Mechanical Thrombectomy Access Score: A Systematic Review and Modified Delphi of Global Barriers to Endovascular Therapy

Sushanth R Aroor^#¹, Cynthia B Zevallos^#², Kaiz S Asif³, Nishita Singh⁴, Jennifer Potter-Vig⁵, Aaron Rodriguez-Calienes⁶, Bijoy K Menon⁷, Aravind Ganesh⁷, Jeffrey L Saver⁸, Hooman Kamel⁹, Anne W Alexandrov¹⁰, Edward C Jauch¹¹, Zhongrong Miao¹², Xiaochuan Huo¹³, Pankajavalli Ramakrishnan¹⁴, Shashvat M Desai¹⁵, Kaustubh Limaye¹⁶, Mohammad El-Ghanem¹⁷, Gabor Toth¹⁸, Chetan V Rao¹⁹, Hesham E Masoud²⁰, Qingliang Tony Wang²¹, Nabeel A Herial²², Kunakorn Atchaneeyasakul²³, Viktor Szeder⁸, Krishna Amuluru²⁴, Victor C Urrutia²⁵, Fawaz Al-Mufti²⁶, Dileep R Yavagal²⁷, Santiago Ortega-Gutierrez²

Affiliations

¹ University of Texas Health Science Center, Houston (S.R.A.).
² University of Iowa Hospitals and Clinics, Iowa City (C.B.Z., S.O.-G.).
³ Ascension Health, Chicago, IL; University of Illinois Chicago (K.S.A.).
⁴ Rady Faculty of Health Sciences, Division of Neurology, University of Manitoba, Winnipeg, Canada (N.S.).
⁵ University of Illinois Springfield, IL (J.P.-V.).
⁶ Universidad Cientifica del Sur, Lima, Peru (A.R.-C.).
⁷ University of Calgary, Alberta, Canada (B.K.M., A.G.).
⁸ University of California Los Angeles (J.L.S., V.S.).
⁹ Weill Cornell Medicine, New York City, NY (H.K.).
¹⁰ University of Tennessee Health Science Center, Memphis (A.W.A.).
¹¹ University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville (E.C.J.).
¹² Beijing Tiantan Hospital (Z.M.), Capital Medical University, China.
¹³ Beijing Anzhen Hospital (X.H.), Capital Medical University, China.
¹⁴ Riverside Regional Medical Center, Newport, VA (P.R.).
¹⁵ HonorHealth, Scottsdale, AZ (S.M.D.).
¹⁶ Indiana University School of Medicine, Indianapolis (K.L.).
¹⁷ Hospital Corporation of America Houston Northwest and University of Houston, TX (M.E.-G.).
¹⁸ Cleveland Clinic, OH (G.T.).
¹⁹ Baylor College of Medicine, Houston, TX (C.V.R.).
²⁰ State University of New York Upstate University, Syracuse (H.E.M.).
²¹ State University of New York Downstate Health Sciences University, Brooklyn (Q.T.W.).
²² Thomas Jefferson University, Philadelphia, PA (N.A.H.).
²³ Virginia Mason Medical Center, Seattle, WA (K. Atchaneeyasakul).
²⁴ Goodman Campbell Brain and Spine, Indianapolis, IN (K. Amuluru).
²⁵ Johns Hopkins University School of Medicine, Baltimore, MD (V.C.U.).
²⁶ Westchester Medical Center at New York Medical College, Valhalla (F.A.-M.).
²⁷ University of Miami Miller School of Medicine, FL (D.R.Y.).

^# Contributed equally.

PMID: 39450508
DOI: 10.1161/STROKEAHA.124.047805

Free article

Mechanical Thrombectomy Access Score: A Systematic Review and Modified Delphi of Global Barriers to Endovascular Therapy

Sushanth R Aroor et al. Stroke. 2025 Jan.

Free article

. 2025 Jan;56(1):158-167.

doi: 10.1161/STROKEAHA.124.047805. Epub 2024 Oct 25.

Authors

Affiliations

¹ University of Texas Health Science Center, Houston (S.R.A.).
² University of Iowa Hospitals and Clinics, Iowa City (C.B.Z., S.O.-G.).
³ Ascension Health, Chicago, IL; University of Illinois Chicago (K.S.A.).
⁴ Rady Faculty of Health Sciences, Division of Neurology, University of Manitoba, Winnipeg, Canada (N.S.).
⁵ University of Illinois Springfield, IL (J.P.-V.).
⁶ Universidad Cientifica del Sur, Lima, Peru (A.R.-C.).
⁷ University of Calgary, Alberta, Canada (B.K.M., A.G.).
⁸ University of California Los Angeles (J.L.S., V.S.).
⁹ Weill Cornell Medicine, New York City, NY (H.K.).
¹⁰ University of Tennessee Health Science Center, Memphis (A.W.A.).
¹¹ University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville (E.C.J.).
¹² Beijing Tiantan Hospital (Z.M.), Capital Medical University, China.
¹³ Beijing Anzhen Hospital (X.H.), Capital Medical University, China.
¹⁴ Riverside Regional Medical Center, Newport, VA (P.R.).
¹⁵ HonorHealth, Scottsdale, AZ (S.M.D.).
¹⁶ Indiana University School of Medicine, Indianapolis (K.L.).
¹⁷ Hospital Corporation of America Houston Northwest and University of Houston, TX (M.E.-G.).
¹⁸ Cleveland Clinic, OH (G.T.).
¹⁹ Baylor College of Medicine, Houston, TX (C.V.R.).
²⁰ State University of New York Upstate University, Syracuse (H.E.M.).
²¹ State University of New York Downstate Health Sciences University, Brooklyn (Q.T.W.).
²² Thomas Jefferson University, Philadelphia, PA (N.A.H.).
²³ Virginia Mason Medical Center, Seattle, WA (K. Atchaneeyasakul).
²⁴ Goodman Campbell Brain and Spine, Indianapolis, IN (K. Amuluru).
²⁵ Johns Hopkins University School of Medicine, Baltimore, MD (V.C.U.).
²⁶ Westchester Medical Center at New York Medical College, Valhalla (F.A.-M.).
²⁷ University of Miami Miller School of Medicine, FL (D.R.Y.).

^# Contributed equally.

PMID: 39450508
DOI: 10.1161/STROKEAHA.124.047805

Abstract

Background: The availability of mechanical thrombectomy (MT) for acute ischemic stroke is limited, and vast disparities exist between countries. We aim to create a MT access score to measure the drivers of access to help quantify and accelerate treatment worldwide.

Methods: We used a systematic review complemented by a modified Delphi method. In the first of 3 rounds, 4 independent investigators performed a systematic literature review using key search terms that drive MT access, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In the second round, a panel of 6 anonymous international experts selected key attributes needed for scoring. In the final round, a total of 12 attributes were selected on consensus, each given a score on a 0 to 3 scale. An ultimate MT access score (range, 0-36) was proposed as a new tool to use in identifying barriers to MT access and assist in providing an initial framework for public health interventions.

Results: Of 2864 abstracts screened, 121 studies were included in the final systematic review. A total of 34 attributes that potentially drive MT access were initially identified. In the final round, 12 attributes were selected by the expert panel: public awareness, emergency medical services transportation, prehospital large vessel occlusion screening, interhospital transfer policy, emergency department protocols, stroke imaging protocols, emergency department stroke expertise or telestroke availability, interventionalists, MT-capable centers, device availability, and insurance coverage. These attributes were weighted as part of the final score of 0 to 36.

Conclusions: The MT access score represents the first tool to quantify barriers to global MT access. Its implementation stands not just as an academic achievement but as a beacon of hope for improving stroke care and outcomes worldwide, bringing us a step closer to bridging the gap in stroke treatment disparities.

Keywords: Delphi technique; emergency medical services; ischemic stroke; stroke; thrombectomy.

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Conflict of interest statement

Dr Ganesh reports grants from MicroVention Inc; compensation from Biogen and Alexion Pharmaceuticals for other services; stock options in SnapDx Inc; and stock holdings in Collavidence Inc. Dr Saver reports compensation from Stream Medical, Boehringer Ingelheim (prevention only), CSL Behring, Johnson & Johnson Health Care Systems Inc, Bayer, BrainQ, Biogen, Roche, BrainsGate, Medtronic USA Inc, Aeromics, and Abbott Laboratories for consultant services; compensation from Occlutech and MIVI Neuroscience for data and safety monitoring services; and stock options in MindRhythm, Rapid Medical, and Neuronics Medical. Dr Kamel reports an ownership stake in TET Medical; compensation from American Medical Association and Javelin Medical for consultant services; compensation from Boehringer Ingelheim, Novo Nordisk, and AstraZeneca for end point review committee services; and compensation from Medtronic and Janssen Biotech for other services. Dr Jauch reports compensation from RapidAI for consultant services. Dr Toth reports compensation from Kaneka Pharma America LLC, Penumbra Inc, and EBSCO for consultant services; and compensation from Medtronic USA Inc for other services. Dr Venkatasubba Rao reports stock holdings in Migegesys; compensation from DECISIO for other services; and compensation from Medical Expert Consulting for expert witness services. Dr Amuluru reports compensation from Medtronic for consultant services. Dr Szeder reports compensation from Medtronic for consultant services. Dr Urrutia reports grants from Genentech. Dr Yavagal reports compensation from Stryker Corporation, Gravity Medical Technology, Vascular Dynamics, Athersys, Johnson & Johnson Health Care Systems Inc, Poseydon, and Medtronic USA Inc for consultant services; and stock options in Rapid Medical, Poseydon, and Athersys. Dr Ortega-Gutierrez reports grants from National Institutes of Health, Methinks, National Institutes of Health, Siemens, MicroVention Inc, and Stryker; compensation from MicroVention Inc, Stryker, and Medtronic for consultant services; and employment by Carver College of Medicine, University of Iowa. The other authors report no conflicts.

Comment in

Mechanical Thrombectomy Access Score: A Pragmatic Tool to Quantify Barriers to Global Mechanical Thrombectomy Access.
Tsivgoulis G, Rubiera M. Tsivgoulis G, et al. Stroke. 2025 Jan;56(1):168-169. doi: 10.1161/STROKEAHA.124.049403. Epub 2024 Dec 20. Stroke. 2025. PMID: 39705396 No abstract available.

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Mechanical Thrombectomy Access Score: A Systematic Review and Modified Delphi of Global Barriers to Endovascular Therapy

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Mechanical Thrombectomy Access Score: A Systematic Review and Modified Delphi of Global Barriers to Endovascular Therapy

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