24hr Thrombectomy Postcode Lottery with Dr Richard Pullicino (Consultant Interventional Neuroradiologist)

Hello guys and thanks for joining us for another edition of Radcast. You can all breathe a huge sigh of relief because we're back to our regular format for today and we've got another guest in the hot seat. Since ramblings we've both had a very different couple of weeks. You were living it up in Brazil. No, I I was at a conference.

Working. Anyway, whilst you were doing that, I was actually working. I was at the uh inaugural Northwest MSK Imaging Group Upper Limb course. So for those interested in MSK, I can really recommend it. They had some fantastic speakers and Livel. And it was actually really well organized and very reasonably priced. So they've got the lower limb course coming up in the

Really recommend going. And I strongly recommend the trip to Brazil if anyone's everyone's thinking about it. So yeah. Um, anyway, let's get back to the topic in hand. And today we're at the prestigious Water Neurocentre in Liverpool to speak to Dr. Richard Pilicino, who's a consultant interventional neurocenter.

So thanks for joining us, Richard. Thanks. Thanks for the invite. Dr. Pulocino, should I say, sorry. We're going to be speaking to him about neurointervention in general, but more specifically about thrombectomy. Now thrombectomy is the gold standard management for acute But there's all sorts of issues regarding how you actually deliver that service nationally, or if it's even possible to. So it'll be really interesting to get some insight on this from someone at the front.

So um Richard, can you start by telling us um a bit about what an interventional neuroradiologist does? Because it's not an area we get much exposure to on a day. Um so uh our our job essentially um uh entails uh or say seventy percent uh dealing with uh vascular abnormalities uh within the brain. So uh what I would say our normal workload would be is eighty, eighty percent aneurysms. And then the remaining you would have AVMs and the thrombectomy is slowly uh cropping up.

We also do spinal interventions, so um things like vertebroplastys for example, um facet joint infiltrations as well, um and some and uh the run-of-the-mill lumber x-ray guided lumbar punctures. That is essentially what our typical work consists of. We also have a diagnostic component, so we are still part of the on-call diagnostic service as well. um as well as we are we are part of the duty duty rota. So we give second opinions for general neuroradiology, vascular neuroadiology as well.

So in terms of the procedures that you're doing, how's the splits between therapeutic and then like diet? Okay. Um So uh I'll just uh rephrase phrase a phrase is slightly slightly different.

Th yes, we diagnostic angiography is part of neurointervention. So for example uh since um a cerebral angiogram is the gold standard in order to uh identify and characterize vascular malformations within the brain, But it goes hand in hand with therapeutic as well. What's different in our job compared with uh other, for example, uh interventional sub specialties is that uh majority of work the majority of work that we do is preventative.

So someone comes in uh with uh for example intracranial neurism which hasn't ruptured, okay. And recoil it in order to prevent rupturing. Okay, so patient comes in walking, you you you do your utmost on the patient, let's say. Uh they walk out. Hopefully, hopefully. Um in uh ruptured aneurysms, um, the idea behind that is to prevent a rerupture, which is usually much more severe than the initial uh rupture.

Um Thrombectomy obviously is is different because you are you have a patient who comes in with a stroke and the idea is to either either ideally make him better as it make him ideally independent or prevent further worsening of his stroke. Um, is neurointervention particularly stressful? Because that's the perception I have and I know I know a lot of my colleagues have. I mean, if you're doing a peripheral angio and you're fiddling around

in a femoral artery and you dissect it or knock off some clot, then they might get a dusky toe. But if you're in the MTA and you sort of make a mistake, then that that the consequences can be catastrophic. So Are you constantly No, I I mean uh adrenaline Um uh I think every every intervention subspeciality has uh its own risks. Uh l let me just put it like that. Um Right. So, one of the main reasons we're having this conversation is to talk about thrombectomy, which has been a hot issue.

So just for the benefit of our pre radiology and undergraduate listeners. Can you just start by telling us a little bit about exactly what thrombectomy is? So we'll start with essentially what a stroke is, right? So a stroke is essentially you have a clot which uh forms inside one of the uh vessels that supply the brain, so intracerebral vessel, right? So you have essentially a blockage. And uh thrombectomy is essentially a mechanical means of retrieving the clock.

So uh what we essentially do is that we take up a catheter, okay, and then we take something known as a stent retriever, which is essentially a stent, which usually does not detach, okay. We deploy it within the clot and then using combination of pulling in the sand and also aspiration, pull the whole thing back and restore circulation. So this concept has been around for quite some time.

And uh the stent retriever, the use for it in stroke came around in uh treatment of intracranial aneurysms ironically. So there was one interventionist um in Germany if if I if I recall correctly, who was uh treating an aneurysm. and had deployed this stent. Partially deployed it, essentially. It hadn't detached it completely. And then he realized that clot was actually forming within the stent, and what he did, he just pulled it out. And then here is oh wow, clot came out. Um

This can actually be used for stroke. In fact, the first hand solitaire, its first use was as an adjunct for coiling intracranial aneurysms. Then the big five studies came out, the largest one being Mr.Ekling which was done in the Netherlands. and that will essentially show that It's beneficial across all severities of stroke. Although the goal is to make people independent and

forty percent of people do become independent. You even even in those who for example so we use something known as an MRS scale. Okay? Zero is completely normal, six is essentially the And uh independence is classified as someone whose MRS between 0 and 2. So uh and what we're saying is that 40% of patients go to an MRS with 0 to 2.

But also there's uh what is known as a shift, if you do a shift analysis, so you get someone who starts as an MRS of five, for example, becomes an MRS of four. Okay. So the benefit is across the board. Um Uh And uh what they had then uh done is that they pulled all the individual patient data into what is known as the Hermes metanalysis. And what the Hermes metanalysis had shown is that you can actually extend the window uh up to seven point three hours. Oh wow.

Instead of the traditional yeah, traditional six. Four four or four and a half for um thrombolysis with uh with altoplays. But uh for thrombectomy it was essentially six hours and seven point three. So out of three patients at you get one benefit. So for example coronary angioplastic number needs to treat is one uh is fifteen. Um the only thing which is I think better if I remember correctly is warfarin for AF, which I think is 2.

But even antibiotics and sepsis it's four or five. So this in itself started a revolution. So the evidence really is strongly pointing towards using it routinely. Yes, yes. Um what are the criteria for thrombectomy? Is it the same as from belight? Well uh we're sort we're less stringent, so one you need to be human Um

And uh second so currently I'll just tell you what is currently within a lot of uh regions in the UK. So in the majority of the case it is um astro presenting within the first six hours, okay? Now we don't have the stringent criteria that for example thrombolysis have. So for example, even we can do it even if you had recent surgery, okay? And we can also do it so we can also do the procedure without having thrombolysis on board.

And would do you normally like them to have thrombolysis on board? Is it That is something that is currently being answered in a a randomized control trial, sort of whether whether or not you should use um thrombolysis for bridging therapy or not. So So thrombectamine itself poses a lot of challenges, okay, especially to our subspeciality.

One um there's a question of how to set up the infrastructure. Yeah. Because not a question of just having interventionists on board, right? You need to have a dedicated team, you need to have

scrub nurses, you you need to have um I the O ODBs, anaesthetists as well, um uh radiographers. Okay, so all of that automatically puts pressure on on a system which is already um uh which is already uh stretched. Okay. Yeah. So that's that's one. So that is within within the hospital. But I also pre hospital. So how do I do you identify the patient? that require thrombectomy and which center do you take them to? Would you take them to, for example, a peripheral hospital?

Get them thrombos and then they get transferred here to Walton or should they come straight here to Walton? So there's this whole debate about drip and ship versus mothership. And currently there's a trial being that is happening in Barcelona called the Race Cat Trial which should be answering this as well. Yeah, because obviously the the setup with cardiology is if a patient chest pain, they call an ambulance, they've got S T elevation on the E C G then they go straight to the

Cardiac Center for primary PCI. So the the research that is currently currently happening is in terms of scores, per hospital score. So characteristically what we use is the NIHSS score, right? but it's quite long to do. What's the NIH SS score? Essentially it's a stroke severity score. So it gives you an idea of how severe your stroke is, okay? uh but essentially

From our end, what we would like to know is does this patient have a large vessel occlusion? Yes or no? Now if the NIHSS is more than nine, then you have an eighty five percent chance of having a large vessel occlusion, meaning that either your um internal carotid, anterior cerebral artery or middle cerebral artery are are are involved essentially. Um so there are other scores available. There's the what's called the race score, um which is it's simpler to use, easier to train.

There are something like twenty different scores to be fair. So there's a lot of research on how how do you train um paramedics, for example, to identify the right patients, okay? In Berlin, for example, one way of uh of doing that is actually equipping um ambulances with uh CT scanners. Yeah. I think they cost something like a million each. Um they're not they're not cheap. They're quite heavy as well. But uh but that is part That's just part of the plan of art. And then they...

But paramedics interpret the scan or who interprets the I I d I'm not sure I'm I'm not sure about the details in terms of um uh but I think if I'm not mistaken, I think there's a uh radiology resident who does that so it's via telemedicine. So at the moment what happens is someone ファーザーストライト The ambulance go to that person. Just a normal A&E. They're near a hospital. And they have a CT scan and a CT angio. You need a CT angio. So something that we strongly emphasize is that...

As soon as you come up here and you're suspecting that this patient has a stroke. Um and uh has a most likely has symptoms of a a large vessel occlusion, then you do a C T and a Ct anger within the same sitting. And the reason is that essentially to shorten the time that it takes to uh arrive to a diagnosis. And then if the C C NGO shows a large vessel occlusion and they're within

Six was it six hours six hours then thrombetomy is the best the gold standard treatment. Yeah. We we have no problems in them having having thrombolysis. But the importance is that yeah, give them thrombosis but transfer them immediately. So they can have thrombosis on their way on their way here and then we can just um continue with our thrombectomy.

Um do you provide twenty a twenty-four hour phone back to me service? So currently in this region, no. I think there are currently two or three regions in the UK which do offer a 24-7 service. Um ch what regions are those? I think it's uh London, St George's, um I think offer and stock on Trent, um and I'm not sure whether

Leeds and Chal have a joint, but I'm not too sure about that, to be fair. So if you're lucky enough to have a stroke in those areas out of the outer nine to five, then you'll get from Bectomy, otherwise... you're gonna get a less optimal treatment No am I reading the situation correctly? Currently as it is, so there are plans in place, okay. Um to extend this to twenty four seven. Okay. So NHS Singland has uh allocated the funding for this, okay.

And the idea is that uh um we first extend our day, so we'll provide a seven day service, okay, and then gradually m from there move to a twenty-four-seven service. But the the challenge is and this is something which I think people it's important people recognise and I think even from a management point of view it will be a good case study is that this is not just a question of yes, we'll just

employ more intervention neural radiologists. Okay. It's the old team. You have to involve exactly it's a whole infrastructure. So you need to make sure that for example you have the imaging capability. Do you have uh radiographers who can man your CT scanners who are able to do CT perfusion, especially in terms of beyond six hours thrombectomy, for example. They have the ambulance services too. Transfer patients, for example. Within a certain time. Within a certain time period. Exactly.

So uh all of this is uh system wide uh um making sure that system wide changes. Yeah. Well yes, so we are planning for training. Okay, so we're we we also have funding for that in order to train registrars and also provide some education to uh radiology consultants in terms of interpreting city angiograms. But the other option is artificial intelligence. W so there are I think one or two companies which um essentially um have these algorithms which have they have trained on huge data sets.

And uh what you do is just give it the C T, C T A and C T perfusion and it will tell you for example, what's the aspect score, whether there is a large vessel occlusion or not. What is the core in fact volume, for example. It's it's actually um I mean I've uh when I've seen previews of it, I I must admit it's quite impressive. That is one way of addressing part of the problem in terms of uh providing the service.

So I know um you said there are a number of barriers to providing a twenty four hour service. One of them is workforce, am I right in thinking? Yeah. Yeah. Um so I've heard a few um solutions to address this. So for example, I've heard the suggestion that maybe cardiologists could start doing thrombectomy or or may or or or neurologists or neurosurgeons. Um what do you think about that? It's a bit of a hot topic, I just like that. And yeah, there's a lot of terrafores involved as well.

I think that as a specialty we are positioned in a in a optimum place, I think. I I sincerely believe that this is something that radiologists can provide and that we should all rise rise to the occasion. That is my my my sensibil Now yes there are problems with uh in terms of recruitment, training, training numbers, uh funding and all of that. But th those problems aren't just in radiology, they are in in all other other specialties as well.

So I would encourage people, uh I would encourage uh junior registers to consider um uh join joining the interventionary radiology workforce. Okay, um so it's clear that we really need more neurointervention lists and if you really want to make a difference And definitely be in demand, then it seems like a good subspecialty to consider. So, um, do you have any advice for anyone interested in neuro intervention?

Yeah. Um I I think one uh so the there's the British Society of Neuro Radiology, which I would uh encourage people to uh even they they organize training days um which are for um uh dedicated uh for fellows and uh registrars. And there's also the UK Neurovascular Group which meets uh every I think six months. double double check on that. So that is that is one one one way one way of um of of addressing that.

Um uh then there's the European Society of Neuroradiology which provides diagnostic and interventional courses. So for inter for diagnostic it's uh four course spread out on uh um four sections okay which address different so uh things from anatomy, um vascular diseases, tumors and all that. And then you have uh an exam at the end. And they also recently just uh started an interventional course which is spread on uh three modules.

En dan heb je een examen aan het eind. Heb je dat? Ik heb de diagnostic module gedaan. So e education the education is there. Um so if uh three societies. Yes, no no there are there are three societies. I think that's about it for today. Thank you, Richard, for taking the time out of your busy schedule to talk to us. It'll be really interesting to see how things develop with NeuroIR, specifically surrounding the 24-hour provision of thrombectin.

Because if the evidence shows that it's the best treatment Really it should be available to everyone at any time of the day, uh not just in normal office hours. Yeah, um uh so we hope you've enjoyed today's episode. Next month we'll hopefully be bringing you some interviews that we're planning on recording at UKIO later this month. Um all our previous episodes are available on various platforms and at www.

anchor.fm forward slash radcasts. And for more updates in the meantime, check out our social media channels at Radcast Podcast on Twitter and at rad dotcast on Instagram. Um bye. Um bye if if anyone wants to um ask any questions. By all means I'm contactable on Twitter at Ricardo R-I-K-A-R-D-U. By all means, drop drop a drop a message. Brilliant, brilliant. Great. Thanks very much. Bye. Bye. Bye.