LAUSR

Dear Editor, ESCAPE, MR CLEAN, EXTEND IA, REVASCAT, and SWIFT-PRIME trials provided strong evidence to support the use of endovascular therapy (EVT) for achieving revascularization in acute ischemic stroke (AIS) with large vessel occlusion (LVO). These results absolutely renew the scenery of AIS management, encouraging worldwide changes in the guidelines for management of AIS by EVT. As a consequence, neurologists, in addition to patient management in stroke units and to administering intravenous thrombolysis in eligible patients, are now confronted with other specialists, as radiologists and neurosurgeons, previously not involved in ischemic stroke treatment. Thus far, there has been a separation of tasks between the stroke physicians and the interventionalist (although a few experiences of stroke physicians performing both first clinical evaluation and EVT are also reported [1]). Given the need for a fast recanalization of LVO, there is an increasing urge to recruit and form professional figures for endovascular stroke treatment but this process is limited by the shortage of neurointerventionists [2], probably due to the rigorousness of training standards for endovascular treatment of al l the neurovascular diseases (ar tero-venous malformations, sub-arachnoid hemorrhages, brain and neck tumors), discouraging neuroradiologists to pursue this professional career [3]. Moreover, vascular interventional radiologists usually do not fit the expertise standards required for stroke endovascular treatments and cannot be considered a resource for thrombecthomy. Furthermore, since care for stroke patients is based on the individual patients’ status (i.e., presence of comorbidities, concomitant anticoagulant/antiaggregant therapy, pre-morbid disability), it seems reasonable that taking decisions and consequently undertaking minimally invasive procedures could be done by physicians trained in the clinical neurosciences, highlighting the concept of Borgan specialists.^ This already happens for coronary diseases in which the utilization of interventional diagnostic/therapeutic procedures is increasingly accessible by cardiologists. Despite these considerations and the increasing numbers of stroke patients eligible for endovascular treatments, for physicians specialized in neurology, the access to endovascular treatment is still limited. The US Accreditation Council for Graduate Medical Education (ACGME) in 2006 and an international consensus paper subscribed by European Society of Minimal Invasive Neurological Therapy (ESMINT) in 2016 included physicians with a neurology background in the Endovascular Surgical Neuroradiology (ENS) education program, a subspecialty dedicated to diagnosis and treatment of neurovascular disease using x-ray fluoroscopy and angiography [4]. Since there, the evolution of the field has led some neurologists to pursue the necessary additional training to perform these procedures. To our knowledge, in few countries (the USA, Australia, Germany, France), there is the possibility for neurologists to work in angiographic rooms, after an adequate training, for neurologists to work in angiographic rooms. In Italy, the situation still remains unclear, with the only possibility for neurologists to attend a 2-year master in EVTwhich has the preferential selection criteria of being a specialist radiologist and is not qualifying to operate as an EVT specialist; moreover, the job positions for neurointerventionist are opened only for specialist in radiology. Given this background, we asked to the Neurology residents of Rome universities (the neurologists of the next * Francesco Di Lorenzo [email protected]