Background

Ischemic stroke is a leading cause of death and disability worldwide. Much of the long-term disability occurs in patients with Emergent Large Vessel Occlusion (ELVO). In fact, in these patients, occlusion of a major intracerebral artery results in a large area of brain injury often resulting in death or severe disability.1 Until recently, intravenous tissue plasminogen activator (t-PA) was the only proven treatment for ELVO.

However, the landscape of stroke treatment has changed with the publication of five randomized multicenter controlled clincal trials. These trials provide Class 1, Level A evidence that endovascular thrombectomy (ET) is the standard of care for patients with ELVO. In particular, thrombectomy results in significantly better clinical outcomes compared to best medical therapy in patients with acute occlusion of the intracranial internal carotid artery (ICA) and/or M1 segment of the middle cerebral artery (MCA).2–6 These results have led to guideline recommendations advocating for endovascular treatment in addition to t-PA for patients with ELVO. In addition, ET is now offered as first line therapy for patients that are not eligible for intravenous thrombolysis.7–9 However, achieving the best possible clinical outcomes with endovascular stroke treatment mandates structured training and education of those physicians who are providing endovascular stroke treatment. On this regard, a recent meta-analysis of these five clinical trials showed that the vast majority of thrombectomies were performed by experienced neurointerventionalists. These include interventional neuroradiologists, endovascular neurosurgeons, and interventional neurologists who routinely perform neuroendovascular procedures.10 None of the studies allowed physicians without previous experience in mechanical thrombectomy to enroll patients. The centers participating in these trials offered endovascular stroke therapy 24 hours a day (with the exception of those in the EXTEND-IA trial) with expertise in vascular neurology and neurocritical care in a comprehensive stroke center. On-site expertise in vascular neurology and …