The Neurovascular Center Model for Practice

EDWIN J. CUNNINGHAM AND MARC R. MAYBERG

Objectives: After completing this chapter, the reader should be able to describe how to organize neurosurgeons, interventional neuroradiologists, and neurologists into a specialized group outside of their different departments.

Accreditation: The AANS^* is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians.

Credit: The AANS designates this educational activity for a maximum of 15 credits in Category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she spent in the educational activity.

The Home Study Examination is online on the AANS Web site at: http://www.aans.org/education/books/controversy.asp

^* The acronym AANS refers to both the American Association of Neurological Surgeons and the American Association of Neurosurgeons.

The Neurovascular Center Model is an integrated multidisciplinary program of excellence designed to advance state-of-the-art care for patients with cerebrovascular disorders. The Center consists of physicians, nurses, and researchers from multiple specialties (Neurosurgery, Interventional Neuroradiology, Neurocritical Care, Neurology, and Basic Research) who comprise an autonomous clinical and research unit. In this chapter, we address the structure, benefits, and prerequisites for the establishment of successful neurovascular centers.

Benefits of the Center Model

Foremost among the benefits of an integrated neurovascular center is improved patient outcome. Randomized clinical trials and prospective observational studies suggest that organized stroke centers deliver better care and achieve better outcomes for patients suffering acute ischemic stroke.¹^–⁴ The results of these studies led to the recent publication of Recommendations for the Establishment of Primary Stroke Centers by the Brain Attack Coalition.⁵ The authors cite several reasons for the development of the recommendations:

1. There are a large number of strokes per year (~750,000).

2. Many patients with stroke do not receive optimal therapy as defined by established guidelines.⁶^–¹¹

3. It is important to make new therapies available efficiently and safely to patients with strokes.

The need for such centers is underscored by a study demonstrating that only 1.8% of patients suffering acute ischemic stroke in the Cleveland area received FDAapproved intravenous tissue-type plasminogen activator (tPA).¹² Nationally, only 2 to 3% of patients with acute ischemic stroke receive tPA.¹³^,¹⁴ Reasons for the low rate of thrombolytic therapy include the inability of some medical systems to triage and evaluate such patients rapidly, patient presentation beyond the 3-hour treatment window, and clinician concerns about cerebral hemorrhage. Hemorrhage complicating intravenous tPA administration for acute ischemic stroke appears to be related to clinician expertise and experience in managing stroke. The Cleveland study also found that the rate of symptomatic intracranial hemorrhage following tPA administration was 15.7%, but for 50% of patients treated, national treatment protocols were violated. In a separate multicenter study, the rate of intracranial hemorrhage following tPA administration was 3.3%, with only 15% of treated patients having violations of treatment protocols.¹⁵ These studies and others suggest that regional centers with expertise and experience in stroke management treat a higher proportion of acute stroke patients more aggressively, follow detailed protocols more closely, and achieve better results. Other expected clinical benefits of stroke centers are summarized by the Brain Attack Coalition in Table 24-1. It is likely that stroke centers will be certified in the near future, using credentialing methods analogous to that used to designate trauma centers.¹⁶

Aside from improving the level of care for stroke patients, there are other advantages of a neurovascular center. Education of medical students, residents, and fellows benefits from the center model. The integrated neurovascular team is especially advantageous for seniorlevel residents and neurovascular fellows in neurology, neurosurgery, and radiology. In the center model of multispecialty management, trainees acquire a working knowledge of diagnostic and therapeutic options that may be outside their primary discipline. This occurs during daily rounds, in weekly neurovascular meetings, and during interdisciplinary rotations.

Basic and clinical research of neurovascular diseases should improve in the multidisciplinary approach of the neurovascular center model. Under the leadership of a single director of cerebrovascular research, clinicians and postdoctoral researchers from multiple specialties collaborate on projects and provide critical feedback to one another on proposed and ongoing research. This collaborative process will focus efforts on the most clinically relevant areas in need of research, will assist in refining the objectives and methodology of planned research, and will eliminate overlapping projects.

A final advantage of the center model is consolidation of administrative, financial, and operational functions. Physician, nursing, and secretarial duties and inpatient and outpatient services are combined. There are reduced operational costs, and patient management is streamlined. For example, since the establishment of a center model at the Cleveland Clinic Foundation in 2001, there has been a significant increase in inpatient (11%) and outpatient (19%) procedures and a 16% increase in gross revenues (unpublished data).

Table 24-1 Expected Benefits of Primary Stroke Centers

Improved Efficiency of Patient Care
Fewer Peristroke Complications
Increased Use of Acute Stroke Therapies
Reduced Morbidity and Mortality
Improved Long-Term Outcome
Reduced Costs to Health Care System
Increased Patient Satisfaction