious complications include vessel perforation (0.9 to 4.9%), arterial dissection (3%), emboli to new territories (6%), symptomatic intracranial haemorrhage (4.3%), and subarachnoid haemorrhage (2.5%).6,26,27 Vasospasm and vascular access site complications (including dissection, pseudoaneurysm formation, retroperitoneal haematoma, and infection) are other potential complications.6,26. The procedure remains very time-dependent; for every 15 minutes saved in reperfusion, an estimated 39 patients per 1000 treated would be less disabled at 3 months, including 25 more who would achieve functional independence.13. Mechanical thrombectomy services: can the UK meet the challenge? The assessment has to be rapid but thorough and consists of stroke diagnosis, likely localisation, assessment of severity, pre-stroke functional status, and co-morbidities.6 Stroke severity is assessed by the National Institutes of Health Stroke Scale (NIHSS) and pre-stroke functional status by the modified Rankin Scale (mRS).9,10 Urgent vascular imaging, typically plain CT and CT angiogram to confirm LAO prior to consideration of thrombectomy, is required. Endovascular thrombectomy and medical therapy versus medical therapy alone in acute stroke: a randomized care trial. There are a few centres where thrombectomy is available in the UK but there are not enough trained professionals for the services to be rolled out across the country. The study found outcomes at 90 days were better with MT plus standard care than with standard care alone.33 The DEFUSE 3 trial found that MT for ischaemic stroke 6 to 16 hours after a patient was last known to be well plus standard medical therapy resulted in better functional outcomes than standard medical therapy alone among patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion and a region of tissue that was ischemic but not yet infarcted (assessed by CT perfusion or MRI diffusion and perfusion scans).27 The NHS England criteria for commissioning allow for the extension of the time window to 12 hours if advanced brain imaging (perfusion or multiphase computed tomography angiography [CTA]) indicates substantial salvageable brain tissue is still present.3. There are significant barriers to the full implementation of round-the-clock mechanical thrombectomy but much progress is being made. Twelve cost-effectiveness studies were also identified, including 2 from a UK payer perspective. With regard to a consultant interventional radiologist training to provide a mechanical thrombectomy (MT) service, the RCR, the British Society of Interventional Radiology (BSIR), the British Society of Neuroradiologists (BSNR) and UK Neurointerventional Group (UKNG) continue to support the supplementary agreement that was published in 2017 and would advise that the following high-level … Introduction: The clinical efficacy and cost-effectiveness of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke is well established, but uncertainty remains around the true cost of delivering this treatment within the NHS. In order to make a referral, the referring Stroke Physician from a local HASU should contact the on-call Neurology Registrar on 07779987168. Lyden P, Brott T, Tilley B et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. 14How many comprehensive and primary stroke centres should the UK have? Mechanical thrombectomy is a new treatment modality for a subset of acute ischaemic strokes that has been proven to be very effective (NNT approximately 3);24 however, it will be necessary to overcome some practical difficulties for the treatment to be universally implemented. Schellinger P, Köhrmann M, Nogueira R. Logistical and financial obstacles for endovascular therapy of acute stroke implementation. How many stroke patients in the UK are eligible for mechanical thrombectomy? Improved reliability of the NIH Stroke Scale using video training. Clifton A. Background Mechanical thrombectomy (MT) is a time-sensitive emergency procedure for patients who had ischaemic stroke leading to improved health outcomes. Goyal M, Menon B, van Zwam W et al, for the HERMES collaborators. Muir K, Ford G, Messow C et al, on behalf of the PISTE Investigators. Update September 2020Training of interventional radiologistsWith regard to a consultant interventional radiologist training to provide a mechanical thrombectomy (MT) service, the RCR, the British Society of Interventional Radiology (BSIR), the British Society of Neuroradiologists (BSNR) and UK Neurointerventional Group (UKNG) continue to support the supplementary agreement that was … At present, at least one centre in the UK is running such a rota and other existing, within hours, services are in the process of expanding their coverage. The current Thrombectomy service at the Walton Centre is available Monday to Friday 7am to 7pm (last call taken at 5pm). Milne M, Holodinsky J, Hill M et al. 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