Objective: Acute endovascular thrombectomy for major artery occlusion is recommended in Japanese Guidelines for the Management of Stroke as grade A. There was no precise data about the current status of acute thrombectomy including the number of treatment cases or the number and location of institutes. The aim of this study is to clarify the current status of acute endovascular thrombectomy.

Methods: We have sent the e-mail for all the members of the Japanese Society for Neuroendovascular therapy (JSNET) to collect the number of acute thrombectomy cases. We calculated the number of acute thrombectomy and board physician per 100,000 persons.

Results: We collected 574 responses from the facilities with JSNET board physician, and the response rate from institution with JSNET specialist was 96.6%. The total number of acute thrombectomy in Japan in the year 2016 was 7,702 cases. The number of acute thrombectomy cases was calculated as 6.06/100,000 people, and the number of board physician was 0.85/100,000 people.

Conclusion: We obtained the correct data about acute thrombectomy from the national survey. The number of acute thrombectomy cases were calculated as 6.06/100,000 people, and increase of treatment cases is expected in the near future.

Objective: Thrombectomy for cerebral infarction caused by major artery occlusion was recently established based on a number of evidences. Moreover, growing body of evidences is expected to bring further drastic changes to the treatment for cerebral infarction.

Methods: After Kobe Declaration at the Annual Meeting of the Japanese Society for Neuroendovascular Therapy in 2016, nationwide effort to bring the benefit of this therapy to the patients has been made by physicians working on the endovascular therapy and other areas.

Results: In Hokkaido, population is concentrated to limited areas in the broad land. Thus, the distance between the urban area and the underpopulated area is relatively long compared to that in other prefectures. Moreover, the bad weather in winter in this area often prevents use of air ambulance. Such the conditions in this area are disadvantageous for thrombectomy which particularly needs immediate operation.

Conclusion: I would like to introduce the effort of the physicians working on the endovascular therapy and the thrombectomy teams to develop this treatment in Hokkaido area despite the bad conditions.

Objective: The purpose of this study is to report the activity about mechanical thrombectomy in the Japanese Society for Neuroendovascular Therapy Tohoku branch association.

Methods: We started REBIRTH (REgional systems for brain attack to improve efficacy of clot retrieval treatment in Tohoku Hospital network) to investigate the present situation of mechanical thrombectomy about each prefecture in the Tohoku district. We report the data of REBIRTH in 2016. REBIRTH shows the number of JSNET specialists/instructors, the cases of mechanical thrombectomy, and some problems about the present situation of mechanical thrombectomy in the Tohoku district. Besides, we report the presentation status of REBIRTH at the national conference.

Results: In 2016, 66 JSNET specialists/instructors worked in the Tohoku district. About 516 mechanical thrombectomies were performed in this area. The representatives of each prefecture about mechanical thrombectomy made announcement about REBIRTH at The 36th Meeting of the Japanese Society for Neuroendovascular Therapy Tohoku branch association, the 76th Annual Meeting of The Japanese Neurosurgical Society and the 33rd Annual Meeting of The Japanese Society for Neuroendovascular Therapy.

Conclusion: We report REBIRTH as the activity of the Japanese Society for Neuroendovascular Therapy Tohoku branch association. We propose that the activity of REBIRTH can contribute to information sharing and to resolving problems of mechanical thrombectomy in the Tohoku district. We continue to announce the content of REBIRTH.

Objective: We report here the current status of mechanical thrombectomy performed in the Tama region of the Tokyo metropolitan area.

Methods: The Tama region, with a population of about 4.3 million, comprises the western half of Tokyo metropolis. Mechanical thrombectomy in the region is performed by a limited number of specialists, in a limited number of centers. To make mechanical thrombectomy more available throughout the region, several efforts are underway. Creation of a study seminar for mechanical thrombectomy (Tama Forum of Acute ischemic Stroke Therapy: Tama-FAST), sharing of information, initiation of a multicenter registration of mechanical thrombectomy (Tama-REgistry of Acute endovascular Thrombectomy: TREAT), and educating emergency service personnel.

Results: There are 44 acute stroke centers in the region, of which 33 provide intravenous tissue-plasminogen activator (t-PA), and of which 13 perform mechanical thrombectomy. A triannual study seminar, which started 3 years ago, resulted in a close relationship between health care providers, leading to a better coordination between hospitals for acute neurosurgical care. We have started a multicenter registration from April 2017, with over 600 patients registered at this point, and with data analysis planned in the future.

Conclusion: In the Tama region, many patients are already being transported to hospitals providing mechanical thrombectomy, making them function in essence as stroke care centers. In the future, taking regional characteristics into account, efforts should be made to maximize the opportunities of mechanical thrombectomy, like the creation of an emergency transport system that gives priority to patients potentially in need of endovascular treatment.

Objective: Endovascular therapy for acute ischemic stroke (emergency neuroendovascular revascularization; ENER) had been performed in Japan, and endovascular thrombectomy for major artery occlusion is strongly recommended in Japanese Guidelines for the Management of Stroke revised in 2017. We summarized the current status of ENER and regional activities in Kinki region, and discussed a solution for spreading ENER.

Methods: The current status of ENER in each prefecture of Kinki region were evaluated based on data received from the nationwide surveillance, Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Project (RESCUE-Japan Project). The regional activities in each prefecture were summarized from contents of presentation at the 4th Regional Conference of Japanese Society for Neuroendovascular therapy (JSNET) held on September 2, 2017, at Osaka.

Results: In Kinki region, the annual number of ENER was the largest in Osaka Prefecture, while the number of ENER per population was the largest in Hyogo Prefecture. Board physicians and thrombectomy-capable stroke center concentrated in urban areas, resulting in disparities of the annual number of ENER among each second medical service. In all prefecture, transportation of stroke patients by helicopter emergency medical services has been introduced in clinical practice and regular meeting have been held to strengthen collaboration between centers and ambulance service.

Conclusion: Multi-fold approach, including consolidation of thrombectomy-capable stroke centers in the urban area, close co-operation between nearby second medical service areas, and a combination of transportation by helicopter and remote medical support system, will be necessary to make all local residents receive rapid ENER.

Objective: Endovascular treatment with or without tissue-plasminogen activator (t-PA) infusion has been becoming the standard first-line therapy for acute ischemic stroke (AIS). It is very difficult to treat patients with AIS in underpopulated regions, because medical resources are limited in such areas. We have discussed about this problem in the special symposium titled “Emergent Neuroendovascular therapy for AIS” at the annual Chugoku-Shikoku regional meeting of the Japanese society for NeuroEndovascular Therapy. We introduce our efforts to overcome these local problems in underpopulated regions.

Methods and Results: 1) A specialist of neuroendovascular therapy was invited to a core hospital in the mountain area. This hospital was covering wide medical regions with predominantly elderly people. The system in the hospital was then constructed for the treatment of AIS like a comprehensive stroke center (CSC). The patients with AIS were concentrated to the core hospital, which resulted in a rapid increase of endovascular treatment and improvement of patients’ outcome.

2) A core hospital started “Mobile Endovascular-therapy” in cooperation with a university hospital which had enough specialists. These efforts made not only a steep increase of endovascular treatment, but also upskilling of the regional physicians. Finally, the regional physicians became able to perform endovascular treatment without aid of the university hospital in a few years.

3) A university hospital was established as a CSC using telemedicine and helicopter transportation for covering the whole area of the prefecture. This method is called “hub-and-spoke” style for AIS treatment, and effectively brought the AIS patients to the university hospital. This energy resulted in improvement of patients’ outcome even in underpopulated regions where the specialists are absent. This “hub-and-spoke” style is becoming a good role model in Japanese remote medical care.

Conclusion: We hope these examples would be helpful references for other Japanese hospitals. In addition, it is very important to continue these kinds of efforts by not only medical staff, but also by organizations concerned with social support.

Objective: The purpose of this study was to investigate the effectiveness of standardized stroke diagnosistreatment system named “Stroke Scramble” on stroke care system and its clinical outcome.

Methods: From September 2012 to December 2017, acute ischemic stroke patients admitted to our institution within 4.5 h after symptom onset were enrolled. The number of thrombectomy, therapeutic time, and outcomes were retrospectively compared between before and after the introduction of the “Stroke scramble”.

Results: In acute ischemic stroke cases within 4.5 h after onset, the proportion of thrombectomy was significantly increased in the “Stroke Scramble” period (20/63, 32% vs. 86/117, 74%). Both door-to-puncture time (min, median 192, interquartile range [IQR] 146–218 vs. 85, IQR 65–103) and puncture-to-reperfusion time (min, 158, IQR 101–180 vs. 45, IQR 28–73) decreased, resulted in reducing onset-to-reperfusion time (min, 437, IQR 378–552 vs. 241, IQR 185–305). The proportion of successful recanalization (≥thrombolysis in cerebral infarction 2b) increased from 45 to 85% (P < 0.001) and the proportion of good outcome (modified Rankin Scale 0–2) at 90 days also increased from 15 to 42% (P = 0.038).

Conclusion: Standardization of acute stroke workflow by “Stroke Scramble” was associated with increased cases of thrombectomy, shortened therapeutic time, and improved clinical outcomes.

Objective: The number of cerebral endovascular treatment specialists in Kyushu, except for Kumamoto prefecture, it was over the national average. Many cases were treated in Fukuoka, Saga, and Nagasaki prefecture, but in other prefectures, there were less than the national average. In prefectures where the number of cases is small, it was speculated that the specialists were ubiquitous in cities like the prefectural office location, and it was not possible to cover the vast prefecture. From now on, it is necessary to establish the delivery system for patients with acute cerebral infarction, who have indications for endovascular treatment, and to equalize endovascular treatment experts in each prefecture.

Methods: In Kumamoto prefecture, to solve these problems, Kumamoto EliminAting Regional THrombectomy disparity project (K-EARTH).

Results: In this project, we create a common hot line at facilities where endovascular treatment can be performed. If a patient with indication for endovascular treatment is delivered to a hospital where endovascular treatment cannot be performed, contact the hotline and promptly carry it to a treatment-capable facility using a helicopter or the like to perform endovascular treatment.

Conclusion: With this project, endovascular treatment can be performed for patients across the prefecture.