By Arnd Doerfler and Stefan Schwab
The management of acute ischaemic stroke is rapidly developing. Clinical data suggest that interventional stroke treatment may provide superior clinical outcomes when compared with intravenous thrombolytic therapy only. However, organised and comprehensive stroke care is currently delivered in only a few cerebrovascular centres providing an efficient system for rapid diagnosis and especially dedicated interventional stroke treatment. Delivery of expert and timely neuroendovascular interventions to a large number of acute stroke patients is challenging. This objective has fuelled the concept of regional stroke centres of excellence for the comprehensive care of these patients. Based on our own experience within the Cerebrovascular Excellence Center at the University Hospital Erlangen, University of Erlangen-Nuremberg, Germany, we briefly focus in this article on the organisational aspects necessary for providing a neurointerventional radiology stroke service.
There are a number of key areas supported by evidence-based medicine necessary for a high-level interventional stroke service. As a pre-condition, a neurointerventional stroke service has to be organised within a multidisciplinary acute stroke team with stroke-trained physicians, ideally stroke neurologists and nurses, with an in-house emergency department, rapid laboratory testing, established intravenous rt-PA protocols, and advanced neuroimaging and interventional capabilities.
At least brain CT imaging—ideally multimodal MRI using perfusion imaging and various types of cerebral angiography—should be available 24/7 with imaging priority for stroke patients. In the crucial patient selection for subsequent aggressive therapies, the combination of various imaging techniques may help to differentiate patients who may profit from intravenous or interventional therapy even in an extended time window from those who do not. In our centre, we use multimodal CT imaging as first line diagnostic modality for stroke patients presenting within 4.5 hours after onset (ECASS3 time window). For patients presenting beyond 4.5 hours, for wake-up strokes and for posterior circulation strokes, respectively, multimodal MRI including diffusion and perfusion imaging and MR angiography of intracranial and cervical vessels is used as primary modality. Importantly, a team of specialised neurointerventionalists, ideally those familiar with the wide spectrum of intracranial endovascular techniques, should be available 24/7 with access to interventional angiographic infrastructure. In our centre, five senior interventional neuroradiologists provide a full-time neurointerventional service.
Inside the hospital, it is all about streamlined pathways. Any possible delays should be minimised at every step. Neurological examination, laboratory diagnostics, imaging and, of course, treatment—all these steps need to go from one to another smoothly. This standardised workflow is a key element for the success of our centre.
In addition to neurointensive care, a stroke unit or intermediate care beds for close follow-up monitoring and postinterventional care, other components such as neurosurgery, anaesthesiology and vascular surgery are considered necessary in a tertiary neurointerventional stroke centre. In an excellent stroke unit, where secondary prevention starts early, patients are mobilised rapidly, and stroke neurologists, stroke nurses, physiotherapists, occupational therapists, speech therapists and neuropsychologists are available in a multidisciplinary team.
Other elements crucial to organised stroke care include the pre- and post-clinical phase with triage and diagnosis in the field, telemedicine, transportation, triage and imaging in the emergency department, rehabilitation, prevention and reimbursement issues. Here telemedicine for acute stroke care is an issue of growing interest. Currently, our stroke centre supports 15 hospitals in our catchment area with telestroke facilities and neurointerventional expertise. Stroke experts are available for video consultations when a stroke patient is admitted to one of these hospitals, and imaging data is checked immediately via telenetwork.
Administrative support, strong leadership, and continuing education are additional important elements for a high-level interdisciplinary stroke centre. Integration of these elements into a coordinated hospital-based programme or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a dedicated stroke centre. This again emphasises the importance of multidisciplinary collaboration on professional as well as societal levels.
Arnd Doerfler is professor and head of Neuroradiology, University of Erlangen-Nuremberg, Germany. Stefan Schwab is professor and head of Neurology, University of Erlangen-Nuremberg, Germany.