There is no question that acute stroke is a major health problem, with about 800 000 strokes per year in the USA alone. Most stroke victims do not have a good recovery. US stroke healthcare costs are $41 billion a year.1 Dollar amounts do not capture the suffering of the patient, family and friends for the death, disability and loss of independence caused by strokes. There is again no question that strokes are best prevented, but 800 000 strokes a year creates a huge need for emergency stroke treatment, including by endovascular means.

Intravenous tissue plasminogen activator improves outcomes but the improvement is slight for those with large vessel occlusion (internal carotid, middle cerebral and vertebrobasilar) as documented by non-invasive vascular imaging or by the presence of the hyperdense middle cerebral artery sign on non-contrast head CT.2–7 Intra-arterial (IA) catheter directed techniques are more effective in restoring flow in patients with large vessel occlusions,8 9 and randomized trials have confirmed improved outcomes.10–13 Furthermore, newer methods of treatment such as mechanical revascularization devices now allow rapid successful revascularization14–16 and possibly open the door to additional patients with better clinical results.

Hospitals want interventional stroke services to be available in their community both as a critical patient service and also to avoid patient harm from a delay in care caused by a transfer of patients to other centers. Hospitals also have an economic incentive to treat patients locally. Intracranial endovascular procedures are typically performed by physicians who have trained in endovascular surgical neuroradiology (ESNR) fellowships. However, with the increasing demand to provide stroke rescue services quickly and locally, other endovascular trained interventional specialists such as interventional radiologists (IR) and interventional cardiologists (IC) are also providing this care.

Is this right? Is it reasonable? Is it good care? Or is …