Defining the Role of the Stroke Physician During Endovascular Therapy of Acute Ischemic Stroke
2017; Lippincott Williams & Wilkins; Volume: 48; Issue: 3 Linguagem: Inglês
10.1161/strokeaha.116.015385
ISSN1524-4628
AutoresGrant Stotts, Alexandre Y. Poppe, Daniel Roy, Tudor Jovin, Cheemun Lum, David Williams, John Thornton, Blaise Baxter, Thomas Devlin, Donald Frei, Chris Fanale, Ashfaq Shuaib, Jeremy Rempel, Bijoy K. Menon, Andrew M. Demchuk, Mayank Goyal, Michael D. Hill,
Tópico(s)Traumatic Brain Injury and Neurovascular Disturbances
ResumoHomeStrokeVol. 48, No. 3Defining the Role of the Stroke Physician During Endovascular Therapy of Acute Ischemic Stroke Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBDefining the Role of the Stroke Physician During Endovascular Therapy of Acute Ischemic Stroke Grant Stotts, MD, FRCPC, Alexandre Y. Poppe, MD, FRCPC, Daniel Roy, MD, Tudor G. Jovin, MD, Cheemun Lum, MD, David Williams, MB, PhD, John Thornton, MD, Blaise W. Baxter, MD, Thomas Devlin, MD, Donald F. Frei, MD, Chris Fanale, MD, Ashfaq Shuaib, MD, Jeremy L. Rempel, MD, Bijoy K. Menon, MD, Andrew M. Demchuk, MD, FRCPC, Mayank Goyal, MD and Michael D. Hill, MD, FRCPC Grant StottsGrant Stotts From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Alexandre Y. PoppeAlexandre Y. Poppe From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Daniel RoyDaniel Roy From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Tudor G. JovinTudor G. Jovin From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Cheemun LumCheemun Lum From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , David WilliamsDavid Williams From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , John ThorntonJohn Thornton From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Blaise W. BaxterBlaise W. Baxter From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Thomas DevlinThomas Devlin From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Donald F. FreiDonald F. Frei From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Chris FanaleChris Fanale From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Ashfaq ShuaibAshfaq Shuaib From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Jeremy L. RempelJeremy L. Rempel From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Bijoy K. MenonBijoy K. Menon From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Andrew M. DemchukAndrew M. Demchuk From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. , Mayank GoyalMayank Goyal From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. and Michael D. HillMichael D. Hill From the Division of Neurology, Department of Medicine (G.S.) and Department of Medical Imaging (C.L.), Ottawa Hospital, University of Ottawa, Ontario, Canada; Department of Neurosciences (A.Y.P.) and Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal, Québec, Canada; University of Pittsburgh Medical Centre, PA (T.G.J.); Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin (D.W.); Beaumont Hospital, Dublin, Ireland (D.W., J.T.); Erlanger Medical Centre, Chattanooga, TN (B.W.B., T.D.); Swedish Medical Centre, Englewood, CO (D.F.F., C.F.); Division of Neurology, Department of Medicine (A.S.) and Department of Radiology (J.L.R.), University of Alberta, Edmonton, Canada; and Department of Clinical Neurosciences (B.K.M., A.M.D., M.D.H.), Department of Medicine (A.M.D., M.D.H.), Department of Radiology (A.M.D., M.G., M.D.H.), and Department of Community Health Sciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. Originally published31 Jan 2017https://doi.org/10.1161/STROKEAHA.116.015385Stroke. 2017;48:805–807Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2017: Previous Version 1 IntroductionSix recent trials and a patient-level meta-analysis have demonstrated the superiority of endovascular therapy (EVT) compared with standard care (including intravenous alteplase) among patients with large-artery anterior circulation strokes.1–7 The absolute benefit of EVT was substantial in these trials, and EVT now requires careful implementation and optimization in real-world settings to provide all eligible patients with this new standard of care. Parallel rather than serial workflow, with team members having well-defined roles, is a crucial element in providing rapid and effective delivery of acute stroke care.8There is little or no literature on the division of labor or the expected role for each individual in this setting, and existing stroke guidelines do not elaborate on this issue. Although each system may require customization, it is clear is that there must be physician leadership outside of the angiography suite, a physician in addition to the neurointerventionalist (who is most commonly a radiologist, but who may be a neurosurgeon or neurologist) in the angiography suite, and a physician to coordinate care between the other stroke team members throughout the periprocedural period. We suggest that it is necessary to designate a physician to fulfill these roles during the EVT process, and we have termed herein the individual fulfilling this role the stroke physician.The stroke physician must work in close collaboration with the neurointerventionalist to optimize the speed, efficiency, and safety of EVT, elements which are critical to enhancing patient outcomes. A proposed division of physician roles is shown in Table, with emphasis on parallel rather than serial workflow. The administration of intravenous alteplase is ideally performed under the guidance of a stroke physician with specialized training in stroke care. This is most often a neurologist but may also be an emergency physician, geriatrician, internist, or family physician, according to regional differences in the provision of stroke care. Similarly, the evolution of EVT has varied between centers and healthcare systems, at some sites being championed by stroke physicians and at others by neurointerventionalists. Both roles are essential to ensure the highest quality acute stroke care.Table. Respective Roles of the Stroke Physician and the Neurointerventionalist Before, During, and After Endovascular Therapy for Acute Ischemic StrokeStroke PhysicianNeurointerventionalistVerify last seen normal/stroke onset timeDetermine baseline functional status and obtain medical historyDetermine current clinical deficits—neurological examination (NIHSS)Identify patients as a possible EVT case (high NIHSS score, good premorbid status) and alert neurointerventional teamDetermine angiography suite availabilityAssess and manage hemodynamics and medical comorbidities in view of potential reperfusion therapyEstablish if there are contraindications to intravenous thrombolysis (alteplase)Review CT and CTA (or MR and MRA) and determine whether patient is EVT candidateReview CT and CTA (or MR and MRA) and determine whether patient is EVT candidateInitiate alteplase (if indicated) as quickly as possiblePrepare EVT plan based on arterial anatomyManage all patients not candidates for EVT (eg, stroke mimic, no large-vessel occlusion, etc)Interventionalist signs off the caseDiscuss EVT with patient and family if possibleDiscuss EVT with patient and family if possibleObtain verbal consent for EVT if possiblePrepare angiography suite for procedureDetermine potential need for anesthesia (general or conscious sedation) and consult anesthesia as requiredDetermine potential need for anesthesia (general or conscious sedation)Manage conscious sedation or assist anesthetist as requiredPerform EVT procedureMonitor vital signs and hemodynamics during procedurePerform EVT procedureDiscuss therapeutic options (eg, cervical carotid stenting) and termination of EVT when difficultDiscuss therapeutic options (eg, cervical carotid stenting) and termination of EVT when difficultCollect and provide quality metricsCollect and provide quality metricsManage postprocedural medical issues (eg, BP management, antithrombotic management)Collaborate on postprocedural medical managementDocument evolution of patient in chart and order appropriate investigationsAid in management of arterial puncture-site complicationsOrganize any relevant consults (medical, multidisciplinary)Transfer to acute care/stroke unitThose roles shown side by side should be performed in parallel. BP indicates blood pressure; CT, computed tomography; CTA, computed tomographic angiography; EVT, endovascular therapy; MR, magnetic resonance; MRA, magnetic resonance angiography; and NIHSS, National Institutes of Health Stroke Scale.Although recent EVT trials did not prespecify the role of the stroke physician in the periprocedural management of patients, rapid revascularization as was achieved in these trials is likely favored by having a stroke physician experienced in all steps of the EVT process. In practice, the initial decision to proceed with EVT most often occurs immediately after neurovascular imaging. Approximately 20% of a population-based distribution of ischemic strokes patients will be eligible for EVT, and therefore, the stroke physician plays a key role in deciding who is a potential candidate. Importantly, the stroke physician will take charge of patient management for the 80% of stroke patients who are not candidates for EVT.The stroke physician is responsible for collecting the clinical information often from witnesses and family, examining the patient, and obtaining imaging before this decision point. Given the significant loss of brain tissue with every minute of delay in treatment, the stroke physician can independently assess computed tomography–based neurovascular imaging to minimize time to thrombolysis (in part by administering alteplase directly in the computed tomographic scanner) and accelerate mobilization of the endovascular team. Rapid identification of patients with large-vessel occlusion stroke but a clear contraindication to intravenous alteplase is also critical to rapid activation of the neurointerventional team. Proceeding with EVT should then be a joint decision between the stroke physician and the neurointerventionalist, both of whom have assessed clinical and radiological admissibility criteria.The stroke physician leads the initial medical management of the patient and ensures that when appropriate, intravenous alteplase is rapidly initiated. To avoid delays, stroke physicians should have adequate knowledge to obtain consent from the patient or next of kin for the endovascular treatment should the interventionalist be unavailable while preparing for the procedure. However, family contact and discussion with the interventionalist remains crucial typically after the EVT procedure. The stroke physician will have the time to discuss with family and loved ones while the interventional procedure is underway to understand, as best as possible, the wishes of the patient and their baseline level of functioning and the immediate plan for the future care of the patient. The stroke physician is also well placed to offer participation in ongoing clinical trials with next of kin.In the angiography suite, the neurointerventionalist concentrates on the task at hand of rapidly achieving reperfusion. The clinical information gathered by the stroke physician is essential to treatment decisions made during the EVT procedure. A strong trusting relationship between the neurointerventionalist and the stroke physician must exist so that each respects the other's judgment and is willing to act in tandem to avoid delays to successful reperfusion.The medical care of the patient during the procedure should be ensured by the stroke physician and a dedicated nurse. This includes monitoring of blood pressure and maintenance of appropriate hemodynamics, correction of significant metabolic abnormalities, periodic assessment of clinical status, and provision of conscious sedation when necessary. In addition, performance metrics such as key time delays can also be monitored and recorded by the stroke physician or delegate during EVT for continued quality improvement processes. The stroke physician is part of the decision-making process for common interventional issues such as complicated access, carotid stenosis or occlusion, emboli refractory to interventions, and adverse effects of EVT such as dissection or hemorrhage. These decisions are generally facilitated by avoiding general anesthesia because they may require clinical reassessment of the patient in the angiography suite and an understanding of the patient's hemodynamic status and indication for or contraindications to antithrombotic agents. In select situations of significant patient instability or agitation, some of the stroke physician roles may be delegated to an anesthetist; however, routine general anesthesia does not seem to confer any clinical benefit.9It is fundamental to good care that the stroke physician or their delegate is present and involved before, during, and after the EVT procedure. Postprocedural care requires an understanding of the events that unfolded during the case. Because current evidence defining postprocedural care is in its infancy, decisions will be made based on best understanding of the immediate physiology. Knowledge of the affected artery status post-procedure, collateral circulation, and hemodynamic requirements will affect immediate diagnostic and treatment decisions, including the minimization of postprocedural hemorrhage risk by judicious postrecanalization management of blood pressure. This includes the need for repeat imaging, antihypertensive and antithrombotic management, thromboprophylaxis, and early involvement of the rehabilitation team. In some cases, issues may arise about rapid admission to a stroke unit bed or return of a patient to a referring center post-EVT, which is the responsibility of the stroke physician and stroke nursing staff.In summary, the rapid and safe implementation of the entire EVT process requires combined leadership from both a stroke physician and a neurointerventionalist. The stroke physician works with the neurointerventionalist to ensure coordination between members of the acute stroke care team, and both are present during the procedure. The stroke physician is the point of contact with family members throughout the continuum of acute care and helps to coordinate paramedics, emergency department triage nurses, bedside nurses and physicians, computed tomographic technicians, angiography technicians, neuro-angiography nurses, and stroke critical care nurses whose roles are indispensable. Although there is great variability in stroke expertise available emergently at different stroke centers, comprehensive centers, like trauma centers, should strive to have stroke physicians available in house who can perform rapid and accurate stroke diagnosis and initiate proper treatment. As the field moves forward, we predict that stroke physicians will become increasingly involved in developing prehospital aspects of stroke care.Although regional differences in organization and implementation are inevitable, in our opinion, the standard of care should mandate that stroke physicians participate actively alongside their interventionalist colleagues before, during, and after all EVT procedures to optimize swift, safe, and effective reperfusion for patients with stroke caused by large-vessel occlusion.AcknowledgmentsDrs Stotts, Poppe, and Hill conceived of the idea, drafted the article, and completed revisions. Drs Roy, Jovin, Lum, Williams, Thornton, Baxter, Devlin, Frei, Fanale, Shuaib, Rempel, Menon, Demchuk, and Goyal reviewed and edited the article.DisclosuresDr Hill receives grants from the University of Calgary for the ESCAPE trial and the HERMES collaboration from Medtronic, receives consulting fees from Merck, and has stock ownership in Calgary Scientific, Inc. Dr Poppe is the site PI for the ESCAPE trial and receives speaker's honoraria from Medtronic, which is a modest compensation. Dr Roy is in the Core Laboratory for the ESCAPE trial and receives a significant compensation. Dr Williams is in the advisory boards for Boehringer-Ingelheim, Bayer, BMS-Pfizer, and Daichii Sanyko and receives a modest compensation. Dr Thornton has stock ownership in the advisory boards for Neuravi and receives a modest compensation. Dr Baxter is in Speaker's bureau and advisory boards and receives honoraria for Penumbra, which is a significant compensation. Dr Baxter also has stock ownership in Penumbra. Dr Demchuk receives honoraria for continuing medical education events from Medtronic, which is a significant compensation. The other authors report no conflicts.FootnotesGuest Editor for this article was Georgios Tsivgoulis, MD.*Drs Stotts and Poppe contributed equally.Correspondence to Alexandre Y. 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Hassan A, Sanchez C and Johnson A (2017) Endovascular treatment outcomes using the Stroke Triage Education, Procedure Standardization, and Technology (STEPS-T) program, Interventional Neuroradiology, 10.1177/1591019917740100, 24:1, (51-56), Online publication date: 1-Feb-2018. Goyal M, Wilson A, Kamal N, McTaggart R, Jayaraman M, Fisher M and Hill M (2017) Amartya Sen and the Organization of Endovascular Stroke Treatment, Stroke, 48:8, (2310-2312), Online publication date: 1-Aug-2017. March 2017Vol 48, Issue 3 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.116.015385PMID: 28143924 Manuscript receivedSeptember 21, 2016Manuscript acceptedDecember 12, 2016Originally publishedJanuary 31, 2017Manuscript revisedDecember 5, 2016 KeywordsstrokebrainangiographyworkflowthrombectomyPDF download Advertisement SubjectsCerebrovascular Disease/StrokeIschemic Stroke
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