Neurovascular surgery: the way forward—credentialing for thrombectomy (and beyond): a review

Introduction

Background

Mechanical thrombectomy (MT) for ischaemic stroke is one of the newest clinical interventions and only in the last decade has robust effectiveness data from clinical trials become available, contributing to level one meta-analysed evidence (1-6). The number needed to treat (NNT) for MT in ischaemic stroke is estimated to be 2 for an improved score in disability at 90 days or 2.8 for functional independence [Diffusion-Weighted Imaging or CTP Assessment With Clinical Mismatch (DAWN) trial] and this has a confirmed by another trial [Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT Prime)] with an NNT of 2.6 for improved disability outcomes and 4 for functional independence (5,7,8). This means that only two patients need to be treated with MT to improve the function of one person. For perspective, the number NNT from a related but distinct field in primary angioplasty for ST-elevation myocardial infarction (STEMI) when compared to medical therapy, to save one additional life requires 35 patients to be treated (9). MT for stroke has demonstrated 100% probability of meeting the National Institute for Health and Clinical Excellence’s (NICE) cost-effectiveness threshold in eight countries across Europe including the United Kingdom (UK) (10). Despite this compelling clinical and cost-effectiveness evidence, currently only 26 hospitals can offer this treatment in the UK, with the majority of stroke patients being admitted to non-MT providing hospitals (11). Despite representing a clinical emergency, only 35% of these centres offer 24/7 MT service provision (12). Consequently, in 2023, only 3.3% of stroke patients were treated with MT, with almost 7,000 people lacking access in England alone (12). There is significant variance across regions, with nearly 10% of stroke patients receiving MT in London compared to fewer than 3% in other areas (12). International comparison suggests that England performs worse than most countries in Northern and Central Europe, where 5–10% of stroke patients are treated within 100 minutes of hospital arrival (12). In the United Stares of America (USA), geographical access to MT centres is 48.7% (13).

Rationale and knowledge gap

Stroke remains the second leading cause of global mortality and third leading cause of global disability, and access to MT on a global scale is extremely low (14). Aside from infrastructure, clinical pathways, and timely diagnosis with imaging, a lack of sufficient workforce remains a significant barrier to MT delivery (15). In the UK, MT is delivered by interventional neuroradiologists, but the number of these providers falls significantly short of the modelled workforce requirements (16). To help address this challenge, in June 2023, the General Medical Council (GMC) published a credential in MT, to enable trained clinicians from non-radiology specialities to perform MT (16). This was introduced because of the inclusion of MT in the National Health Service (NHS)’s Long-Term Plan to expand access to MT to 10% of stroke patients, specifically highlighting the need to increase workforce numbers through credentialling. The aim is to expand the workforce through training interventional and diagnostic radiologists, neurosurgeons, stroke physicians, interventional cardiologists and neurologists. Neurosurgeons are of particular focus for this review compared with other specialties because of the degree of training in reviewing neuroradiology, practical knowledge of neurovascular anatomy, and potentially transferrable procedural skills may result in accelerated workforce expansion. The combination of unmet need, regulatory pull, and disease burden, sets the context in which the present review describes potential ways forward to increase treatment access through including neurosurgeons in an expanded workforce. The key knowledge gap lies in understanding patient outcomes after treatment by different providers and how to standardise training to reduce regional variation.

Objective

This review explores the challenges and opportunities around how expanding MT provision to include neurosurgeons could be delivered to help address current treatment access gaps, with a focus on the UK context given the recent GMC credential.

Methods

A literature search of key databases including Embase and Medline via OVID were searched for all published articles up till March 2025. The OVID search strategy used is available in the supplementary material (Appendix 1) and papers were included if they reported patient outcome following MT performed by neurosurgically trained providers. Conference abstracts were excluded. As the field of research is still in its infancy given the dynamic and emerging role of neurosurgeons in performing MT, a wider search of Web of Science and Google Scholar was also performed to form a more narrative synthesis of the current evidence and wider issues of relevance to the community. Search terms included for this were “Neurosurg*” AND “Mechanical Thrombectomy”. Papers were included and discussed if they described challenges or opportunities for the emerging role of neurosurgeons in MT from any context. References from identified studies were also reviewed to ensure completeness.

Literature search results

Eight hundred and ninety-three papers had abstracts screened following the OVID searches. No papers reported clinical patient outcomes following MT directly compared between training background of provider (neurosurgery vs. other, e.g., neuroradiologist, etc.). One non-randomised study from the USA demonstrated comparable outcomes for MT when delivered by radiologically trained vs. non-radiologically trained physician providers (17). Given the paucity of data available, a narrative synthesis approach has been undertaken where the following represents a discussion of the available literature structured around key issues relevant to the community,

What does the skillset of a neurosurgeon bring to MT and what does it lack?

Neurosurgeons bring valuable skills that could complement the existing radiology workforce in MT. A primary example is the experience in making emergency decisions in numerous time-sensitive clinical contexts, such as in cases of neurotrauma. A study from a USA stroke centre where a fifth of patients had care led by neurosurgeons and the remaining led by neurologists demonstrated no difference in outcomes such as time to chemical or mechanical treatment and mortality or morbidity rates, suggesting that neurosurgeons can make good time critical decisions for the acute management of these patients (18). Neurosurgeons are also familiar with managing challenging conversations with patients and their families about death and disability, an essential skill when discussing the potential outcomes and risks associated with neurovascular interventions like thrombectomy. Additionally, their awareness with operating theatre logistics, especially in out-of-hours situations, positions them well for managing complex cases that require both surgical and interventional expertise. By training in hybrid neurovascular surgery (both open surgical and endovascular procedures), neurosurgeons could transition into managing a full spectrum of neurovascular conditions, including stroke, subarachnoid haemorrhage (SAH), intracerebral haemorrhage (ICH) and MT.

Neurosurgeons face certain limitations in adopting neurovascular interventional roles. While their knowledge of neurovascular anatomy and pathology is highly complementary, their technical skills in open surgical procedures may not directly translate to the precision catheter-based techniques used in endovascular interventions. These skills require specialised training that neuroradiologists typically acquire over years of practice. Furthermore, the neurovascular field has seen a rapid expansion in stroke research and associated interventional technologies. Neurosurgeons joining this field must also keep updated with these additional literature and device portfolios; a considerable challenge given the existing demands of their surgical practice. This combination of skills and limitations suggests that while neurosurgeons can enhance the neuro-endovascular workforce, structured hybrid training programmes and clear roles and pathways are instrumental to ensure safe and effective patient care.

Evidence from hybrid neurosurgeon outcomes in adjacent diseases

As the spectrum of MT providers expands, understanding the impact of hybrid-trained vs. traditionally trained MT providers on long-term patient outcomes becomes crucial. Hybrid-trained providers, such as neurosurgeons who undergo additional training in endovascular techniques, bring a unique combined skill set that may offer advantages in certain cases such as in patients with acute ischaemic stroke who develop malignant transformation, and others requiring a mix of surgical and interventional approaches. Assessing patient outcomes for these hybrid neurosurgical providers as compared to traditionally trained interventional neuroradiologists remains an area requiring further research.

Several papers report the experience of hybrid neurosurgeons in the treatment of intracranial aneurysms. In a hybrid neurosurgeon’s experience analysis from Japan, comparable outcomes were summarised between endovascular and open surgery approaches to intracranial aneurysms (19). A unit in Spain reported patient outcomes over 10 years [2012–2023] where uniquely all the neurovascular procedures for intracranial aneurysms were caried out by hybrid neurosurgeons. They demonstrated that intervention method was not correlated with outcome suggesting that the practitioners maintained competence in both approaches (20). The authors comment that a dual approach offers advantages in individualising treatment decision protocols for patients. In another study from the USA, an analysis of 11,716 patients undergoing endovascular coiling for unruptured aneurysms compared 1,186 (10.1%) who underwent treatment performed by hybrid neurosurgeons with 10,530 (89.9%) treated by interventional neuroradiology (INR) trained providers. They did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and length of stay between hybrid neurosurgeons and INR trained providers (21).

Current literature lacks direct comparative studies evaluating the outcomes of hybrid-trained providers vs. traditionally trained specialists in MT for acute ischaemic stroke. A USA survey study that investigated multidisciplinary MT providers with 16% of respondents being neurosurgeons revealed that while the operators background did not impact radiographic outcomes, there was wide variation in technique reported (22). This highlights the need for evidence-based standardised protocols in training and care delivery including data from clinical outcome studies that remain lacking.

Comparison with other models of credentialing and workforce training

Training pathways should consider both workforce turnover and service expansion to address unmet need. Deciding when and how neurosurgical trainees begin to acquire skills and experience in INR is an area of active research. In the USA, a training curriculum has been developed to train neurologists into hybrid stroke-neurointerventional care providers, with exposure by serving as primary assistants in neurointerventional procedures beginning from post-graduate year two onwards (23). The American Board of Neurological Surgery have a credential for the Recognition of Focused Practice in CNS Endovascular Surgery for practitioners from neurosurgery, radiology, and neurology to provide MT (24). Much of this training is delivered during accredited, hybrid fellowships. For interventional neurology fellowship training, a subspeciality for medical neurologists in the USA, accreditation is achieved by one of three bodies: Committee on Advanced Subspecialty Training (CAST), Accreditation Council for Graduate Medical Education (ACGME), or United Council for Neurologic Subspecialties (UCNS) (25). These bodies also provide accreditation for neurovascular neurosurgeons to undertake endovascular training including MT.

Comparing neurointerventional MT credentialling to models in cardiology highlights both similarities and unique challenges in establishing standards across specialties that perform emergency, minimally invasive procedures. In interventional cardiology, credentialing and certification have become well established for procedures such as coronary angioplasty and stenting, in the UK as well as many other countries. Interventional cardiologists complete structured training pathways involving a cardiology training followed by specialised fellowship training in the necessary interventional techniques, with requirements for procedural volume and examinations. In the UK and Europe, interventional cardiology has been a recognised and established subspecialty of cardiology for decades (26). In a similar way, interventional neurosurgery could become a subspecialty of neurosurgery by following an analogous training process.

What do patients and their families want?

Patients and their families highlight quality care, transparency, and the best possible outcomes when facing the complex decisions associated with MT (27). Patients consistently prioritise timely access to high-quality care delivered by competent providers. Families often rely on the expertise of clinicians to explain the risks, benefits, and alternatives to the proposed treatment, ensuring that decisions are made collaboratively and in the best interests of the patient. Effective communication is therefore critical, as it helps build trust and sets realistic expectations for potential outcomes, including recovery trajectories, possible complications, and long-term quality of life. Given the urgency of stroke treatment, patients also value systems that minimise delays in care, as well as practitioners who can provide continuous support from the acute phase, through to recovery and rehabilitation.

Expanding the thrombectomy provider workforce to include hybrid-trained practitioners such as those from neurosurgery does raise important ethical and patient-centred considerations. Central to this is the issue of informed consent. In a field with ongoing standardisation of credentialing frameworks for practitioners, ensuring that patients and their families are well-informed about the background of the provider performing the intervention is ethically crucial. As with all clinical innovation, honesty about the lack of evidence should be provided, for example in terms outcomes when compared across provider training types. Establishing clear guidelines on how to communicate the current uncertainty during this service expansion as part of the consent process is essential for ethical practice, as it respects the patient’s autonomy and right to make informed decisions about their care.

While expanding the quantity of MT providers can address workforce shortages and improve access to timely treatment, it also introduces potential patient safety concerns. A more diverse group of practitioners with varying training backgrounds could lead to variability in procedural competence, especially as hybrid training pathways are developed and standardised. This could affect the quality of care and potentially increase the risk of adverse events if providers are not adequately prepared. To safeguard patient safety, it is critical to ensure the training standards and credentialing requirements are transparent and consistent across all disciplines involved in neurovascular interventions. Large, prospective research studies and regular audit of outcomes with a commitment to ongoing professional development are also necessary to ensure that expanding the workforce does not compromise the quality of care. This evidence will contribute to describing a balance between access to high-quality, timely interventions, and confidence in the expertise of providers performing MT.

How can we make it happen safely, efficiently, and effectively?

To safely and effectively expand the MT provider workforce, training pathways must be both rigorous and adaptable. A likely model is the establishment of fellowship programmes that provide dedicated training in endovascular neurointervention, specifically structured for neurosurgeons interested in thrombectomy. Such fellowships could be integrated towards the end of standard training, allowing practitioners to develop the procedural skills without extensive time away from their primary specialty. For instance, hybrid fellowships could offer a part-time model, enabling neurosurgeons to maintain their surgical skills while gaining experience in neurointervention. However, exposure to INR could begin much earlier, to hybridise more elements of neurosurgical training. For example, in some UK neurosurgical centres trainees undertake at least one rotation in INR to increase multidisciplinary team working, neurovascular neuroanatomy understanding, and procedural training. A careful balance is required between the demands of the broader neurosurgical training requirements and the dedicated open and endovascular based training for subspeciality neurovascular skills.

In Europe, the European Board of Neuroradiology credentials endovascular training through the European Diploma in INR (EDiINR) offer a pathway to credentialling for endovascular training including for professionals not from a radiology background (28). There are currently eight countries in Europe (Bulgaria, Denmark, Finland, France, Germany, Greece, Hungary, and Ukraine) that offer training fellowships for neurosurgeons in this subspeciality. In comparison, the USA has 116 fellowships (29). Complementing fellowship programmes, formal courses and simulation-based training are essential to reinforce the specific technical skills required for MT. Courses could include hands-on training in catheter navigation, device deployment, and procedural troubleshooting, using high-fidelity simulators that replicate neurovascular anatomy and procedural scenarios. Simulation training can enable trainees to practise complex cases and handle complications in a low-risk environment before working with patients. Continuous education through workshops and short courses would ensure that practitioners, especially those with hybrid roles, stay updated on new techniques and emerging technologies, such as next-generation thrombectomy devices or artificial intelligence (AI)-assisted imaging.

Expanding MT services safely and sustainably will require significant funding and resource allocation. Investments are needed to support hybrid theatre construction, training programme delivery, and the hiring and retention of specialist multidisciplinary staff to run the theatre suites. Given the high economic burden of stroke, government funding and health system support are essential to ensure expansion of services without facing financial barriers. Evidence suggests that the estimated annual cost to the National Health Service from stroke is set to treble from £3.4 billion in 2015 to £10.2 billion in 2030 (30). An investment of just £10 million into priority areas including MT would substantially reduce the UK economic burden (30). The GMC’s Credential and NHS Long-Term Plan to expand MT services must be fully costed to achieve maximum patient benefit as efficiently as possible.

Workforce modelling studies are essential to determine the optimal composition of neurovascular teams, especially as demand for thrombectomy services continues to rise. These studies can help predict the ideal mix of traditionally and hybrid-trained practitioners to meet patient needs across diverse settings, from city hospitals to regional centres. Effective modelling can guide training and recruitment strategies, ensuring that enough qualified providers are available to deliver timely care without diluting expertise. Moreover, workforce planning must account for geographic distribution, scheduling, and sustainability of skill levels over time, as providers split their practice between traditional surgical roles and endovascular procedures. Together, outcome studies and workforce models will be key to developing a scalable, adaptable neurovascular workforce capable of meeting future demand while optimising patient care.

The integration of advanced technology in neurovascular care, including robotic-assisted devices, AI in imaging analysis, and telemedicine, holds promise for enhancing clinical safety and training. AI tools, for instance, could assist practitioners in identifying suitable patients for thrombectomy, optimising procedural planning, and reducing variability in outcomes. Clinicians, academics, and industry need to work together in these efforts to advance technology appropriately with patient engagement throughout. Many technologies could assist MT training and be integrated into courses and programmes. Furthermore, robotic technology potentially allows for interventionalists to treat patients in other hospitals or even internationally. As this technology evolves, any spoke and hub model could take on a new dynamic and transfer times could be eliminated completely (31).

Overcoming concerns

Expanding neurosurgeons’ role into MT may encounter some resistance, both from within and outside the field. Practical concerns focus on the possibility that time spent training and performing endovascular procedures might detract from the maintenance of a neurosurgeon’s core surgical skills and competencies. Critics argue that prolonged time away from the operating theatre could lead to a decline in complex open surgical abilities, particularly for part-time practitioners. Contrary to this, studies in other surgical disciplines such as Vascular Surgery indicate that part-time surgeons can achieve outcomes comparable to their full-time counterparts, above a certain volume outcome threshold (32). Many current vascular neurosurgeons will have multiple subspecialist areas of interest, including skull base surgery, spinal surgery or even medicolegal/private practice. Endovascular work may in fact better complement open neurovascular practice than other common diversions like spinal or private work. It is not reasonable to assume that an open vascular neurosurgeon with a concurrent endovascular interest would be deskilled any more so than an open vascular neurosurgeon with a private spinal practice, for example. Research showing similar outcomes in hybrid-trained neurointerventionalists and evidence supporting procedural competence maintenance in part-time models could help alleviate these concerns.

Some may question whether neurosurgeons should be expanding into what has traditionally been a radiology-driven field. In the UK, role of neurointerventionalist has historically been filled by neuroradiologists who possess extensive endovascular training focused on neurovascular anatomy and imaging-based diagnosis. Critics may worry that by expanding into this field, neurosurgeons might dilute the role of neuroradiology or create potential overlaps that could lead to fragmented care. However, the growing demand for thrombectomy services and the need for an expanded neurovascular workforce justify a more multidisciplinary approach. Citing studies and successful hybrid training models as they emerge that demonstrate the safe integration of neurosurgeons into endovascular roles could provide a strong counterargument. Of paramount importance is to drive changes in services as a united multidisciplinary front, with input from INR and neurosurgery at all levels. A precedent has been set by analogous examples in similar specialties as detailed earlier in the review.

As the field evolves, several key areas of research will be critical in guiding the safe and effective expansion of the neurovascular workforce. First, studies comparing long-term patient outcomes are needed to assess the impact of diverse training backgrounds on procedural quality and patient recovery. This research could inform best practices for credentialing and help establish evidence-based guidelines for training duration and competency requirements. Additionally, ongoing research into workforce modelling will be essential to determine the optimal number and distribution of practitioners across comprehensive stroke centres and regional hubs, ensuring that patient access is maximised without compromising the quality of care.

Strengths, limitations, and future research

This review provides a timely and insightful exploration of expanding the MT workforce by integrating neurosurgeons, clearly addressing critical healthcare service gaps and regional disparities within the UK. Its key strengths include a comprehensive examination of neurosurgical competencies relevant to MT, thoughtful proposals for hybrid training models informed by successful precedents in cardiology, and clear recognition of both practical challenges and ethical considerations involved in expanding the provider base. Additionally, the article effectively identifies future research priorities, including comparative outcome studies and detailed workforce modelling, making it highly relevant to clinicians, policymakers, and healthcare administrators seeking evidence-based strategies for improving stroke care delivery.

Several important limitations are noted mainly relating to the fact this is a dynamic, early field. First, there is currently limited empirical data comparing long-term patient outcomes between neurosurgeons and traditionally trained interventional neuroradiologists performing MT. Robust, prospective comparative studies will be essential to ensure the safety and effectiveness of expanded workforce models. Second, significant regional variability in practice patterns, infrastructure, and training opportunities could complicate national standardisation efforts. Finally, ethical considerations surrounding informed consent must be explicitly managed, ensuring patients clearly understand provider qualifications and potential risks associated with different providers.

Conclusions

Expanding the neurovascular workforce to include hybrid-trained providers, such as neurosurgeons, represents a necessary and promising direction for improving access to MT and other critical neurovascular interventions. The urgent demand for MT services, driven by the high burden of stroke and limited number of qualified providers, necessitates innovative approaches to training and credentialing. The development of structured training pathways, including hybrid fellowships, courses, and simulation-based learning, can help bridge the gap between traditional neurosurgical and interventional radiology expertise.

Looking forward, the success of these initiatives will depend on rigorous standards, ongoing research, and secure funding to ensure both safety and efficacy. Randomised, comparative studies on patient outcomes alongside workforce modelling studies, will be crucial in refining training frameworks and expanding access without compromising care quality. With a strong commitment to patient-centred and ethical practices, this expanded neurovascular workforce could provide timely, effective interventions to a larger patient population. Ultimately, this approach aligns with the NHS’s and UK Government’s goals to enhance stroke care and addresses one of the most pressing unmet needs in health, creating a path towards equitable, high-quality neurovascular services.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Christos Tolias) for the series “State of Neurovascular Surgery. The Way Forward” published in AME Surgical Journal. The article has undergone external peer review.

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-24-53/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-24-53/coif). The series “State of Neurovascular Surgery. The Way Forward” was commissioned by the editorial office without any funding or sponsorship. I.A.A. reports receiving honoraria from Stryker UK Ltd. as faculty on Neurosurgical Courses. He also received support from Balt Medical Ltd. for attending the Middle Meningeal Artery (MMA) Embolisation Workshop. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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