Endovascular comprehensive stroke center designation parameters.

Nazli Janjua, MD Irene Katzan, MD Aamir Badruddin, MD Thanh N. Nguyen, MD Alex Abou-Chebl, MD Osama O. Zaidat, MD, MS The approval of IV tissue plasminogen activator (IV tPA),1 the first stroke revascularization therapy, limiting ischemia in progress, led to the establishment of criteria to define primary stroke centers (PSCs),2 capable of delivering this treatment. Corollary to PSC designation, the establishment of stroke units, comprising nursing and physician personnel trained in the care of stroke patients, improves outcome for stroke patients.3–7 The market approval of various novel devices aimed at removing thrombus from occluded blood vessels in the setting of acute ischemic stroke (AIS)8,9 and the recognition of these as a potential treatment option for certain patients has helped spur the development of recommendations and metric standards for comprehensive stroke centers (CSCs) by the Brain Attack Coalition (BAC), and endorsement by the Society of Vascular and Interventional Neurology (SVIN).10,11 Additionally, the evolution of the neurocritical care discipline over the past 2 decades, with specialized care for AIS and hemorrhagic stroke, including subarachnoid and intracranial hemorrhage, is considered as an optional component in the proposed metrics criteria for CSCs (table). Many proposed components of CSCs include infrastructure also necessary for PSC function: “acute stroke teams, written care protocols ... [and an] integrated emergency response system.” In addition, basic services required for care of stroke patients remain core requirements for both PSCs and CSCs: “availability and interpretation of CT scans 24 hours ... and rapid laboratory testing, administrative support, strong leadership, and continuing education.”2 Beyond these elements, CSCs may be further distinguished by the availability of “vascular neurosurgery and neurology; advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy.”10 Optional components for CSCs include neuroscience intensive care units (neuro-ICUs), perfusion imaging techniques, and other (laboratory and research) personnel. The designation of PSCs creates an infrastructure for the improved delivery of hyperacute therapy. In addition, it aids emergency medical services (EMS) in identifying appropriate acute stroke facilities for patient transport and improves dialogue and collaborations between EMS and hospitals. PSC-designated facilities must also hold at least biannual community education events, thereby having direct public impact.2 Quality review processes to assess ongoing performance, also required for designated CSCs, further enhance centers’ ability to continually reassess their delivery of stroke care at a high standard. Success of the system is manifested in increased rates of IV tPA utilization in the United States; for example, in Michigan the rate increased by 50% (to 4.6%, from 3%),12 and in New York the rate doubled (to 5.2%, from 2.4%)13 after the certification process began for PSCs. Also, 33% of patients were evaluated by a stroke or rapid response team at certified centers, vs 0.4% at noncertified centers.12 Furthermore, whereas many stroke treatments have failed to demonstrate improvements in mortality rates,1 care of patients in stroke centers has.14 Ideally, the formation of CSCs would have the same effect on the delivery of endovascular recanalization therapy (ERT), by improving institutional support for endovascular services and aiding implementation of a systems-based approach to stroke care with regional transport protocols. There are important practical issues involved in patient transport to CSCs, and these create considerable debate among stakeholders in the CSC certification process. These issues may relate to loss of reimbursement and revenues for hospitals that may be capable of providing PSC level care but not ERT. More important, the greater distance between the patient’s origin and final hospital increases the time to arrival at the tertiary stroke hospital, which could de-