JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 73, NO.

12, 2019

ª 2019 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

JACC REVIEW TOPIC OF THE WEEK

Interventional Cardiology and

Acute Stroke Care Going Forward
JACC Review Topic of the Week

David R. Holmes, JR, MD,a L. Nelson Hopkins, MDb,c,d

ABSTRACT

Stroke is a catastrophic event for patients and their families. Given the frequency of approximately 750,000 events
annually with their associated morbidity and mortality, stroke has assumed increasing importance. Scientific study
has identified several diseases categorized under the broad term of “stroke” that form the rationale for current
treatment strategies. This paper reviews new information, especially on ischemic stroke (particularly large-vessel
occlusions), which identifies the potential for new approaches that can dramatically improve outcome but will require the
need to enhance and embrace the care team required to deliver optimal care and address current unmet clinical
needs. (J Am Coll Cardiol 2019;73:1483–90) © 2019 by the American College of Cardiology Foundation.

S troke is a major concern to patients, their fam-

ilies, and society as a whole, given the associ-
ated mortality and morbidity (1). Occurring in
approximately 750,000 U.S. patients and 15,000,000
patients worldwide, stroke requires optimization of
therapeutic strategies. Treatments for acute ischemic
stroke (AIS) continue to evolve with the accumulation
of new scientific data from randomized controlled tri-
als and registries. Accordingly, the guidelines have
been updated in the 2018 American Heart Associa-
tion/American Stroke Association stroke early man-
agement document (2). Key principles
namely, that the brain is exquisitely sensitive to
ischemia and that time to treatment is of paramount
importance, not only in improving patient outcomes,
but also in providing a metric for quality of care. The
central role of early thrombolysis in eligible patients
continues to be emphasized. Overlying
principles of care, clinical trial results have now accu-
mulated regarding more optimal patient selection
criteria, changes in imaging modalities and parame-
ters, as well as new strategies of care. Of particular
importance has been documentation of the role of
mechanical thrombectomy and expansion of the
time window for endovascular treatment from <6 h
for thrombolysis to 24 h for select patients on the ba-
sis of perfusion imaging findings. This evolution in
strategies of care is following a trajectory similar to
what was seen in the field of care for ST-segment
remain, elevation acute myocardial infarction (STEMI). This
paper explores issues in implementation of the most
recent strategies of care for AIS, assimilating the les-
sons learned in the treatment of STEMI. Included is
a critical discussion of training for interventional car-
diologists and other qualified interventionists as part
these of stroke teams to deal with unmet needs of patients

Listen to this manuscript’s

audio summary by
Editor-in-Chief
Dr. Valentin Fuster on
JACC.org.
From the aDepartment of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; bDepartment of Neurosurgery, Jacobs
School of Medicine and Biomedical Sciences, Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New
York; cDepartment of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York; and the dJacobs Institute,
Buffalo, New York. Dr. Hopkins has received grant/research support from Canon Medical Systems Corporation; has financial
interests/stock in Boston Scientific, Cerebrotech, Endostream, Endomation, Silk Road, Ostial Corporation, Imperative Care,
StimSox, Photolitec, ValenTx, Ellipse, Axtria, NextPlain, and Ocular; and has a board/trustee/officer position in Imperative Care
Inc. Dr. Holmes has reported that he has no relationships relevant to the contents of this paper to disclose.

Manuscript received September 25, 2018; revised manuscript received January 4, 2019, accepted January 7, 2019.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2019.01.033

1484 Holmes Jr. and Hopkins
Interventional Cardiology and Acute Stroke Care Going Forward
ABBREVIATIONS with these disabling clinical events, espe-
AND ACRONYMS
cially in areas devoid of comprehensive
stroke centers (CSCs).
AIS = acute ischemic stroke
CAS = carotid artery stenting
BACKGROUND: TREATMENT OF
CSC = comprehensive stroke
center
ACUTE ARTERIAL OCCLUSION
ELVO = emergent large-vessel
occlusion Earlier efforts on treatment of acute arterial
occlusion focused on STEMI were based on
mRs = modified Rankin scale
PCI = percutaneous coronary
the pathophysiology associated with acute
intervention thrombotic occlusion of a major coronary
STEMI = ST-segment elevation vessel.
myocardial infarction Accordingly, emphasis was placed on the
use of thrombolytic therapy with the development of
strategies to efficiently administer it and to then
gauge its effectiveness. As the field evolved, inter-
ventional strategies with initially percutaneous
transluminal coronary angioplasty and then stent
implantation were studied in multiple registries and
randomized controlled trials. There was initial sub-
stantial debate regarding thrombolysis versus me-
chanical percutaneous coronary intervention (PCI)
(3). Concerns were related to the magnitude of
improvement in outcome, the risk–benefit ratio, and
delivery-of-care models, including patient transport
to centers capable of delivering care. Those issues
were subsequently resolved by the data such that
guidelines indicate that optimal care of STEMI is
primary PCI if it is available in experienced centers
within 4 to 6 h of symptom onset. Subsequent metrics
of quality include a door-to-balloon time of 90 min
(4). In addition, strategies were developed for pa-
tients seen at centers in which PCI was not immedi-
ately available and included the concept of initial
thrombolysis followed by urgent transfer to a PCI
center (5).
The evolution of treatment strategies for acute
arterial occlusion in the brain with acute stroke is
following the same trajectory (2). The issues are
similar in terms of patient selection, risk–benefit ra-
tio, and magnitude of improvement in the delivery of
care at central and peripheral referral hospitals,
including concepts of spoke and hub institutions. The
issues are also similar with the evolution of stroke
intervention, beginning with thrombolytics and only
recently evolving to Level of Evidence: I of substan-
tial benefit for intervention to reopen the artery.
Given the magnitude of the clinical problem, resolu-
tion of these issues is of great importance.
Although the basic concept of reopening an acutely
occluded major artery in the heart or brain has some
similarities, several factors clearly differentiate AIS
from STEMI. Acute myocardial infarction usually
JACC VOL. 73, NO. 12, 2019
APRIL 2, 2019:1483–90
HIGHLIGHTS

Ischemic stroke is now treatable with
catheter intervention. Revascularization
must be accomplished rapidly for optimal
results, but there are not enough
comprehensive stroke centers or neuro-
interventionists to achieve this.

Cardiologists have excellent catheter
skills and extensive experience with
emergency intervention, and catheteri-
zation labs are widespread, suggesting a
possible solution for needed immediate
intervention worldwide.

Stroke intervention must be rapidly
expanded geographically and with a dra-
matic increase in the number of willing
and trained interventionists to meet the
enormous public health need.
results from rupture of a pre-existing plaque in a
coronary artery; by contrast, cardioembolic strokes
comprise approximately 20% of AIS with an addi-
tional 10% to 15% of emboli originating in carotid
artery plaques (6). In these patients, there is a high
rate of recurrence. Thus, the major goal in AIS is most
commonly removal of the offending embolus, rather
than stenting the plaque, to restore flow (Central
Illustration).
There are also important differences in the specific
target organ bed. Both the heart and the brain have
ischemic thresholds beyond which success rates are
low if reperfusion therapy is initiated. The effects of
organ dysfunction are variable in the different beds.
Myocardial infarction with suboptimal reperfusion
may lead to varying degrees of left ventricular
dysfunction for which medical therapy may result in
marked improvement and even render the patient
asymptomatic at normal levels of activity. By
contrast, failure of reperfusion for stroke leads to
significant, often disabling neurological dysfunction
or, at a minimum, residual cognitive defects that may
be very important to the patient and family. In addi-
tion, recent stroke studies confirm that brain tissue is
more sensitive to ischemia than myocardium, so the
time to revascularization is more critical with AIS
(7,8).
Another factor pertinent to this discussion is the
relative fragility of the intracranial arteries as
compared with coronary arteries. Structurally, major
intracranial arteries are approximately one-third to
one-half the thickness of coronary arteries and are
JACC VOL. 73, NO. 12, 2019 Holmes Jr. and Hopkins 1485
APRIL 2, 2019:1483–90 Interventional Cardiology and Acute Stroke Care Going Forward

C ENTR AL I LL U STRA T I O N Interventional Cardiology and Acute Stroke Care

Holmes, Jr., D.R. et al. J Am Coll Cardiol. 2019;73(12):1483–90.

(Left) Angiogram, anteroposterior view, obtained in a 78-year-old man with sudden onset of left hemiplegia and confusion showing complete
occlusion of the right middle cerebral artery (MCA). (Right) Angiogram immediately post-intervention and clot removal with a stent retriever
(Solitaire, Medtronic, Dublin, Ireland) showing restoration of MCA flow. (Bottom) Clot removed from right MCA and Solitaire device.

predominately composed of media (9,10). In addition,
very small and fragile perforating branches from
major intracranial arteries can inadvertently be
instrumented with guidewires during endovascular
intervention, resulting in vessel laceration and
intracranial hemorrhage. Such iatrogenic hemorrhage
from intracranial arteries may be fatal or result in
worsening of the stroke and reducing the chances for
recovery. Finally, to reach the area of occlusion, the
operator must be able to cannulate the internal ca-
rotid artery and navigate the devices required for
thrombectomy distal to the intracranial carotid
siphon.
The discussion in the preceding text highlights the
need for stroke interventionists to acquire an under-
standing of basic craniovascular pathophysiology and
anatomy, and receive training in safely accessing the
fragile cerebrovasculature. A mastery of safe and
effective use of the tools developed specifically for
intracranial procedures is essential. Also important is
an understanding of the clinical evaluation of the
patient who may (or may not) have an evolving
stroke. Finally, the appropriate choice of imaging
modalities is fundamental to accurately diagnose AIS
with emergent large-vessel occlusion (ELVO) to help
determine whether intervention may be feasible or
helpful.
CLINICAL TRIALS DATA
Although early randomized controlled trials
comparing intravenous tissue plasminogen activator
to catheter-based intervention for AIS showed no
significant benefit for intervention, they demon-
strated its safety. The IMS (Interventional Manage-
ment of Stroke) III, MR RESCUE (Mechanical Retrieval
and Recanalization of Stroke Clots Using Embolec-
tomy), and SYNTHESIS EXPANSION (Synthesis
Expansion; A Randomized Controlled Trial on Intra-
Arterial Versus Intravenous Thrombolysis in Acute
Ischemic Stroke) trials compared endovascular stroke
therapies to systemic thrombolysis (11–13). These tri-
als had significant limitations. Large-vessel occlusion
was not confirmed in many cases, delays in initiating
1486 Holmes Jr. and Hopkins JACC VOL. 73, NO. 12, 2019

Interventional Cardiology and Acute Stroke Care Going Forward APRIL 2, 2019:1483–90

T A B L E 1 Summary of Key Randomized Endovascular Trials of Acute Stroke Therapy

Good Functional
Endovascular Outcome (mRs #2)
Trial, Year of Publication (Ref. #) Main Inclusion Criteria Therapy at 3 Months

MR CLEAN (Multicenter Randomized Clinical Trial of Used CT ASPECTS for selection. Stent retrievers in 97% of 33% with endovascular,
Endovascular Treatment for Acute Ischemic Thrombectomy initiated within 6 h. interventions 19% with medical
Stroke), 2015 (29) management
ESCAPE (Endovascular Treatment for Small Core and Used a combination of CT ASPECTS and Stent retrievers in 86% of 53% with endovascular,
Anterior Circulation Proximal Occlusion with multiphase CTA to evaluate collaterals. interventions 29% with medical
Emphasis on Minimizing CT to Recanalization Thrombectomy initiated within 12 h. management
Times), 2015 (7)
EXTEND IA (Extending the Time for Thrombolysis in Perfusion-based patient selection was Stent retrievers in all endovascular 71% with endovascular,
Emergency Neurological Deficits-Intra-Arterial), used. interventions 40% with medical
2015 (30) Thrombectomy initiated within 6 h. management
SWIFT PRIME (Solitaire FR with the Intention for Primarily perfusion-based patient selection Stent retrievers in all endovascular 60% with endovascular,
Thrombectomy as Primary Endovascular was used. Thrombectomy initiated interventions 35% with medical
Treatment of Acute Ischemic Stroke), 2015 (31) within 6 h. management
REVASCAT (Randomized Trial of Endovascular CT or MR ASPECTS for patient selection. Stent retrievers in 68% of 44% with endovascular,
Revascularization with Solitaire FR Device versus Therapy initiated within 8 h. interventions 28% with medical
Best Medical Therapy in the Treatment of Acute management
Stroke Due to Anterior Circulation Large Vessel
Occlusion Presenting Within Eight Hours of
Symptom Onset), 2015 (32)
DEFUSE 3 (Endovascular Therapy Following Imaging Perfusion-based patient selection to Stent retrievers in 80% of 45% with endovascular,
Evaluation for Ischemic Stroke 3), 2018 (19) calculate penumbra/core ratio. Therapy interventions 17% with medical
initiated within 6 to 16 h. management
DAWN (Clinical Mismatch in the Triage of Wake Up Combination of perfusion and clinical Trevo stent retriever in all 49% with endovascular,
and Late Presenting Strokes Undergoing (NIHSS severity)-based patient interventions 13% with medical
Neurointervention With Trevo), 2018 (18) selection. Therapy initiated within management
6 to 24 h.

Reproduced with permission from Mokin et al. (16).

ASPECTS ¼ Alberta Stroke Program Early CT Score; CT ¼ computed tomographic/tomography; CTA ¼ computed tomography angiography; FR ¼ flow restoration; IV ¼ intravenous; MR ¼ magnetic
resonance; mRs ¼ modified Rankin scale; NIHSS ¼ National Institutes of Health Stroke Scale; rtPA ¼ recombinant tissue activator.

the therapy were common, and clot-removal devices
were early generation and less effective than current
tools (14,15).
The next generation of stroke trials reported in
2015 compared modern mechanical stroke thrombec-
tomy stent retrievers plus intravenous thrombolytics
with intravenous thrombolytics alone (Table 1) (16).
These trials showed substantial benefit for endovas-
cular intervention compared with
thrombolysis alone up to 6 h from stroke symptom
onset or time “last known to be well.”
Data in support of thrombectomy during the 6-h to
12-h window were not as robust due to the limited
number of patients treated outside the 6-h window
and were derived from post hoc analysis of the orig-
inal HERMES (Highly Effective Reperfusion Evaluated
in Multiple Endovascular Stroke Trials) collaboration
dataset (17). Subsequent studies, namely, the DAWN
(Clinical Mismatch in the Triage of Wake-Up and Late
Presenting Strokes Undergoing Neurointervention
With Trevo) (18) and DEFUSE 3 (Endovascular Ther-
apy Following Imaging Evaluation for Ischemic
Stroke 3) (19) trials, focused on the treatment of
strokes >6 h on the basis of perfusion imaging. These
findings now form the scientific
guideline-based care.
Goyal et al. (20) performed a meta-analysis of in-
dividual patient data from the 2015 randomized
controlled trials. The collective enrollment was 1,287
subjects; 634 were assigned to endovascular throm-
bectomy and 653 to a control group that included best
medical care. The primary outcome was the degree of
disability on the modified Rankin scale (mRs) at
90 days. Preceding intravenous alteplase was used in
intravenous 83% of the endovascular group and 87% of the control
group, and endovascular treatment was administered
within 180 min of presentation in 70% of cases. The
group receiving endovascular thrombectomy had
significantly less disability at 90 days compared with
the control group (adjusted common odds ratio: 2.49;
95% confidence interval: 1.76 to 3.53; p < 0.001). The
number needed to treat to reduce disability by 1 or
more points on the mRs was 2.6.
The thrombolytic agent used in combination with
thrombectomy in these earlier trials most commonly
was alteplase. The use of alteplase has been studied
further in a head-to-head comparison with the more
fibrin-specific tenecteplase (21). In this study, the pri-
mary outcome was reperfusion of >50% of the
ischemic territory or absence of a retrievable thrombus
rationale of at the time of intervention. The median time from
stroke symptom onset to initiation of intravenous
JACC VOL. 73, NO. 12, 2019
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T A B L E 2 Potential Health Care Facilities for
Neurointerventional Stroke Care
Total Interventionists
U.S. hospitals 5,534 NA
Cardiologists 46,033 >5,000*
Neurologists 18,266 200†
Neurosurgeons 5,476
961‡
Neuroradiologists >5,000
Radiologists 51,018 1,156‡
Vascular surgeons 3,125 2,500§
Total >9,817
Values are n. *From Narang et al. (28). †Estimated membership of the Society of
Vascular and Interventional Neurology. ‡Membership of the Society of Neuro-
Interventional Surgery. §Estimated that 80% of vascular surgeons have a sub-
stantial endovascular practice.
NA ¼ not applicable.
thrombolysis was 125 min for tenecteplase and 134 min
for alteplase. The study investigators found that ten-
ecteplase before thrombectomy was associated with
better functional outcome and higher incidence of
reperfusion. Accordingly, practice may continue to
evolve with more selective thrombolytic drugs to
further optimize care and outcome.
Data from these trials showed that optimal results
were time-dependent. Meta-analysis of individual
patient data from the original HERMES collaboration
showed that each 1-h delay to reperfusion was asso-
ciated with a less favorable degree of disability
(common odds ratio: 0.84; 95% confidence interval:
0.76 to 0.93) (20). The next set of trials focused on the
potential to expand the time to treatment and
therefore expand the number of patients who might
benefit. The results have important implications
because symptom recognition as well as transport
times may involve significant delays before the pa-
tient reaches medical care. In addition, many smaller,
more remote medical centers may not have the
capability to manage acute stroke as recommended by
treatment guidelines. The importance of imaging
triage in patients arriving outside the 6-h window was
demonstrated in the DEFUSE 3 and DAWN trials
(18,19). These trials demonstrated marked improve-
ment for patients last known well up to 16 to 24 h
before randomization (in the DAWN trial) or initiation
of thrombectomy (in the DEFUSE 3 trial), including
patients who awaken having had a stroke during the
night (“wake-up stroke”). In these patients, there was
often severe clinical impairment at baseline presen-
tation. However, when perfusion
applied, there were some patients with large areas of
ischemia, but considerably smaller areas of core
infarction, that were amenable to treatment.
Holmes Jr. and Hopkins 1487
Interventional Cardiology and Acute Stroke Care Going Forward
T A B L E 3 Joint Commission Certification for Thrombectomy-
Capable Stroke Centers
Comprehensive Neurointerventionists who routinely take calls must be certified by
Stroke Centers CAST or meet all of the following criteria:
1) Completed ACGME-accredited or equivalent residency in
212
neurosurgery, neurology, or radiology
NA
2) For neurologists—stroke or neurocritical care fellowship
NA
3) For radiologists—neuroradiology subspecialty fellowship
NA
4) Neuroendovascular training program in CAST-approved program
NA
5) Performed 15 mechanical thrombectomy procedures over the
NA past 12 months or 30 over the past 24 months
NA
Adapted from The Joint Commission (26).
ACGME ¼ Accreditation Council for Graduate Medical Education;
CAST ¼ Committee for Advanced Subspecialty Training.
The importance of specific perfusion imaging data
for optimal patient selection in this “mismatch”
group was studied in the DEFUSE 3 trial, a multi-
center, randomized, open-label trial that evaluated
182 patients 6 to 16 h after they were last known to be
well (19). Patient selection criteria included a prox-
imal middle cerebral artery or internal carotid artery
occlusion with an initial infarct size of <70 ml, but a
ratio of the volume of ischemic tissue on perfusion
imaging to infarct volume of $1.8, indicating that the
region of tissue ischemia was greater than the area of
infarction. The primary endpoint was the ordinal
score on the mRs. A 90-day mRs score of 0 to 2
(indicating less disability) was documented in 45% of
the thrombectomy group compared with 17% in the
control group (p < 0.001). There was also a reduction
in 90-day mortality in the thrombectomy group
versus the control group (p ¼ 0.05). These and other
data indicate that the time window for dramatic
improvement in outcome with invasive intervention,
based on perfusion imaging, may be significantly
longer in selected patients than what had been
initially thought, broadening strategies for care of
patients with AIS.
STROKE CENTERS
As stroke therapy awareness grew and hospital
reimbursement for treating AIS with thrombolytics
increased, the concept of stroke centers was devel-
oped and defined. Individual states developed their
own definitions of stroke centers on the basis of their
demographics and politics. Currently, there are 4
basic types of stroke centers (namely, stroke-ready,
primary, comprehensive, and thrombectomy-
imaging was capable) defined and accredited at a national level.
The agencies that provided accreditation for all 4
types are The Joint Commission (22) and the Health-
care Facilities Accreditation Program (23). Det Norse
1488 Holmes Jr. and Hopkins
Interventional Cardiology and Acute Stroke Care Going Forward
Veritas (24) and the Center for Improvement in
Healthcare Quality (25) provide accreditation for all
but thrombectomy-capable centers. Comprehensive
and thrombectomy-capable centers have stroke-
intervention capability, but only CSCs must consis-
tently have 24/7/365 coverage.
Primary stroke centers must have the capability to
administer intravenous tissue plasminogen activator
and have specialty physician backup available, but
not necessarily immediately. CSCs must have a well-
organized stroke team capable of rapid triage, imag-
ing, and stroke intervention available 24/7/365. As of
May 2018, there are approximately 212 of these cen-
ters in the United States. The number of neuro-
interventionists varies, from estimates of 800 to 1,100
(Table 2). Whether all these centers have the capa-
bility of 24/7/365 coverage is unclear from personal
observation. In addition, time from stroke onset to
emergency room arrival is variable, depending upon
whether the patient is seen at a local hospital and
then transferred to the CSC or presents initially to the
CSC. Time to intervention is variable, depending on
the stroke pathways at each center.
The Joint Commission has published guidance for
the certification of neurointerventionists who
routinely take calls for endovascular treatment of
stroke (Table 3) (26). These requirements are detailed
and include training and experience. They cover
neurologists, radiologists–neuroradiologists, and
neuroendovascular trainees with intracranial and
extracranial training and expertise. Specific training
mandates have recently been removed, but contro-
versy exists as to final requirements. The guidelines
do not cover interventional cardiologists, interven-
tional radiologists, and interventional vascular sur-
geons (i.e., extracranial interventionists) (Table 2)
(26). However, each of these latter groups has
training and established expertise in evaluation and
endovascular treatment of the extracranial carotid
artery.
Central questions relate to whether these extra-
cranial interventionists should or might be active
members of the stroke team and how they might best
be integrated into it. The answer appears to be local.
In large centers with multiple active neuro-
interventionists who are able to staff the laboratories
24/7/365 and provide very rapid procedural coverage,
extracranial interventionists may not be needed for
catheter-based stroke intervention. Conversely, as
stroke intervention becomes more mainstream,
especially when regulators begin to impose the door-
to-needle mandates that are now common for STEMI,
having additional trained physicians on the inter-
ventional stroke team including appropriately trained
JACC VOL. 73, NO. 12, 2019
APRIL 2, 2019:1483–90
extracranial interventionists could be a welcome
addition.
For this to happen, these interventionists must
receive effective training. Experience with carotid
artery stenting (CAS) for access is invaluable for
stroke intervention. Vetting of the interventionists in
the CREST trial (Carotid Revascularization Endarter-
ectomy versus Stenting Trial) required appropriate
clinical evaluation of stroke symptoms (and con-
founding symptoms) and expertise in cervical angi-
ography, embolic protection, and successful stent
placement (27). The results of the CREST trial,
compared with those of other carotid stenting trials,
showed excellent results for CAS among the multiple
interventional specialties discussed here. No safety
disadvantages were detected for those interventional
specialists who did not receive intracranial training.
The next steps for these carotid-skilled in-
terventionists are for clinical neurology training and
intracranial interventional training. The degree of
neurology training ideally should be determined
locally. For example, for stroke teams for which a
vascular neurologist is always present, complete
clinical neurology expertise may not be required of
the interventionist, regardless of specialty.
Many of the 5,534 hospitals in the United States
have abundant neurological expertise, but do not
have an adequate number of neurointerventionists (if
any) for 24/7/365 coverage sufficient to avoid physi-
cian burnout. Even at the approximately 212 CSCs,
such around-the-clock coverage can be a burden
because some of these centers have only 1 or 2 stroke-
trained neurointerventionists on staff. There are
many more cardiology and other interventionists
than neurointerventionists, and they are more widely
distributed (Table 2) (28). Extracranial in-
terventionists could be trained and could become
experienced in intracranial thrombectomy. Training a
skilled interventional cardiologist, radiologist, or
vascular surgeon in many instances will be different
from training a neurointerventionist. And it is
important to note that the level of training required
varies greatly and depends on the individual’s per-
sonal experience and skill set. Interventional cardi-
ologists, interventional radiologists, and
interventional vascular surgeons must learn the ba-
sics of anatomy, pathophysiology, diagnosis of ELVO,
neurotechnology, and methodology if they have in-
terest in joining a stroke intervention team. An
advantage of including interventional cardiologists is
that they have worked under the time constraints
imposed as metrics of care for 24/7/365 delivery of
treatment of acute myocardial infarction. In addition,
they have extensive STEMI experience opening
JACC VOL. 73, NO. 12, 2019 Holmes Jr. and Hopkins 1489
APRIL 2, 2019:1483–90 Interventional Cardiology and Acute Stroke Care Going Forward

occluded arteries on awake patients with a rapidly
moving target. Interventional cardiologists skilled in
STEMI and trained in stroke intervention in areas of
the world with no neurointerventionists could have a
significant positive impact on AIS.
In rural areas and in small- to medium-sized com-
munities without CSCs or “stroke-ready” teams,
skilled extracranial interventionists can play a criti-
cally important role in stroke intervention. Today in
the United States, patients with AIS and ELVO are
often initially evaluated in local hospitals but must be
transferred to a CSC for intervention. Unfortunately,
the time it takes for initial evaluation in the outside
hospital, arranging and transferring the patient to the
CSC, re-evaluation, imaging, and preparing for and
performing the intervention often result in unac-
ceptable delays to reperfusion.
CONCLUSIONS
The interventional workforce needs to be expanded
for stroke teams of the future (Central Illustration).
The 800 to 1,100 neurointerventionists need help if
the availability of urgent mechanical thrombectomy
for eligible stroke patients is to be optimized at the
5,000þ hospitals across the United States. Neuro-
interventional training programs in neuroradiology,
neurology, and neurosurgery will not be sufficient to
provide the necessary people power. Interventional
cardiology, radiology, and vascular surgery can add
value for the stroke teams of the future. Combined,
these interventional groups number up to nearly
10,000 (Table 2). Many strokes originate in the heart,
and cardiologists can add value to the stroke team.
Brain imaging continues to advance rapidly, and its
role in patient selection continues to expand; inter-
ventional radiologists can add skill and experience to
image interpretation. Because of STEMI, in-hospital
vascular emergencies, ruptured aortic and other
vascular aneurysms, interventional cardiologists, ra-
diologists, and vascular surgeons have developed the
mindset needed for urgent 24/7/365 intervention.
Recognition of the importance of intervention for
STEMI has resulted in widespread distribution of
interventional cardiologists and catheterization
laboratories. The existing paradigm of evaluation in
local hospitals, then transferring patients with ELVO
to major CSCs in larger cities routinely puts patients
outside the ideal time window for optimal revascu-
larization. Emergent, mechanical stroke intervention
locally by a stroke team and then transferring the
patient with a reperfused brain (if necessary for
complex cases) to a brain rehabilitation center could
preserve the ideal time window, resulting in better
outcomes. Uncomplicated interventions with good
results would not require transfer of all patients,
given that evaluation and preventive strategies could
well be handled by the vascular neurologist with help
from the cardiologist and other interventionists.
What is required is a willingness on the part of the
neurointerventional community to train interested
interventional cardiologists, radiologists, and
vascular surgeons in stroke intervention, incorporate
these interventionists into stroke teams, and make
interdisciplinary collaboration the norm for this
compelling public health issue. Another less obvious
benefit will be the synergies that spring from inter-
action and collaboration among different vascular
disciplines.
Given the mandate for rapid intervention, new
technology may offer help. There is currently signif-
icant interest in robotics for catheter-based inter-
vention that hopefully will lead to rapid remote
robotic stroke intervention in areas underserved by
stroke interventionists. Multidisciplinary collabora-
tion will be essential for this to occur.
The sight of a paralyzed, aphasic, cognitively
devastated patient destroyed by AIS returning to a
functional human being within minutes after brain
reperfusion is achieved is perhaps the most dramatic
event any physician will ever see. With everyone
working together, the future for stroke patients is
indeed bright.
ADDRESS FOR CORRESPONDENCE: Dr. L. Nelson
Hopkins, Department of Neurosurgery, University at
Buffalo, 100 High Street, Suite B4, Buffalo, New
York 14203. E-mail: lnhopkins@icloud.com. Twitter:
@UB_Neurosurgery, @MayoClinicCV.

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KEY WORDS acute ischemic stroke,
interventional cardiology, interventional
workforce, stroke team