Minimum training requirements for acute stroke interventions

1. Accreditation Council for Graduate Medical Education (ACGME)-approved residency training including documented cerebrovascular training including the diagnosis and management of acute stroke, and the interpretation of cerebral arteriography and brain imaging under the supervision of a board-certified neurologist, neurosurgeon or neuroradiologist with subsequent National Board of Medical Examiners eligibility or certification. A minimum of 6 months during a 4-year residency is suggested.

2. One year of graduate medical education in endovascular surgical neuroradiology. An ACGME-approved program is preferred but not required.

1. Documented prior training and experience in catheter arteriography including 100 cerebral arteriograms. Clinical outcomes must meet or exceed American College of Rheumatology benchmarks for technical success and complications.^{11 16}

2. Documented prior training and experience in microcatheter (≤3 French) and microguidewire (≤0.014 inches) navigation under the supervision of fellowship-trained and credentialed neurointerventionalist(s).

3. Documented prior experience in assessment and performance of endovascular stroke interventional procedures as the primary operator in 10 patients under the supervision of fellowship-trained and credentialed neurointerventionalists(s).

4. Previously credentialed physicians who perform intra-arterial catheter-directed stroke procedures at their local institutions should have documented procedural and clinical outcomes that meet national standards and published evidence-based guidelines.^{12 13}

During the next 2–3 years as the nation progresses to regional stroke care with comprehensive stroke centers it is conceivable that selective hospitals may choose to credential individuals for intra-arterial stroke therapy, who have not had a full year of neurointerventional fellowship training. While this is not endorsed as best clinical practice, if such local situations occur and if hospitals choose to credential individuals who have not had a full year of neurointerventional training, it is recommended that at a minimum these individuals should have had adequate neuroscience cognitive training (including a minimum of 6 months' documented neuroscience training in an ACGME-approved postgraduate training program); adequate technical and interpretive cerebral angiography training (including a minimum primary operator experience of 100 appropriately supervised cerebral angiograms, which is the minimum prerequisite for neurointerventional training); adequate cerebral microcatheter experience (including a minimum of 30 cases as primary operator in the intracranial internal carotid artery/vertebral basilar circulation mentored by a credentialed fellowship-trained neurointerventionalist); and mentored experience in intra-arterial stroke therapy (including a minimum of 10 cases mentored by a credentialed fellowship-trained neurointerventionalist credentialed in intra-arterial stroke therapy) prior to being credentialed to perform intra-arterial therapy. It is anticipated that by 2012 stroke centers that are providing intra-arterial stroke therapy will be staffed with exclusively fellowship-trained neurointerventionalists and/or practitioners who have met the above prerequisite guidelines and have demonstrated credentialed experience in intra-arterial therapy with adequate outcomes. Further, it is anticipated that after 2012 additional manpower for providing intra-arterial stroke therapy in stroke centers will come exclusively from fellowship-trained neurointerventionalists.

Training in endovascular surgical neuroradiology

In the USA, Canada, Europe, and Japan, educational programs are specifically designed to train neuroscience physicians to treat acute hemorrhagic and ischemic stroke. This training represents the “gold standard” for performance of endovascular cerebrovascular procedures including the endovascular treatment of acute stroke.

Since the year 2000, program requirements have been formally established and published in North America to ensure uniform training in endovascular surgical neuroradiology, a field specializing in the endovascular treatment of acute stroke.¹⁷ “Endovascular Surgical Neuroradiology” is the title or moniker used to describe the training pathway that is recognized by the ACGME.^{17 18}

Mechanical revascularization (thrombectomy/embolectomy) devices have not yet been proven to improve patient outcomes. In addition, it is not possible to define general training requirements when there is currently significant clinical experience with only one mechanical revascularization clot retrieval device and it is unknown what the necessary interventional skills would be for newer generations of clot retrieval devices. There is consensus that the skills needed and risks associated with use of these devices are greater than the skills needed and risks associated with use of catheter-based pharmacologic lysis, but it is not possible to make specific training recommendations at this time. However, at a minimum, the physician must meet the training criteria described herein for pharmacologic lysis for emergency stroke therapy and have successfully completed a training course for use of any specific device. Furthermore, procedural complication rates including intracerebral hemorrhage should conform to evidence-based national guidelines.

Maintenance of physician and facility qualifications

The physician should have ongoing stroke-specific continuing medical education of at least 16 h/2 years according to Joint Commission requirement. The physician should have procedure outcomes that conform to national standards and institutional requirements.

Neuroendovascular acute ischemic stroke procedures should be performed only at Joint Commission or state-certified primary or comprehensive stroke centers.¹⁹ Outlying and community hospitals should develop access to endovascular acute stroke therapy through the development of stroke systems of care.²⁰ The interventionalist must have 24/7 access to neurologists and neurosurgeons knowledgeable in patient selection and in the pre- and postneurological critical care of endovascularly treated patients with stroke. There must be 24/7 neurology and neurosurgical availability to treat possible complications of stroke therapy. There must be an active quality assurance program for stroke therapy to monitor outcomes both in the periprocedural period and at 90 days. All emergency interventional stroke therapy patients must be reviewed by the quality assurance program. Outcomes should be tracked and recorded. All centers should participate in and enroll all patients with stroke in available national stroke registries or multicenter stroke trials.

Conclusions

Medical disciplines with ACGME-approved training in neurosciences and the care of patients with stroke agree on the importance of safety and quality of care for patients with stroke. Due to the grave consequences of inadequate or deficient training, stringent credentialing criteria with formal neuroscience training as specified herein and by peer-reviewed published standards should be mandated for emergency endovascular stroke therapy,^{17 21} analogous to vascular interventions for acute myocardial infarction or other high morbidity and mortality conditions.^{22 23 24 25 26 27 28 29 30} Credentialing committees at each healthcare facility are empowered to enforce training and practice standards and, thus, have an obligation to maintain recognized accreditation standards and to be aware of recommendations endorsed by the national organizations most directly involved in the diagnosis and management of acute stroke. Physician credentials, maintenance of certification, and quality improvement programs must be consistent with mandated and accepted standards defined by the ACGME, American Medical Association, American Board of Medical Specialties, and state licensing boards.