Dundee stroke expertise to save lives across the world

The World Federation for Interventional Stroke Treatment (WIST) has accredited the University as its official global training centre. This means doctors and teams from relevant specialities looking to train in Endovascular Stroke Treatment (EST) for WIST accreditation will be able to do so.

The announcement coincides with the publication of WIST competency-based training guidelines. Professor Iris Grunwald, Chair of Neuroradiology at Dundee’s School of Medicine, is the lead author of the guidelines, which have been produced in conjunction with other leading figures from the fields of neuroradiology, interventional neurosurgery, stroke neurology and cardiovascular medicine.

Each year, there are about 15 million strokes worldwide. For the UK, the aggregate societal cost is estimated at £26 billion per year, including £8.6 billion for NHS and social care. EST is considered the most effective way to treat patients with stroke caused by a large, blocked brain vessel but, in many parts of the world, less than 1% of patients receive this life- and brain-saving treatment.

One of the major constraints to expanding thrombectomy services is the inadequate number of interventional neuroradiologists required to carry out the work. In response, it was proposed that experienced clinicians from varying backgrounds could – and should – undertake training to equip them with the skills to undertake thrombectomy.

Professor Grunwald is one of the pioneers in the endovascular treatment of stroke and an advocate of cross-specialty and multidisciplinary collaboration, uniting experts from across the world to develop a curriculum based on competencies.

“When I first experienced the power of EST, now nearly 20 years ago, I realised this treatment was here to stay,” she said.

“On the one hand, we needed more interventionalists to cover a worldwide demand, on the other hand, it would not be feasible to ‘produce’ thousands of extra interventional neuroradiologists. The number of other neurointerventional cases is just too small. That is when I started advocating cross-specialty training.

“The manpower of cardiologists and radiologists is much greater, and most hospitals already have angiographic services that would allow incorporating EST, without much additional infrastructure.”

The WIST guidelines map out a training and credentialling pathway for interventionalists from varying backgrounds and provide a global solution to the need to increase the number of ESTs carried out. The WIST strategy has already proven effective in different healthcare systems across the world, including in Scotland.

Professor Grunwald utilised Dundee’s high fidelity simulators and unique perfused cadaveric model to develop the training guidelines. Her innovative work in this area has helped establish the School of Medicine as a global centre of excellence for stroke training and treatment.

She added, “We are delighted with this designation and to be able to bring doctors from around the world to Dundee to equip them with skills that will save lives and improve the quality of life for stroke patients in their own countries.

“This development is of great significance to healthcare professionals, stroke associations, governments, healthcare services and, ultimately, patients and their families.

“Despite some important differences in the vessels and organs, many of the techniques involved in EST, including thrombectomy, angioplasty and stenting are familiar to the interventional radiologist and cardiologist. However, while technical nuances can be easily learned by skilled interventionalists, WIST emphasises the importance of team training and training in pathophysiology, neuroanatomy, image interpretation, clinical examination and decision making and the management of complications.”

Stroke is a disabling and often deadly disease. Worldwide, it remains the second most common cause of death and the third most cause of permanent disability. During the past three decades, global stroke incidence has increased by 70% and its mortality by 43%. The global burden of stroke is expected to rise in the future.

EST is essentially brain resuscitation. Indications for EST are now well established and continue to expand with the publication of new evidence.

The WIST guidelines offer personalised training to achieve standardised learning outputs that enable doctors to perform cerebral angiograms, carotid stenting and EST safely. They include training on the detection and management of complications, assessment of imaging and patient eligibility, and peri- and post-procedural management.

In an accompanying editorial, Dr Angus Cameron, Scottish Government Advisor and Chair of the Scottish Thrombectomy Group, said, “The inclusivity of the WIST training guidelines enables a training path for more operators across different specialities and will increase the currently highly insufficient number of EST-capable centres that can perform timely brain resuscitations.

“Safe and effective training according to WIST guidelines has recently been established in Scotland and, with Scottish Government support, training is now being delivered in Dundee. The guidelines map out a rational and effective approach to meeting the demand for EST, which fits within any modern healthcare system.”