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Are Telerobotic Devices the Answer to Stroke Care Dissemination?

Article In Brief

A telerobotic system for endovascular care, in the early phases of development, could provide stroke treatment in remote and hard-to-reach places.

Figure

Shown here is an interventional suite located a variable distance from the interventional room. All necessary monitoring and control equipment are available for the operator.

A bedside robotic unit and a remote physician workspace, allowing real-time surgery to be controlled from a remote location, may well represent a future strategy for providing endovascular care for stroke in remote and hard-to-reach places, suggests a paper published in late November 2019 in the Journal of Neurosurgery.

Although more institutions are now able to provide endovascular care than ever before, there is also a greater need for comprehensive care teams to deliberate on the complex questions about pathology and symptomatology after patients' initial presentations, Gavin W. Britz, MD, MBA, MPH, professor and chair of the department of neurological surgery, and colleagues from Houston Methodist Hospital, wrote in the paper.

These resources can be hard to find in hospitals that do not see a large enough volume of such patients, they noted. The use of telemedicine and teleoperated robots may offer a potential solution for disseminating interventional stroke care to smaller regional or rural centers, they said.

How Does It Work?

The “cockpit-like design” of the system allows a physician to sit at a remote radiation-shielded workstation and use a set of touchscreen controls and joysticks that are then translated to the movements of the local robotic device.

The robotic unit features “an extended reach arm, a robotic drive mechanism, and a single-use cassette containing all the necessary endovascular tools, including angiographic and hemodynamic monitors and foot pedal–controlled fluoroscopy.

The software for the system, which was cleared by the US Food and Drug Administration in 2018, was initially developed for endovascular percutaneous coronary intervention (PCI) procedures.

A 2019 study in EClinicalMedicine reported that it had successfully demonstrated the system's use for PCI in five individuals from a 20-mile distance. And a feasibility study by Dr. Britz and colleagues in Neurosurgery last June demonstrated the device's ability to navigate the cerebrovascular system, manipulate the guidewires and microcatheters routinely used for endovascular intervention, and successfully deploy coils and stents in a live animal.

Is It Viable?

But while the use of telemedicine and teleoperated robots may bridge the gaps in interventional stroke care in smaller regional or rural centers, operational and financial challenges remain, independent stroke and neurovascular care experts said. They told Neurology Today they look forward to a future where this technology would be safe, effective, and feasible, but said that it was much too early to consider this a viable reality.

Indeed, the authors of the current study acknowledged the high cost of the device would be a potential barrier—coming in at $650,000 per unit, with another $650-$750 for its single-use accessory cartridges—in addition to the investment needed to hire and train the surgical technicians and other operating room staff. They suggested that non-tertiary hospitals may be able to “spread out” some of those expenses between cardiovascular and neuro-interventional services, however.

The study authors acknowledged that there was still a lot of work to be done before the system would be ready for primetime, including “performing preliminary trials of intracranial endovascular procedures such as angiography, coilings, and stent deployments in humans safely as a proof of capability.”

Tests of the system need to be performed to mirror a range of potential scenarios in multiple subjects with diverse anatomical locations and complexities, the study authors wrote. In addition, Remote procedures would need to be performed in coordination with locations where adequate contingency options (such as experienced neuro-interventionalists) also exist onsite, they added.

“Only then, by studying the metrics and outcomes of robotically performed procedures and comparing them to those of the hub-and-spoke or diffused care models, can a decision be made regarding the efficacy of the device and its capability to address deficiencies in the status quo,” Dr. Britz and colleagues concluded, adding, however, that they believe these hurdles can be overcome.

Expert Commentary

In an accompanying editorial, Jeffrey T. Nelson, MD, and Nicholas C. Bambakidis, MD, both from the University Hospitals Cleveland Medical Center, acknowledged the relevance of future research into the development of neuroendovascular robotics. But they said its use as “a solution to our current access issues in the delivery of stroke care seems premature....If and when a telerobotic neurointerventional procedure is available, it may prove to be a useful adjunct to stroke treatment if the technical limitations are overcome. For now, we must continue to develop systems of stroke care that provide access to all patients with acute ischemic stroke.”

Independent experts who spoke with Neurology Today agreed that these interventions were an exciting prospect but they were far from ready for widespread use.

“The challenge of making endovascular thrombectomy more accessible to patients living in rural areas is very complex as the number of patients who would be treated locally at a small rural hospital is not sufficient to support an interventionalist,” Carolyn A. Cronin, MD, PhD, associate professor of neurology and director of the vascular neurology fellowship program at the University of Maryland School of Medicine, acknowledged. This article presents “a novel idea” to respond to that challenge, she said.

However, Dr. Cronin added, “Even if the interventionalist could be off-site, there are still many resources that would be needed locally and also may be cost-prohibitive. These include a fully capable endovascular suite with biplane imaging, technicians familiar with neurointerventional procedures and all the different devices in use, and an interventionalist to obtain vascular access.”

She added that supplementary training would be necessary for the neurointerventionalists who would be using the robotic equipment in order to ensure they would be “equally as competent with the procedures remotely as they are in person” which is a time and cost consideration.

Telerobotic surgery would be “an intriguing potential option but needs further study regarding both the safety and quality of the intervention done remotely and also whether it would be financially viable,” Dr. Cronin concluded.

Pooja Khatri, MD, MSc, FAAN, professor of neurology at the University of Cincinnati (UC) and co-director of the UC Stroke Team, agreed that the article was “very intriguing” and did a good job of laying out the currently available evidence and pros and cons of telerobotic stroke intervention.

“The concept of using telerobotics for mechanical embolectomy makes intuitive sense, compared to open surgery, when one considers that the operator is already using a screen to guide his or her work even in person. But much more work is to be done before we get there,” she cautioned.

“The technical tradeoffs for the operator seem to be tactile feedback for mechanical precision, and early data from cardiac trials suggest that these tradeoffs might not sacrifice technical safety or efficacy. The question will be whether the same will be true in the brain. The brain has more twists and turns in arteries, and more to lose with delays and complications.”

Dr. Khatri said an important factor will be the availability of stable, strong, and fast internet connections at all participating centers.

It is exciting to consider the advantages of these systems, Dr. Khatri said, including expedited “access for patients in much more remote areas to a highly effective and highly time sensitive treatment.”

There are many questions that need to be answered before this can happen, however, including: Who sets up the procedure and takes the first steps? Who steps in when there are procedural failures and complications?

“As the editorial lays out nicely, the need to expand access to neurointerventional care is urgent and the road to development of telerobotics is relatively long. We can't wait for telerobotics to expand our workforce and resources for acute stroke care,” Dr. Khatri said.

“At the same time, even with an adequate workforce and resources countrywide, the authors make a compelling case for robotics enhancing care even when the interventionist is there in person.”

Dr. Khatri said she was looking forward to seeing the data from these technologies in humans with stroke.

Disclosures

Drs. Britz, Khatri and Cronin had no relevant disclosures to report.

Link Up for More Information

• Panesar SS, Volpi JJ, Lumsden A, Desai V, et al. Telerobotic stroke intervention: A novel solution to the care dissemination dilemma https://thejns.org/view/journals/j-neurosurg/aop/article-10.3171-2019.8.JNS191739/article-10.3171-2019.8.JNS191739.xml. J Neurosurg 2019; Epub 2019 Nov 29.
    • Nelson JT, Bambakidis NC. Editorial: The delivery of stroke intervention in the community: Is telerobotic endovascular surgery the solution https://thejns.org/view/journals/j-neurosurg/aop/article-10.3171-2019.10.JNS192195/article-10.3171-2019.10.JNS192195.xml. J Neurosurg 2019; Epub 2019 Nov 29.
      • Britz GW, Tomas J, Lumsden A: Feasibility of robotic-assisted neurovascular interventions: Initial experience in flow model and porcine model https://academic.oup.com/neurosurgery/article-abstract/86/2/309/5471815?redirectedFrom=fulltext. Neurosurgery 2019; Epub 2019 June 21.
        • Patel TM, Shah SC, Pancholy SB. Long distance tele-robotic-assisted percutaneous coronary intervention: First-in-human experience https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30137-3/fulltext. EClinicalMedicine 2019;14:53–58.