Factors Associated with the Decision-Making on Endovascular Thrombectomy for the Management of Acute Ischemic Stroke

Gustavo Saposnik, Bijoy K. Menon, Nima Kashani, Alexis T. Wilson, Shinichi Yoshimura, Bruce C.V. Campbell, Blaise Baxter, Alejandro Rabinstein, Francis Turjman, Urs Fischer, Johanna M. Ospel, Peter J. Mitchell, Pillai N. Sylaja, Mathew Cherian, Byungmoon Kim, Ji Hoe Heo, Anna Podlasek, Mohammed Almekhlafi, Mona M. Foss, Andrew M. DemchukMichael D. Hill, Mayank Goyal

Research output: Contribution to journalArticle

10 Scopus citations

Abstract

Background and Purpose - Little is known about the real-life factors that clinicians use in selection of patients that would receive endovascular treatment (EVT) in the real world. We sought to determine patient, practitioner, and health system factors associated with therapeutic decisions around endovascular treatment. Methods - We conducted a multinational cross-sectional web-based study comprising of 607 clinicians and interventionalists from 38 countries who are directly involved in acute stroke care. Participants were randomly allocated to 10 from a pool of 22 acute stroke case scenarios. Each case was classified as either Class I, Class II, or unknown evidence according to the current guidelines. We used logistic regression analysis applying weight of evidence approach. Main outcome measures were multilevel factors associated with EVT, adherence to current EVT guidelines, and practice gaps between current and ideal practice settings. Results - Of the 1330 invited participants, 607 (45.6%) participants completed the study (53.7% neurologists, 28.5% neurointerventional radiologists, 17.8% other clinicians). The weighed evidence approach revealed that National Institutes of Health Stroke Scale (34.9%), level of evidence (30.2%), ASPECTS (Alberta Stroke Program Early CT Score) or ischemic core volume (22.4%), patient's age (21.6%), and clinicians' experience in EVT use (19.3%) are the most important factors for EVT decision. Of 2208 responses that met Class I evidence for EVT, 1917 (86.8%) were in favor of EVT. In case scenarios with no available guidelines, 1070 of 1380 (77.5%) responses favored EVT. Comparison between current and ideal practice settings revealed a small practice gap (941 of 6070 responses, 15.5%). Conclusions - In this large multinational survey, stroke severity, guideline-based level of evidence, baseline brain imaging, patients' age and physicians' experience were the most relevant factors for EVT decision-making. The high agreement between responses and Class I guideline recommendations and high EVT use even when guidelines were not available reflect the real-world acceptance of EVT as standard of care in patients with disabling acute ischemic stroke.

Original languageEnglish (US)
Pages (from-to)2441-2447
Number of pages7
JournalStroke
Volume50
Issue number9
DOIs
StatePublished - Sep 1 2019

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Keywords

  • Acute ischemic stroke
  • Decision-making
  • Endovascular therapy
  • Evidence-based medicine
  • Neuroeconomics
  • Thrombectomy
  • Treatment guidelines

ASJC Scopus subject areas

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

Cite this

Saposnik, G., Menon, B. K., Kashani, N., Wilson, A. T., Yoshimura, S., Campbell, B. C. V., Baxter, B., Rabinstein, A., Turjman, F., Fischer, U., Ospel, J. M., Mitchell, P. J., Sylaja, P. N., Cherian, M., Kim, B., Heo, J. H., Podlasek, A., Almekhlafi, M., Foss, M. M., ... Goyal, M. (2019). Factors Associated with the Decision-Making on Endovascular Thrombectomy for the Management of Acute Ischemic Stroke. Stroke, 50(9), 2441-2447. https://doi.org/10.1161/STROKEAHA.119.025631