Bracard S, Ducrocq X, Mas J et al, THRACE Investigators. However, mechanical thrombectomy was shown to be cost-effective over a lifetime horizon, with an ICER of £3466 per QALY gained. NINDS TPA Stroke Study Group. o Critical care anaesthetists & nursing staff. NHS England announced in April 2017 that it will commission mechanical thrombectomy so it can become more widely available for patients who have certain types of acute ischaemic stroke. In 2016, St George’s Hospital became the first, and to date only, hospital in the UK to have a fully staffed 24/7 mechanical thrombectomy service for acute stroke. For further clinical detail on mechanical thrombectomy, see the November 2018 issue of our sister publication, Specialised Medicine, where Dr Dipankar Dutta has contributed an article aimed at healthcare professionals and managers with an interest in specialised commissioning. This has been called the ‘drip and ship’ model.6,8 Communication between centres has to include telephone contact and viewing of images remotely via a picture archiving and communication system (PACS). Regarding thrombectomy centre volumes and maximising access to thrombectomy services for stroke in England: A modelling study and mechanical thrombectomy for acute ischaemic stroke: An implementation guide for the UK Show all authors. In 2016, St George’s Hospital became the first, and to date only, hospital in the UK to have a fully staffed 24/7 mechanical thrombectomy service for acute stroke. There are significant barriers to the full implementation of round-the-clock mechanical thrombectomy but much progress is being made. This is likely to result in a severe stroke unless the blood supply to the affected area can be restored quickly. The devices in current use are stent retriever devices sometimes with balloon guide catheters for flow occlusion (to reduce forward flow thereby reducing the chance of distal embolisation), direct aspiration catheters, or combined stent retrievers/aspiration catheters.6,7 Acceptable standards are considered to be groin puncture time to start of revascularisation of <45 minutes in at least 65% of patients and end of revascularisation in a time of median ≤60 minutes.4, Figure 1: Patient management algorithm for acute stroke and mechanical thrombectomy, ED=emergency department; IV=intravenous; MT=mechanical thrombectomy; TIA=transient ischaemic attack; CT=computerisedtomography; LAO=large artery occlusion; HASU=hyper-acute stroke unit; ITU=intensive therapy unit, Patient selection is usually made jointly between stroke physicians and neurointerventionists.6 Depending on stroke service configurations in different regions, patients may present directly to a tertiary centre. Vilela P, Rowley H. Brain ischemia: CT and MRI techniques in acute ischemic stroke. Results of the first 106 endovascular treatments (EVT) are presented here. Interobserver agreement for the assessment of handicap in stroke patients. new google.translate.TranslateElement({pageLanguage: 'en', layout: google.translate.TranslateElement.InlineLayout.SIMPLE}, 'google_translate_element'); NHS England Specialised Commissioning team. Despite the impact of COVID-19 on most medical device markets, global sales of mechanical thrombectomy devices for the emergency treatment of acute ischemic stroke (AIS) - which includes both stent retrievers and aspiration devices and associated products - is expected to increase at a healthy CAGR of approximately 5.7%, from nearly $677m in … Thrombectomy is more effective than the current standard treatment of thrombolysis (clot-busting drugs) however only a very small minority of patients are currently able to access thrombectomy. Mocco J, Zaidat O, von Kummer R et al, for the THERAPY Trial Investigators. Mechanical thrombectomy (MT) aims to remove the obstructing blood clot from arteries within the brain directly by introducing a clot retrieval device delivered via an intravascular catheter, thereby restoring blood flow and minimising tissue damage. Guidance for practitioners seeking training to participate in an acute ischaemic stroke thrombectomy service in the UK: a response to level-1 evidence of the benefit of mechanical thrombectomy for... Read Summary. Introduction The clinical efficacy and cost-effectiveness of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke is well established, but uncertainty remains around the true cost of delivering this treatment within the NHS. Estimating the number of UK stroke patients eligible for endovascular thrombectomy. A review of the service performed in 2014 demonstrated endovascular therapy-based services could be safely and effectively delivered in a UK setting, with nearly 50% of patients having a favorable outcome [8]. Albers G, Marks M, Kemp S et al for the DEFUSE 3 Investigators. Milne M, Holodinsky J, Hill M et al. The current Thrombectomy service at the Walton Centre is available Monday to Friday 7am to 7pm (last call taken at 5pm). To ask the Secretary of State for Health, with reference to the announcement by NHS England of 11 April 2017 on mechanical thrombectomy, when the assessment of the readiness of each of the 24 neuroscience centres to carry out mechanical thrombectomy will be completed; and whether the results of this assessment will be published. The University Hospital of North Staffordshire (UHNS) has treated the largest number of cases in the UK. In a 6-month period in 2018, just 478 mechanical thrombectomies were performed in the UK, compared to over 9000 in Germany and over 4500 in France [ 7 ]. Mechanical thrombectomy services: can the UK meet the challenge? Consultant Stroke Physician, Gloucestershire Royal Hospital. For instance, 2 specialists referred to the British Society of Neuroradiologists' training guidance for mechanical thrombectomy, which noted that the numbers of fully trained interventional neuroradiologists in the UK would have to double to meet the demands of a 24/7 MT service. Organising ambulance services for effective implementation of mechanical thrombectomy 23 Chris Price and John Black 5. Balami J, White P, McMeekin P et al. The procedure remains very time-dependent; for every 15 minutes saved in reperfusion, an estimated 39 patients per 1000 treated would be less disabled at 3 months, including 25 more who would achieve functional independence.13. The Walton Centre for an urgent procedure called thrombectomy or clot retrieval from a blocked artery in the brain following a stroke. The HERMES collaboration presented patient level data for 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to usual treatment that included intravenous tPa in 87%).23 Endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted common odds ratio [cOR] 2.49, 95% confidence interval [CI] 1.76–3.53; p<0.0001).23 The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on mRS for one patient was 2.6.23 The benefits of mechanical thrombectomy over usual care were present in patients aged 80 years or older, those randomised more than 300 min after symptom onset, and those not eligible for intravenous alteplase.23 Mortality at 90 days and risk of symptomatic intracranial haemorrhage did not differ between groups.23 Other meta-analyses have presented very similar conclusions; number needed to treat (NNT) to reduce disability of 2.5, and NNT for an extra patient to achieve independent outcome of 4.25 (3.29–5.99).24,25, The overall complications rate of mechanical thrombectomy is about 4 to 29%, based on recent trial data.6,26 However, many complications are minor and do not affect the eventual outcomes for patients.6 Serious complications include vessel perforation (0.9 to 4.9%), arterial dissection (3%), emboli to new territories (6%), symptomatic intracranial haemorrhage (4.3%), and subarachnoid haemorrhage (2.5%).6,26,27 Vasospasm and vascular access site complications (including dissection, pseudoaneurysm formation, retroperitoneal haematoma, and infection) are other potential complications.6,26. 10 Peter McMeekin and Martin James 3. Goyal M, Menon B, van Zwam W et al, for the HERMES collaborators. Mechanical thrombectomy can only be carried out in tertiary stroke centres by neurointerventionists, usually interventional neuroradiologists (although other groups also perform this procedure). Mechanical thrombectomy (MT) is a very effective, but highly time dependent, reperfusion technique in the management of acute ischaemic stroke caused by large artery occlusion. NHS England and Health Education England will then work with trusts to build up the number of centres capable of providing thrombectomy to patients with certain types of acute ischaemic stroke. This reflects new evidence building on the Society of NeuroInterventional Surgery (SNIS) recommendations published in 2015.1 Recommendations herein supersede those of previous SNIS guidelines where … The Royal Stoke University Hospital (RSUH) was the first UK centre to perform mechanical thrombectomy for ischaemic stroke on a regular basis and the first to deliver this 24/7. mechanical thrombectomy (akin to crash Caesarean Section calls). Lyden P, Brott T, Tilley B et al. The Atkinson Morley Regional Neurosciences Centre at St George’s University Hospitals NHS Foundation Trust is where the emergency treatment is undertaken with a highly-skilled team with staff from Interventional Neuroradiology, Stroke and Neuroanaesthesia. Using decision modelling, we aimed to evaluate the cost-effectiveness of secondary transfer by helicopter emergency medical services … There are no special requirements for antiplatelet or other secondary prevention medication. As with other medical emergencies, primary care physicians may encounter patients with suspected acute strokes within the treatment time window. Lenthall R, McConachie N, White P et al. Lenthall R, McConachie N, White P et al. Quite where the manpower will come from is still unclear. The resource impact may be lower if effective treatment results in a reduction in long-term care. Muir K, Ford G, Messow C et al, on behalf of the PISTE Investigators. Methods. Mechanical thrombectomy for acute ischaemic stroke during the COVID-19 pandemic: changes to UK practice and lessons learned D. McConachie, N. McConachie, P. White, R. Crossley, W. Izzath Nottingham University Hospitals NHS Trust Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. Safety and efficacy of solitaire stent thrombectomy. Third, it can save lives or avert significant life-changing disability. o Stroke Physician (Consultant at least available by phone). Thrombectomy is more effective than the current standard treatment of thrombolysis (clot-busting drugs) however only a very small minority of patients are currently able to access thrombectomy. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. The Barts Health stroke service will now offer mechanical thrombectomy 24 hours a day, seven days a week. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Evidence base for mechanical thrombectomy in acute ischaemic stroke 5 Phil White 2. Health systems need to ensure that MT is delivered to as many patients as quickly as possible. This is because thrombectomy is a highly-skilled operation. Regarding thrombectomy centre volumes and maximising access to thrombectomy services for stroke in England: A modelling study and mechanical thrombectomy for acute ischaemic stroke: An implementation guide for the UK PM White1,2, GA Ford3,4, M James5,6 and M Allen5,7 Dear Dr Norrving Re Maximising access to thrombectomy services for stroke in England: a modelling study1 and Mechanical … After treatment, patients are often admitted to William Drummond ward to recover before going back to their usual place of residence, 2nd floor , Atkinson Morley Wing, St George's Hospital, Atkinson Morley Regional Neurosciences Centre, The Atkinson Morley Regional Neurosciences Centre, William Drummond Ward – Hyper Acute Stroke Unit. thrombectomy in the UK but it is thought that fewer than 10% of those eligible actually receive it. 2. Implementation of mechanical thrombectomy: … thrombectomy centre (Goyal et al., 2016). Type: Guidance . PM White 1 2. The University Hospital of North Staffordshire (UHNS) has treated the largest number of cases in the UK. Once the procedure is complete, the patient will need to be monitored in the hyperacute stroke unit (HASU) or neurocritical care of the tertiary centre. Supporting evidence UHNM has the largest patient population treated by mechanical thrombectomy in the UK. written by Dr David Jenner, GP, Cullompton, Devon. Mechanical thrombectomy (MT) alongside intravenous thrombolysis ... UK centres have adapted local processes at pace to ensure ongoing provision of this vital health service with no significant changes to the reported rate of successful recanalisation. Complications of endovascular treatment for acute ischemic stroke: Prevention and management. A delivery catheter is inserted, usually through the femoral artery in the groin, and advanced into the occluded artery using X-ray guidance. Institute of Translational and Clinical Medicine, Newcastle University, Newcastle upon-Tyne, UK . The assessment has to be rapid but thorough and consists of stroke diagnosis, likely localisation, assessment of severity, pre-stroke functional status, and co-morbidities.6 Stroke severity is assessed by the National Institutes of Health Stroke Scale (NIHSS) and pre-stroke functional status by the modified Rankin Scale (mRS).9,10 Urgent vascular imaging, typically plain CT and CT angiogram to confirm LAO prior to consideration of thrombectomy, is required. Thrombectomy services are being established in Neuroscience Centres with established interventional radiology services, sufficient expertise in the procedure and a co-located hyper acute stroke service. Fourth, mechanical thrombectomy may be available for patients where contra-indications prevent use of thrombolysis. UHNM has been at the forefront of pioneering the revolutionary Mechanical Thrombectomy stroke treatment since 2009. There are 24 adult Neuroscience Centres in England (5-8 in each Region). Background Mechanical thrombectomy (MT) is a time-sensitive emergency procedure for patients who had ischaemic stroke leading to improved health outcomes. Twelve cost-effectiveness studies were also identified, including 2 from a UK payer perspective. Mechanical thrombectomy services: can the UK meet the challenge? Nogueira R, Jadhav A, Haussen D et al for the DAWN Trial Investigators. The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial. Feigin V, Forouzanfar M, Krishnamurthi R et al. This briefing describes technologies that fulfil a similar purpose. Campbell B, Hill M, Rubiera M et al. Bhatia R, Hill M, Shobha N et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. Aspiration thrombectomy after intravenous alteplase versus intravenous alteplase alone. McMeekin P, White P, James M et al. CONCLUSION: Mechanical … INTRODUCTION:The clinical efficacy and cost-effectiveness of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke is well established, but uncertainty remains around the true cost of delivering this treatment within the NHS. It has several advantages over IV clot lysis including greater efficacy, a larger treatment window, and it can be performed in patients with some contraindications to IV thrombolysis.3,4. Health service to roll out mechanical thrombectomy, currently only offered at a handful of hospitals, to 8,000 patients a year Denis Campbell Health policy editor Mon 10 … Acute strokes within the available resources for mechanical thrombectomy 23 Chris Price and John Black 5 hours. 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