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Table 3 Summary of results from ranking exercises

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

  Wider BASP members (N = 43) Percentage Responses
Using your experience and judgement, please take the following elements into consideration when assigning scores to the options: availability; practicality/deliverability; and cost (including of any additional software or hardware likely to be required in your region) 1 very strongly disapprove 2 quite strongly disapprove 3 disapprove 4 neutral 5 approve 6 quite strongly approve 7 very strongly approve
 1. Patients with large artery occlusive stroke are transferred to nearest [neuroscience] centre for thrombectomy based on local CT/CTA alonea   2    21 53 23
 2. Patients are transferred to nearest [neuroscience] centre for thrombectomy based on advanced imaging obtained at referring hospitalb 12 5 16 23 21 16 7
 3. Selective transfer to nearest on call [neuroscience] thrombectomy centre for expert thrombectomyc 16 19 12 19 14 12 9
Using your experience and judgement, please take the following elements into consideration when assigning scores to the options: availability; practicality/deliverability; and cost (including of any additional software or hardware likely to be required in your region)
Whilst options 2 & 3 are both “Advanced Imaging Triage” they may differ in deliverability, cost & practicality so they have been separated out for this exercise. There is of course uncertainty over the strength of evidence supporting either option
Full members of the BSNR (N = 21) Percentage Responses
 1. Patients are transferred for thrombectomy based on local CT/CTA aloned 5   5 5 19 29 38
 2. Patients are transferred for thrombectomy based on formal ASPECTS & Collateral Scoring in addition to confirming large artery occlusion present - “Advanced Imaging Triage ACS”e**    24 29 14 14 14
 3. Patients are transferred for thrombectomy based on CT Perfusion parameters in addition to confirming large artery occlusion present - “Advanced Imaging Triage PERFUSION”f** 14 19 38 14   10  
 4. Selective transfer to nearest on call neuroscience centre for “expert thrombectomy”g   5 29 5 29 5 29
  1. **N = 20
  2. a 37% of all stroke patients arrive at hospital within 4 h with ischaemic stroke of known onset time. ~ 40–50% of patients have large artery occlusive strokes
  3. 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
  4. Facilities will need to be available for the neurointerventionist to rapidly review CT/CTA prior to accepting a referral. This may require additional IT infrastructure
  5. Responsibility for formal reporting will be with the centre acquiring the CT/CTA images unless other contractual arrangements are formally agreed
  6. b Selective 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. Facilities will need to be available for the neurointerventionist to rapidly review imaging prior to accepting a referral. This will require additional IT infrastructure. Responsibility for formal reporting will be with the centre acquiring the imaging unless other contractual arrangements are formally agreed
  7. cThis is a flexible clinical judgement driven referral route – so that for example if plain CT shows an obvious hyper-dense MCA sign, the ASPECTS score is good (7+) & NIHSS is ≥6, referral for thrombectomy is made without CTA if obtaining such locally would add significant delays. However, this may add delay downstream in the pathway for thrombectomy as a second CT scanner visit will be required on arrival at receiving hospital. This may entail networking of Neurorinterventional 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)
  8. dFacilities will need to be available for the neurointerventionist to rapidly review these prior to accepting a referral. This may require additional IT infrastructure. Responsibility for formal reporting will be with the centre acquiring the CT/CTA images unless other contractual arrangements are formally agreed
  9. eThis reflects evidence of ESCAPE trial. Footnotes above also apply to all these options
  10. fThis reflects evidence of EXTEND/SWIFT PRIME trials. Footnotes to option 1 also apply. This may require a region wide adoption of a standardised protocol & software such as RAPID or OLEA
  11. gThis is a flexible clinical judgement driven referral route – so that for example if plain CT shows an obvious hyper-dense MCA sign, the ASPECTS score is good (7+) & NIHSS is ≥6, referral for thrombectomy is made without CTA, which may add delay to the pathway to thrombectomy
  12. NB The propositions that reached consensus from the respective groups have been highlighted in bold text. Percentages may not equal 100 due to rounding