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Original research
Workflow patterns and potential for optimization in endovascular stroke treatment across the world: results from a multinational survey
  1. Johanna Maria Ospel1,2,
  2. Mohammed A Almekhlafi3,
  3. Bijoy K Menon4,
  4. Nima Kashani5,
  5. René Chapot6,
  6. Jens Fiehler7,
  7. Ameer E Hassan8,
  8. Dileep Yavagal9,
  9. Charles B L.M Majoie10,
  10. Mahesh V Jayaraman11,
  11. Michael D Hill12,
  12. Mayank Goyal13
  1. 1 Radiology, Universitatsspital Basel, Basel, Switzerland
  2. 2 Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  3. 3 Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  4. 4 Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
  5. 5 Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  6. 6 Department of Neurointerventional Therapy, Krupp Krankenhaus, Germany, Essen, Germany
  7. 7 Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
  8. 8 Valley Baptist Medical Center, Harlingen, Texas, USA
  9. 9 Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, USA
  10. 10 Radiology, AMC, Amsterdam, The Netherlands
  11. 11 Diagnostic Imaging, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
  12. 12 Clinical Neurosciences, University Of Calgary, Calgary, Alberta, Canada
  13. 13 Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  1. Correspondence to Dr Mayank Goyal, Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB T2N 1N4, Canada; mgoyal{at}


Background The benefit of endovascular treatment (EVT) is highly time-dependent, and treatment delays reduce patients’ chances to achieve a good outcome. In this survey-based study, we aimed to evaluate current in-hospital EVT workflow characteristics across different countries and hospital settings, and to quantify the time-savings that could be achieved by optimizing particular workflow steps.

Methods In a multinational survey, neurointerventionalists were asked to provide specific information about EVT workflows in their current working environment. Workflow characteristics were summarized using descriptive statistics and stratified by country and physician characteristics, such as age, career stage, personal and institutional caseload.

Results Among 248 respondents from 48 countries, pre-notification of the neurointerventional team was used in 70% of cases. The emergency department (ED) and CT scanner, and the CT scanner and neuroangiography suite, were on different floors in 23% and 38%, respectively. Redundant procedures in the ED were often routinely performed, such as chest x-rays (in 6%). General anesthesia was the most frequently used anesthesia protocol for EVT (42%), and an anesthesiologist was available in 82% for this purpose. 52% of the participants used a pre-prepared EVT kit.

Conclusion The current structure of EVT workflows offers possibilities for improvement. While some bottlenecks, such as the spatial department set-up, cannot easily be resolved, pre-notification tools and pre-prepared EVT kits are more straightforward to implement and could help to reduce treatment delays, and thereby improve patient outcomes.

  • stroke
  • thrombectomy
  • brain

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  • Correction notice Since the online publication of this article, the authors have noticed that affiliation 8 'Neurology, University of Minnesota, Minneapolis, Minnesota, USA' is incorrect. Affiliation 8 has now been corrected to 'Valley Baptist Medical Center, Harlingen, TX, USA'

  • Contributors MG: conceptualization, drafting and critical revision of the manuscript. JMO: drafting and critical revision of the manuscript and figures. NK: drafting of the figures, critical revision of the manuscript. RC: data curation, critical revision of the manuscript. Remaining authors: critical revision of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Map disclaimer The depiction of boundaries on these maps does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The maps are provided without any warranty of any kind, either express or implied.

  • Competing interests MG is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, Mentice. JMO is supported by the University of Basel Research Foundation, Julia Bangerter Rhyner Foundation and Freiwillige Akademische Gesellschaft Basel.

  • Patient consent for publication Not required.

  • Ethics approval Since no patient data were used for this study, ethics approval was not required. Consent from the survey participants was obtained before completing the survey.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.