Factors Associated With the Decision-Making on Endovascular Thrombectomy for the Management of Acute Ischemic Stroke
- 1 September 2019
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Stroke
- Vol. 50 (9), 2441-2447
- https://doi.org/10.1161/strokeaha.119.025631
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.This publication has 39 references indexed in Scilit:
- MRI-Guided Thrombolysis for Stroke with Unknown Time of OnsetThe New England Journal of Medicine, 2018
- Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion ImagingThe New England Journal of Medicine, 2018
- Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and InfarctThe New England Journal of Medicine, 2018
- Visual Aids for Patient, Family, and Physician Decision Making About Endovascular Thrombectomy for Acute Ischemic StrokeStroke, 2018
- Visual aid tool to improve decision making in acute stroke careInternational Journal of Stroke, 2016
- Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trialsThe Lancet, 2016
- Endovascular Treatment with Stent-Retriever Devices for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled TrialsPLOS ONE, 2016
- Endovascular Thrombectomy for Acute Ischemic StrokeJAMA, 2015
- 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular TreatmentStroke, 2015
- Acute stroke, Bayes’ theorem and the art and science of emergency decision-makingJournal of NeuroInterventional Surgery, 2013