Influence of guidelines in endovascular therapy decision making in acute ischemic stroke insights from UNMASK EVT

Background and Purpose-The American Heart Association and the American Stroke Association guidelines for earlymanagement of patients with ischemic stroke offer guidance to physicians involved in acute stroke care and clarify endovasculartreatment indications. The purpose of this study was to assess concordance of physicians' endovascular treatment decisionmaking with current American Heart Association and the American Stroke Association stroke treatment guidelines using asurvey-approach and to explore how decision-making in the absence of guideline recommendations is approached.Methods-In an international cross-sectional survey (UNMASK-EVT), physicians were randomly assigned 10 of 22case scenarios (8 constructed with level 1A and 11 with level 2B evidence for endovascular treatment and 3 scenarioswithout guideline coverage) and asked to declare their treatment approach (1) under their current local resources and(2) assuming there were no external constraints. The proportion of physicians offering endovascular therapy (EVT) wascalculated. Subgroup analysis was performed for different specialties, geographic regions, with regard to physicians' age,endovascular, and general stroke treatment experience.Results-When facing level 1A evidence, participants decided in favor of EVT in 86.8% under current local resources andin 90.6% under assumed ideal conditions, that is, 9.4% decided against EVT even under assumed ideal conditions. In casescenarios with level 2B evidence, 66.3% decided to proceed with EVT under current local resources and 69.7% underassumed ideal conditions.Conclusions-There is potential for improving thinking around the decision to offer endovascular treatment, since physicians didnot offer EVT even under assumed ideal conditions in 9.4% despite facing level 1A evidence. A majority of physicians wouldoffer EVT even for level 2B evidence cases.