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Intracranial Thrombectomy: The future of stroke care

College of Paramedics Stroke Lead, Joe Dent MCPara discusses Intra Arterial Thrombectomy and how it could save lives.

At the last UK stroke conference, there was extensive discussion regarding the future of stroke care within the UK. There is an ever-increasing body of evidence that suggests taking patient to centres that offer Intra Arterial Thrombectomy (IAT) services will not only reduce long term disability, but also save lives. IAT services must be as an add-on to the use of thrombolysis. Obviously, how patients will access this service will be down in some part to the acute pre-hospital service that you as professionals deliver. This was recognised with the conference on a number of occasions, but the IAT service across the country is not mature and is in need of further development.
Whilst this is the case and that IAT as a countrywide service will be some years off, there are areas of the country where IAT is currently used, but the breadth of the service is limited. Although this is the case, it is still important that we as a profession realise the implications the development of such a service will have.
I took the opportunity recently to speak and film an interview with Professor Tony Rudd. Professor Rudd is the National Clinical Director (NCD) for Stroke in England but lot of what he had to say was equally pertinent to other parts of the UK.

We started our discussion talking about what IAT is and what the benefits are to patients. IAT is a procedure, where much like the PPCI technique, a catheter is placed into the groin and finds its way into the brain, into the artery that is affected, and the clot removed. This is a very skilled procedure and I would suggest having seen both techniques used, IAT is much more difficult due to the vascular territories the Interventionist has to navigate. There are only a small proportion of patients who are eligible for the procedure, but new evidence suggests that this could be widened, not only for the category of patient but also the time from onset can be extended and still have good affect.

Following on from this we discussed what is the preferred model to deliver IAT. Professor Rudd was quite open here by stating a lot of what happens to the patient in the first instance and the decision as to where the patient will go will be down to the ambulance crew on scene. Identifying who should go to the IAT centres will be a challenge for all involved. The FAST test is a relatively crude method of identifying stroke patients and has a high mimic rate yet is still seen as the best method of identifying pre-hospital stroke patients. High rates that FAST delivers will put extra pressure on IAT and Hyper Acute Stroke centres. It will be interesting to see if the trial in the East of England using a modified stroke tool will be able to identify stroke more readily and the research by Graham McClelland MCPara on stroke mimics is eagerly awaited. Professor Rudd does state that although mimics are an issue, he accepts that these patients still need to be in hospital in the main as some of them are still very acutely ill. on reflection though, being able to wean out some of these mimics will not exclude them from appropriate hospital care, it is just that their care will be at another centre more suitable for their condition.

 

 

Again, on the point of identifying stroke patients and those who will need to go direct to IAT centres, Professor Rudd did say that he would be interested in investigating how the use of technology in aiding the correct diagnosis and then therefore the right destination may have benefits to the patient. There is already evidence from as far afield as Melbourne, Australia on the use of telemedicine for stroke patients and in a couple of centres across the world, one being in the UK, where other technologies are being used to identify stroke patients sooner by mobile scanning.

Finally, we spoke about the need for data to be collected by all concerned, but in particular the ambulance service in regard to stroke patients. It is evident from what Professor Rudd said, there are differing practices across the country in regard to what if any data is collected. The recent changes by the Secretary of State asking for stroke related data from ambulance services may cause issues going forward, will require a mature IT infrastructure and clinicians with a serious interest in informatics, but that is another topic for another day.
IAT may be some time off as a country-wide option, but it is important to realise that some of the patients you already see go for this procedure without any development in the stroke pathway and increasing the amount of IAT procedures will affect the way in which pre-hospital stroke care is delivered.

Please have a look at the website below as it describes of what IAT looks like.  
www.youtube.com/watch?v=Cr9Pb3liSlA