Those who advocate training non-neurointerventional physicians to perform endovascular stroke therapy generally hold three assumptions. First, physicians with interventional experience in other vascular territories can become competent in stroke intervention with a relatively small number of neurointerventional cases. Second, the benefit of endovascular stroke intervention and the prognosis without it are so disparate that there is an obligation to provide the treatment when and where an experienced stroke neurointerventionalist is not available. Third, the time sensitive and emergent nature of acute stroke means that decentralization of care is necessary. In my opinion, the available evidence does not support any of these conclusions at present.

There is an important difference between medical and procedural based therapies. Both require cognitive training and expertise to make a proper diagnosis and decide on the best treatment strategy. Procedural based therapies, however, require mental and physical dexterity in contradistinction to medical treatments which are generally operator independent. Assuming appropriate patient selection, the success, effectiveness or complications of medical treatment are the same irrespective of who administers the drug or treatment. Surgery and other procedural based treatments are obviously quite different. The same cognitive training is needed to decide when to operate but technical training is also crucial. The maximal theoretical benefit of any procedure is always compromised by the imperfection of the operator and is therefore inextricably linked to the experience and training of the operator. This is why we seek out ‘good hands’ in a surgeon after selection of therapy whereas such a consideration in a medical therapist is irrelevant.

The risk of a surgical complication is particularly important when the recommended surgical treatment has a relatively narrow window of benefit over non-surgical management. Carotid artery stenting (CAS) is a good neurointerventional example of this situation. The absolute risk reduction with carotid endarterectomy for …