New Training Guidelines for Endovascular Intervention in Ischemic Stroke

The guidelines recommend that physicians be specially trained in endovascular neurosurgery in order to perform the procedure.

LOS ANGELES — A consortium of 12 international neurointerventional medical societies have come together to release new training guidelines for endovascular intervention in patients with ischemic stroke. 

The guidelines, which were introduced at this week’s 2016 International Stroke Conference, are aimed at new practitioners who do not currently perform intra-arterial clot removal.

Set to be published in 7 peer-reviewed journals, the guidelines address the baseline training, qualifications, and maintenance of qualifications for physicians performing endovascular intervention, as well as requirements for the medical centers where these procedures are performed.

“Not all vascular systems are the same,” Karel terBrugge, MD, FRCPC, Chief of Neuroradiology at Toronto Western Hospital, said in a statement. “These guidelines underscore the importance of a collaborative acute stroke team approach, knowledgeable with respect to the clinical and imaging findings in acute stroke patients and the training needed to acquire the unique technical skills to operate in one of the body’s most complex organs.”

With endovascular thrombectomy quickly growing in favor, the guideline recommends that physicians performing these procedures be properly trained neurointerventionalists. This includes interventional neuroradiologists, endovascular neurosurgeons, and interventional neurologists with routine experience performing neuroendovascular procedures. Of note, the vast majority of thrombectomy procedures performed in the 5, randomized, controlled clinical trials that have provided Class 1, Level A evidence for endovascular thrombectomy as the standard of care in large vessel occlusions were performed by experienced neurointerventionalists.

For baseline training and qualifications, the guideline recommends that new practitioners complete:

  • Residency training in radiology, neurology, or neurosurgery including the diagnosis and management of acute stroke, interpretation of cerebral arteriography, and neuroimaging under the supervision of a board-certified neuroradiologist, neurologist, or neurosurgeon with subsequent board eligibility or certification.
  • Fellowship training of minimum 1 year in interventional neuroradiology, endovascular neurosurgery, or interventional neurology under direction of a neurointerventionalist at a high-volume medical center. This should include specific training in intra-arterial therapy for acute ischemic stroke, including obtaining access, microcatheter navigation, training on stroke-specific devices, as well as complication avoidance and management.

For maintenance of qualifications:

  • Physicians should complete a minimum of 16 hours of stroke-specific continuing medical education every 2 years
  • Participation in an ongoing quality assurance and improvement program (Participation in a national quality improvement registry is also encouraged), with threshold levels of at least:
    • successful recanalization (modified TICI 2b or 3) in 60% of cases
    • embolization to new territory of less than 15%
    • symptomatic intracranial hemorrhage rate of less than 10%

Recommended hospital requirements include 24/7 access to:

  • Fully-equipped angiography suites
  • Dedicated stroke and intensive care units staffed by appropriately trained physicians
  • Vascular neurology and neurocritical care expertise
  • Neurosurgery expertise, including vascular neurosurgery
  • All relevant neuroimaging modalities, including CT/CTA, MR/MRA, TCD, and 24/7 access to CT and MRI

The following international societies contributed to this guideline:

American Academy of Neurological Surgeons/Congress of Neurological Surgeons; American Society of Neuroradiology; Asian Australasian Federation of Interventional and Therapeutic Neuroradiology; Australian and New Zealand Society of Neuroradiology – Conjoint Committee for Recognition of Training in Interventional Neuroradiology (CCINR) representing the RANZCR (ANZSNR), ANZAN and NSA; Canadian Interventional Neuro Group; European Society of Neuroradiology; European Society of Minimally Invasive Neurologic Therapy; Japanese Society for Neuroendovascular Therapy; Sociedad Ibero Latino Americana de Neuroradiologica; Society of NeuroInterventional Surgery; Society of Vascular and Interventional Neurology; and the World Federation of Interventional and Therapeutic Neuroradiology.

For more coverage of ISC 2016, go here


Training Guidelines for Endovascular Stroke Intervention: An International multi-society consensus document. J NeuroIntervent Surg. 2016;0:1–3.