Could you tell us a bit about The Walton Centre and what it does?
Andrew Nicolson: The Walton Centre is a specialist trust based in Liverpool and the only standalone trust for neurosciences in the UK. Our main services are neurology, neurosurgery, pain and rehabilitation. As part of those services, we have interventional radiology services including thrombectomy. We cover the population across Cheshire, Merseyside, north Wales, the Isle of Man and parts of Lancashire – a catchment area of around 3.2 million.
What is thrombectomy and how did you come to provide it?
Mani Puruthan: The thrombectomy service initially started on the back of stroke treatment. So, in the past, if somebody had a stroke, you would come to A&E and you would get an intravenous injection to make the clot in the brain dissolve, and hopefully the patient then gets better.
In mechanical thrombectomy, we put a catheter into the blood vessel and into the patient’s brain, so you can physically remove the clot. I trained in this technique at the Karolinska Institute in Sweden and did the first case in The Walton Centre in 2012 with the support of Alakendu Sekhar, a consultant neurologist. Within a couple of years, there were randomised trials that showed this technique was the most effective way to treat stroke in some cases. For example, blood clots in particular parts of the brain just will not respond to injection treatment, and thrombectomy offers the only chance for the patient. More broadly, the outcomes for patients are very good. It is a very effective treatment.
We started initially providing the service nine to five, and then in October of last year we moved into a 24/7 service. There are 24 neuroscience centres in the country that can provide this treatment, of which four are 24/7.
What does the process look like from a patient perspective?
Mani Puruthan: Once a patient comes to hospital, the hospital does a CT brain scan. And if they suspect that this patient has had a stroke, they then get a specialist scan to look specifically at the blood vessels in the brain and to look for large blood vessel occlusion. And if that’s the case, they immediately send the patient to us – they call our team. We have a fantastic team of nurses, radiographers and anaesthetists working together, and we crack on and do this procedure. We put a catheter from the groin all the way into the brain. And then we have got specific devices we use to capture a clot and pull it out. So, usually, on average, the procedure should take about 20 minutes to half an hour. The whole idea is to be quick with the procedure.
What are some of the challenges in providing this treatment?
Andrew Nicolson: Working across such a wide and varied area that covers urban Liverpool as well as rural north Wales and Cheshire creates challenges. The biggest hurdle is from the peripheral hospital – how quickly they can come to a specialist centre like ours. If you’re delaying by one or two hours, then the outcomes for the patient will be worse. The outcomes are best when the patient can be transferred to the thrombectomy centre as quickly as possible.
We have to organise across many different hospital providers and ambulance services to make this happen. The NHS has moved to more collaborative working in the past few years and towards an integrated care system. So that helps with working across organisational boundaries, but that’s still the biggest challenge: getting the patients to thrombectomy centres as quickly as possible.
Another challenge is that interventional neuroradiologists are in short supply. One of the solutions that’s been discussed is whether you could get other specialists like general interventional radiologists or cardiologists trained up to do thrombectomy. The advantage the interventional radiologists have, of course, is that they’re all already day-to-day doing much more complex procedures in and around the brain. By comparison, thrombectomy is a relatively simple procedure.
The other thing internally that we’ve really learned over the last couple of years is about the infrastructure that’s required. In particular, the required staffing – which includes nursing support, the radiographer, the theatre support, critical care, the anaesthetics, junior doctors, and many other staff – for the procedure to go smoothly so that when the patient arrives at the door, we can do the thrombectomy.
And how do you plan to further develop the service?
Mani Puruthan: So now we’re doing on average between 15 to 17 of these procedures a month. And for a catchment area that we have, we should be aiming to do about close to 25 to 30 a month. That’s what I would expect to happen in about two to three years.
Andrew Nicolson: The move to 24/7 service has been the most significant development for us so far. We found quite early on that the numbers have increased quite significantly as a result. This was because there wasn’t any confusion with a referring trust as to when services would be available. The biggest advantage from the referring hospital’s point of view is that they know whatever time of the day, they can ring us and we’ll be able to consider taking the case.
If you look at the figures, you would expect to be seeing about 10 per cent of strokes potentially eligible for thrombectomy. We’re nowhere near that yet. So potentially, you’d be looking at even as many as 400 cases a year in this region. The main focus over the next year or two will be to sort the whole pathway for patients as efficiently as possible in order to get the patients to the thrombectomy centre more quickly.
We are in discussions in this region over the organisation of stroke services, with a proposal for a larger hyper-acute stroke unit on the Aintree hospital site. We are part of the same site, with a link bridge between ourselves and the next-door trust, so we will be working together on developing a comprehensive stroke service to include as rapid access as possible to thrombectomy for appropriate patients in our region.
Mani Puruthan: One of the things I see in the future is things like CT scans in ambulances. That is happening in Switzerland. So, you can have a patient scanned in an ambulance and straight away bring them into the hospital for treatment.
Mani Puthuran is consultant neuroradiologist at The Walton Centre;
Andrew Nicolson is the medical director at The Walton Centre