Defining the Role of the Stroke Physician During Endovascular Therapy of Acute Ischemic Stroke
Six 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.8
There 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.
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.9
It 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.
Drs 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.
Dr 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.
Guest Editor for this article was Georgios Tsivgoulis, MD.
↵* Drs Stotts and Poppe contributed equally.
- Received September 21, 2016.
- Revision received December 5, 2016.
- Accepted December 12, 2016.
- © 2017 American Heart Association, Inc.
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