Essential Requirements to Develop a Stroke Thrombectomy Program in Limited Resource Settings: A Delphi-style Survey

Introduction: Mechanical thrombectomy (MT) has revolutionized stroke care in patients with ischemic strokes from large vessel occlusion (LVO) leading to excellent outcomes. The procedure has led to rapid adoption as the standard of care. However, the Mechanical Thrombectomy Global Access For Stroke (MT-GLASS) study, demonstrated that global access to mechanical thrombectomy is < 3% of the demand. Our aim was to understand what infrastructure, equipment and staff are required to perform a safe and effective MT for LVO-stroke in resource limited settings through Delphi-style survey of international MT providers.

Methods: An international panel of stroke MT providers were identified by the steering committee. Rounds of online surveys were distributed via email to assess essential resources necessary to establish a stroke thrombectomy service in low resource setting. Initial survey consisted of free-response statements that underwent thematic analysis to identify statements. These statements were distributed in a second round of surveys to assess agreement with each statement. Consensus was defined as 70-100% of respondents sharing the same opinion (i.e. agreement or disagreement).

Results: A total of 29 of 48 (60%) invited panelists participated in surveys. Panelists included neurosurgeons, neurologists, and interventional neuroradiologists from 20 countries. Consensus was achieved on 28 items. Statements reaching consensus fell into four categories: system, equipment, procedure, personnel. Panelists agree that a formalized stroke triage pathway with 24-hour/7-day per week access to neuroimaging is essential. Pulse-oximeter, ECG, blood-pressure monitoring, and post-thrombectomy CT imaging are necessary peri-procedurally. Panelists agree that MT can safely be performed in the low-resource setting with conscious sedation, palpation for access, and manual pressure for closure.

Conclusion : International stroke providers agree that developing a stroke thrombectomy service is feasible in low resource settings. Here we present the consensus recommendations of essential requirements of the system, equipment, procedure, and personnel necessary to provide this lifesaving intervention in low resource settings.