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Organisation of the early management of acute ischaemic stroke using mechanical thrombectomy

Health technology assessment - Posted on Jul 26 2018

Ischaemic stroke (IS) is an acute condition which, according to the World Health Organization (WHO), represents the second leading cause of mortality worldwide, and the third cause of mortality in developed countries.

It requires extremely urgent care, which represents a major public health challenge. Until 2015, the treatment of IS was based on timely recanalisation of the occluded artery by intravenous (IV) thrombolysis. The arrival of mechanical thrombectomy (MT) has made it possible to expand the therapeutic arsenal for IS, and modify its management.

A request relating to mechanical thrombectomy (MT) has been submitted to the French National Authority for Health (HAS) by the Directorate General of Health Care Provision (DGOS). It relates more specifically to the organisational aspect associated with the introduction of this technique into conventional practice.

As such, DGOS requested HAS to specify the practice and environmental requirements as regards MT in terms of:

  • composition and coordination of teams involved in care;
  • technical platform;
  • organisational requirements for the implementation of MT under optimal conditions.

Therefore, the endpoint of this assessment report is to analyse the changes caused by the introduction of MT in the strategy for the early management of stroke, and describe the arrangement of an organisational system including:

  • the practice and environmental requirements in respect of endovascular intracranial artery thrombectomy in the treatment of acute ischaemic stroke;
  • referral of patients with suspected stroke to treatment facilities;
  • multidisciplinary coordination.

In view of the points described above, HAS has issued the following recommendations:

R1 ⇒ Expand the pool of physicians with MT expertise in order to meet future care needs by extending MT training (initial SCDT and continuous training) to other radiologists and to other medical specialities (neurologists, neurosurgeons and if the need is not sufficiently covered to interventional cardiologists).

R2 ⇒ Increase the human and material resources of the 39 stroke centres in order to provide MT under optimum conditions.

R3 ⇒ Create complementary care provision by setting up new MT units within healthcare institutions already including primary stroke centres.

R4 ⇒ Define a minimum activity threshold in respect of MT procedures annually and per unit. Failing literature of a sufficient level of evidence, HAS on the opinion of experts proposes an initial annual threshold of 60 cases. This threshold level should be assessed during the scheme ramp-up phase and after five years, in the light of the number and distribution of cases.

R5 ⇒ Promote and repeat information campaigns aimed at the general public. The information should not be restricted to subjects with vascular risk factors, but should target the population as a whole, including young people.

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