A wealth of new data confirming the beneficial role mechanical thrombectomy can play in the treatment of acute ischaemic stroke came to light through the 2010s, but global healthcare systems are still fighting to make these procedures available for more patients, more of the time, and on a more universal basis. Around-the-clock services are yet to be established across the UK and, even in regions where this has been achieved, such as the USA and other parts of Europe, notable access disparities remain, with recent developments reflecting the urgent, worldwide need to rectify this.
In October, representatives of the Stroke Association were at 10 Downing Street in London, UK to hand over an open letter encouraging Prime Minister Rishi Sunak and the British government to prioritise a 24/7 thrombectomy service for eligible patients across the country.
The letter, and the benefits associated with this intervention, were backed by more than 9,000 signatures from among the stroke community—and supported by the World Stroke Organization (WSO), the British Heart Foundation and the Royal College of Radiologists, along with many other groups.
Sanjeev Nayak (University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK), a consultant interventional neuroradiologist who played a leading role in establishing the first 24/7 thrombectomy service in the UK, and is now championing the Stroke Association’s attempts to make this a nationwide offering, recently spoke to NeuroNews to discuss this in more detail.
Having submitted the aforementioned letter to 10 Downing Street on 17 October, the charity is yet to receive a response from the British government, but a subsequent parliamentary reception held at the House of Lords saw various stakeholders involved in stroke thrombectomy care meet with UK members of parliament (MPs). Nayak noted that this event was well attended, with many MPs strongly supporting the need for a 24/7 thrombectomy service throughout the UK.
“The concept of a postcode lottery is no longer acceptable,” he added. “This life-changing service should be available round the clock throughout the UK. Last year, more than 6,000 patients in the UK missed out on this treatment—which meant they suffered significant physical disabilities because of severe stroke [that] could potentially have been prevented. The costs of stroke rehabilitation because of disability runs in [the] millions of pounds and this money can instead be used to fund the 24/7 stroke thrombectomy service within UK.”
In its letter addressed to the UK prime minister, the Stroke Association asserts that thrombectomies can save brains, save money and, ultimately, change lives, yet provision of these procedures is “patchy”, as treatment rates vary from 80% of patients who need them in London to 0–30% in other parts of England.
With National Health Service (NHS) England having missed its target of fully rolling out this treatment by 2022, and the current thrombectomy rate standing at 2.8%, the Stroke Association’s recent ‘Saving Brains’ report outlined several measures to help meet the newly revised target for a 24/7 service by 2029. These include urgent funding for infrastructure, equipment, training and support, as well as developing a sustainable stroke workforce plan; the need for NHS England to address wider systematic challenges; and for research funders to increase accessibility and improve rates of thrombectomy.
“The input from the government is too little and I hope they can see the harm caused [by] not offering this service round the clock within the UK,” Nayak continued. “The biggest barrier is the lack of capital funding to run a 24/7 service. Every region in the UK has its unique requirements. Hence, capital funding should be provided to UK thrombectomy centres, which can then be used as per their local requirement. Also, investment must be made into the patient transfer pathways, and quicker transfer [facilitation] through road and air ambulance for thrombectomy patients should be prioritised. Time is brain and faster treatment times can lead to significantly better patient outcomes.
“I would like to see a 24/7 thrombectomy service throughout the UK by 2025. However, being more realistic, we should be able to achieve this in next five years.”
In addition to highlighting that the use of artificial intelligence (AI) has “revolutionised” stroke care, and claiming that “all stroke centres should avail such software to improve thrombectomy diagnosis and treatment”, Nayak pointed to the need for global partnerships in helping to develop more effective thrombectomy pathways—including the Society of Vascular and Interventional Neurology’s (SVIN) global ‘Mission Thrombectomy’ campaign (MT2020+), which the Stroke Association is currently in talks with and hoping to be a part of moving forward.
Across the pond
Another comment made by Nayak on this topic was that “the UK can learn from other countries where such treatments have been successfully implemented on a 24/7 basis”—something that interventional stroke neurologist Dileep Yavagal (University of Miami, Coral Gables, USA) echoed in conversation with NeuroNews.
“Thrombectomy in the USA is provided 24/7—no exceptions or off hours for this emergency service—for all eligible patients at hospitals that are certified as thrombectomy stroke centres (TSCs),” he said. “The main difference is that availability of TSCs in the USA is market-driven and not centrally planned, as in Europe. TSCs have proliferated rapidly in all US states as the hospitals are highly reimbursed for each thrombectomy by Medicare, with federal insurance for patients >65 years, as well as by private insurances.
“The other big difference [compared to Europe and the UK] is that denial or delay of thrombectomy is heavily punished by the medico-legal system. Another is the widespread adoption of a ‘bypass protocol’ by prehospital services, in which a non-TSC hospital is bypassed even if it is the closest hospital, and the suspected large vessel occlusion patient is taken to the nearest TSC as long as they are within 30 minutes travel time.”
While TSCs are now present in all 50 US states—a feat achieved within just a few years of thrombectomy becoming the standard of care in 2015—acute stroke services in the USA are not without their own difficulties. According to Yavagal, owing to variable distribution of these thrombectomy-certified centres, and them being concentrated in more densely populated, urban areas, the uniformity of time to access these treatments remains a key challenge.
“The large size of the USA and variable population centres are the geographical challenges that make it hard [to enable] uniform, 60-minute access to a thrombectomy centre for everyone,” he continued. “Currently, 21 states have >50% of their population living outside a 60-minute drive radius from a thrombectomy centre. Implementing public health interventions to ensure 60% access to 100% of the US population is a major priority for MT2020+.”
On World Stroke Day (29 October 2022), the need for eligible large vessel occlusion (LVO) stroke patients to be triaged and transported directly to Level 1 stroke centres capable of performing thrombectomy—something that is being increasingly recognised and has led to protocol shifts across many US states already—was emphasised by the Society of NeuroInterventional Surgery (SNIS) via its Get Ahead of Stroke campaign.
As the chair for the MT2020+ health campaign—which was founded by the SVIN in 2016 to accelerate global access to stroke thrombectomy surgery—Yavagal is well placed, not only to comment on the current state of affairs in the USA, but also to discuss ongoing efforts to improve stroke interventions across the globe. These efforts were showcased recently at the 2022 SVIN meeting (16–19 November, Los Angeles, USA).
“We had a very informative and detailed update at the MT2020+ session on Wednesday 16 November,” Yavagal noted. “The MT2020+ campaign now has regional committees in over 90 countries—100% growth since 2020. The keynote talk was given by the Minister of Health from Uruguay, Dr Daniel Salinas, who highlighted the contribution of MT2020+. He shared the inclusion of mechanical thrombectomy in the Uruguayan National Stroke Plan and universal reimbursement coverage for mechanical thrombectomy in Uruguay through the plan. The impact of MT2020+ in different regions of the world was [also] discussed by a panel of MT2020+ global leaders.”
At the SVIN meeting, Yavagal himself announced the development of a pilot observership programme that will allow early-career neurointerventionists to observe thrombectomies at designated, high-volume centres using new remote proctorship technologies in the USA. Other notable developments included a novel Mechanical Thrombectomy Access Score (MTAS) to quantify regional barriers to thrombectomy access, and “highly successful” thrombectomy workshops teaching hands-on technical and workflow skills to neurointerventional teams from 10–15 countries in the Caribbean. All of these efforts are being supported or conducted by the MT2020+ project.
“The global burden of stroke in 2019 [was] estimated to be 12 million strokes per year, out of which 9.6 million [were] ischaemic strokes,” Yavagal concluded. “A conservative estimate is that 20% of ischaemic strokes are LVOs that are eligible for thrombectomy, which is roughly 1.9 million LVOs per year worldwide. However, in 2021, only 240,000 thrombectomies were estimated to be performed globally—thus leaving nearly 90% of eligible patients untreated, resulting in severe disability in 60% of these patients and around 10–20% mortality.
“A recent global survey of 59 countries (conducted by MT2020+ and being submitted for publication) showed that the median mechanical thrombectomy access rate globally is a dismal 2.79%. More importantly, the disparity [between the country with] the highest thrombectomy access rate, Australia (46%), and the [country with] the lowest access rate, Bangladesh (0.1%), is a massive 460 times! This is after excluding eight countries that have zero access to mechanical thrombectomy. For a brain-saving and life-saving therapy, this should be unacceptable for us as a global village.”
Across the globe
It is well accepted that there is room for improvement regarding existing thrombectomy services in the UK and throughout Europe. In a recent video interview with NeuroNews, Deniz Bulja (Sarajevo University Clinical Center, Sarajevo, Bosnia and Herzegovina) described the current situation in his country, noting that it and many other eastern European regions are somewhat lagging behind their western counterparts when it comes to tackling gaps in their thrombectomy services.
“I think we are facing similar problems [to those] that western Europe actually faced 5–10 years, or even before, when all of these major RCTs [randomised controlled trials] came along,” he said. “We are now walking this path and will, of course, overcome all of these obstacles—it takes time, but the people who are involved in endovascular stroke care management are anxious to see it happen rather quickly.”
Bulja further noted that educating physicians and raising public awareness are among the most pivotal tasks in achieving improved thrombectomy services, also highlighting a recent, European Society of Minimally Invasive Neurological Therapy (ESMINT)-endorsed meeting in Sarajevo that led to increased recognition and reimbursement of mechanical thrombectomy nationally. He added that this “small, but really major” step forward is one of many efforts he is involved with as president of the Radiology Society of Federation of Bosnia and Herzegovina.
Another significant European development recently came from Hungary, with the country rolling out a new, national imaging network across every one of its stroke care units—including all seven of the country’s comprehensive, thrombectomy-capable centres. This programme, which is being supported by an AI-powered software technology called e-Stroke (Brainomix) and an automated radiology workflow solution (eRAD), was unveiled at the start of the Hungarian Stroke Society XVI Congress and XIII Conference of the Hungarian Society of Neurosonology (1–3 September 2022, Siófok, Hungary).
Further details of the programme were then discussed at a press conference in October, with István Szikora (National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary), who played a key role in driving these plans forward, noting that there are “inherent disadvantages” to previously used ‘drip-and-ship’ models—the majority of which are time-related. He went on to state that many of these can be overcome via the ‘mothership’ approach currently being introduced under this initiative, whereby patients are transported directly to a thrombectomy-capable centre.
Szikora also stated that this approach has been set up at 28 of the 39 stroke centres across Hungary already, and the hope is that all 39 will be interconnected through the system by the end of 2022. Later discussions at the press conference highlighted the “lack of standardisation” this nationwide programme is seeking to solve by automating processes on a large scale; enabling more efficient data transferral; and, ultimately, supporting improved physician decision-making.
To provide insights from the Asia-Pacific (APAC) region, World Federation of Interventional and Therapeutic Neuroradiology (WFITN) president Michihiro Tanaka (Kameda Medical Center, Kamogawa, Japan) also recently spoke to NeuroNews.
“Regarding the logistics of the patient, and the standardised approaches and policies in Japan, we follow the systems and protocols in EU and North American countries,” Tanaka said. “One significant point of our protocol [is that] there are many hospitals where MRIs [magnetic resonance imaging] in the acute phase are available. Actually, MRI is widely used in Japan for the diagnosis of acute ischaemic stroke and the use of automated software to determine the ASPECTS [Alberta stroke programme early computed tomography score] value may have allowed more precise measurement of infarct size from MRIs.”
He went on to assert that the 24/7 thrombectomy services set up in Japan “are, so far, well developed” as is the case in the USA and parts of Europe, but also stresses that there are “plenty of issues” still to be solved within the APAC region.
“APAC is a very wide area, and the level of medical care in each country varies from country to country,” Tanaka continued. “In Japan and South Korea, patients with acute ischaemic stroke can be transported by ambulance on a priority basis, because they have well-developed medical insurance systems. However, in countries where medical insurance systems have not been established, it is still impossible to provide prompt treatment for acute ischaemic stroke.”
Expanding the discussion onto a more global basis, Tanaka stated that the WFITN is currently collaborating with more than 12 international societies; recently published international recommendations for acute ischaemic stroke interventions; and has organised an endowment fund to promote the development and training of young endovascular neurosurgeons and interventional neuroradiologists throughout the world, and in low- and middle-income countries in particular; all in an effort to advance stroke care moving forward.
“All of the people in the world should be guaranteed to receive this innovative therapy [thrombectomy],” he added. “This is my message, which is [also] presented on our website. I hope we can continue to collaborate to promote this mission, and contribute to stroke patients and their families [across] the world.”