Mechanical thrombectomy for ischaemic stroke

Specialised commissioners in England have given approval to fund 24/7 services to deliver mechanical thrombectomy (MT) as an effective treatment for ischaemic stroke caused by large vessel occlusion.

The current workforce

Only interventional neuroradiologists (INRs) are currently able to provide this service in neuroscience centres (24 in England, 28 across the UK). INR staffing levels vary between centres (ranging from 0-5) and currently only one centre in England is staffed to provide 24/7 cover for MT.

The current number of fully-trained INRs in the UK would need to almost double to approximately 150 to meet the service expansion needed to provide 24/7 MT services and the number of radiology trainees currently training to receive a CCT in interventional radiology sub-specialising in INR is insufficient to meet this demand.

Training to deliver mechanical thrombectomy

In order to achieve the desired delivery of a 24/7 service in MT across England, the number of operators capable of contributing to MT services needs to expand more rapidly than will be achieved by current INR trainee numbers. This means training other specialists to perform MT.

The British Society of Neuroradiologists (BSNR) has produced “Training guidance for mechanical thrombectomy” (Lenthall R, McConachie N, White P, Clifton A, Rowland-Hill C. BSNR training guidance for mechanical thrombectomy. Clin Radiol 2017; 72(2): 175.e11–175.e18.) which details the training that will be required for practitioners from different clinical backgrounds to achieve the necessary skills and experience to effectively contribute to the acute stroke service. This guidance will underpin all routes to increasing the workforce.

Increasing the workforce

There are two clear routes to achieving the necessary INR workforce expansion:

1. Trained interventional radiologists

Consultant interventional radiologists already have many of the skills required to perform MT, such as prior experience of image interpretation and familiarity with using catheters. Their previous training and experience should therefore facilitate more rapid training in MT than for those from different clinical backgrounds. In order to facilitate and support this training The Royal College of Radiologists, the BSNR, the British Society of Interventional Radiology (BSIR) and the UK Neurointerventional Group (UKNG) have worked together to produce “Supplementary guidance to facilitate the training of interventional radiology (IR) consultants to undertake stroke thrombectomy”.

This supplementary guidance only applies to consultant interventional radiologists who have undertaken a period of training in a range of diagnostic and interventional radiology practice culminating in the FRCR and a period of post-FRCR training in IR, or IRs who have demonstrated similar levels of training, experience and qualification by equivalence. 

While it is hoped that significant numbers of interventional radiologists will opt to undertake this additional training it is unlikely that this route alone will completely address the shortage of qualified operators in the short to medium term. Therefore a second option is also being pursued.

2. INR credential for clinicians from non-IR or INR backgrounds

Multidisciplinary discussions, convened by the College, with representation from all interested specialty groups including: radiologists, stroke physicians, neurologists, neurosurgeons and cardiologists, have led to a consensus to begin development of an INR credential focused on acute stroke. The aim of this credential (now under development) will be to enable clinicians from other specialty backgrounds, to train in the broad skills of INR and learn to perform MT for acute stroke and other interventions such as coiling intracranial aneurysms.

After such training, it is anticipated that doctors with the credential would join INR teams and contribute to 24/7 services providing MT for acute stroke and the coiling of intracranial aneurysms. Enabling such training for clinicians from other specialty backgrounds in the UK, would also align with practice in Europe and North America.

Further information will be posted here as the work progresses.  If you have any questions please contact credentials@rcr.ac.uk