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Table 1 Options (propositions) for Thrombectomy Service Provision

From: A Delphi study and ranking exercise to support commissioning services: future delivery of Thrombectomy services in England

Below we present a description of 12 potential options for delivering thrombectomy with an explanatory footnotes (where required). Please score each of the 12 options using a 7-point Likert scale:
 1. Any local provider “ad hoc”a
 2. Any local provider delivers IAT on a formal rotab
 3. Transfer to nearest primary coronary percutaneous intervention unit and cardiology managec
 4. Transfer to nearest primary coronary percutaneous intervention unit and shared care with stroke physiciansd
 5. Ambulance bypass for all acute stroke patients of known time onset to comprehensive stroke unit where advanced imaging and “expert intra-arterial thrombectomy [IAT]” are available 24/7e
 6. Local CT and transfer all patients with NIHSS ≥10 to the nearest neuroscience centre for interventional neuroradiologist delivered “expert thrombectomy”f
 7. Local CT/CTA then transfer all large artery occlusive stroke patients to nearest neuroscience centre for interventional neuroradiologist delivered “expert thrombectomy”g
 8. Local advanced imaging then selective transfer to nearest neuroscience centre for “expert thrombectomy”h
 9. Local CT/CTA then transfer large artery occlusive stroke patients to nearest neuroscience centre for advanced imaging and “expert thrombectomy”
 10. Advanced imaging performed locally but interpreted centrally by Neuroradiology then selective transfer to nearest neuroscience centre for “expert thrombectomy”
 11. Selective transfer to nearest on call neuroscience centre for “expert thrombectomy”i
 12. Interventional neuroradiologist and necessary support team on standby in Neuroscience centre – they transfer to patient’s hospital to deliver expert intra-arterial thrombectomy when large arterial occlusion stroke is confirmedj
  1. aAny physician with some intra-arterial catheter skills delivers intra-arterial thrombectomy [IAT] as best they can when they can. There is no level I evidence (obtained from at least one properly designed & conducted randomised controlled trial) for this option
  2. bInterventional radiologists would likely be at the core of this option. There is no level I evidence for this option
  3. cThere is no level I evidence for this option
  4. dWhere a primary coronary percutaneous intervention unit and an acute stroke unit are geographically close enough to allow this to be feasible
  5. eAccording to data from the Sentinel Stroke National Audit Programme (SSNAP) 70% of acute stroke patients have known time onset and 60% of those reach hospital within 4 h = 42%; 12% in SSNAP are haemorrhage not ischaemic strokes
  6. fThis option is sometimes called a “drip and ship” approach; The neuroscience centre team might include interventional neuroradiology trained/mentored interventional radiologists or cardiologists to facilitate a 24/7 service
  7. g37% of all stroke patients arrive at hospital within 4 h with ischaemic stroke of known onset time. ~ 50% of patients have large artery occlusive strokes. So IAT currently potentially applies to almost 20% of acute disabling ischaemic strokes; Adjunctive IAT approach is proven (level 1 evidence) to increase mRS 0–2 by 12% to 14% with benefit across the Rankin scale of shift to reduced disability
  8. hSelective brain tissue viability assessment approach to IAT is proven (level 1 evidence) to increase mRS 0–2 by 24% to 31% with benefit across the Rankin scale of shift to reduced disability; All RCT results are based on expert interpretation of advanced imaging as triage for intra-arterial thrombectomy; This option is a less time critical approach
  9. iThis entails networking of Interventional Neuroradiology units to deliver 24/7 cover sooner – with some longer transfer times, but does mean the efficacy data from RCTs can be applied (underpinned by data for UK centres from the PISTE trial)
  10. jThis is provided by very few places worldwide; This model of provision is clearly very expensive