Endovascular Treatment Decision Making in Octogenarians and Nonagenarians

Insights from UNMASK EVT an International Multidisciplinary Study
  • Johanna Maria Ospel
  • Nima Kashani N
  • Bijoy Menon
  • Mohammed Almekhlafi
  • Alexis Wilson
  • Urs Fischer
  • Bruce Campbell
  • Shinichi Yoshimura
  • Francis Turjman
  • Mathew Cherian
  • Ji-Hoe Heo
  • Michael Hill
  • Gustavo Saposnik
  • Mayank GoyalEmail author
Original Article



Evidence for efficacy and safety in stroke patients ≥80 years is limited, since they were underrepresented in randomized thrombectomy trials. This study sought to explore how physicians approach endovascular therapy (EVT) decision making in octogenarians and nonagenarians under their current local resources under assumed ideal conditions, i.e. without external (monetary or infrastructural) limitations.


In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 out of a pool of 22 case scenarios with different evidence levels for EVT, 4 of which involved octogenarians and 2 nonagenarians, and asked how they would treat the patient in the given scenario A) under their current local resources and B) under assumed ideal conditions, i.e. with no external restraints. Decision rates were calculated and clustered multivariable regression analysis performed to determine adjusted measures of effect size for patient age.


In octogenarians, physicians decided in favor of EVT in 76.7% (all of which were level 2B evidence scenarios) under current local resources and in 80.2% under assumed ideal conditions. In nonagenarians, 74.0% decided in favor of EVT under current local resources (level 1A scenarios: 87.7%, level 2B scenarios: 60.3%) and 79.2% would offer EVT under assumed ideal conditions (level 1A scenarios: 91.3%, level 2B scenarios: 67.2%). Age was not a significant predictor for treatment decision under current local resources (adjusted odds ratio, OR: 0.99, confidence interval, CI: 0.96–1.02 per decile increase) and under assumed ideal conditions (adjusted OR: 1.00, CI 0.97–1.03 per decile increase).


The vast majority of physicians participating in this survey would offer EVT to acute ischemic stroke patients above 80 years.


Acute ischemic stroke Elderly patients Mechanical thrombectomy Guidelines 



The authors are most grateful to all participants of the survey.


The study was funded by Stryker through an unrestricted research grant to the University of Calgary. The company was not involved in the design, execution, analysis, and interpretation or reporting of the results.

Compliance with ethical guidelines

Conflict of interest

J.M. Ospel is supported by the University of Basel Research Foundation, the Julia Bangerter Rhyner Foundation and the “Freiwillige Akademische Gesellschaft Basel” Foundation. U. Fischer is a consultant for Medtronic, Stryker and CSL Behring and Co-Principal Investigator of SWIFT-DIRECT, a randomized controlled endovascular stroke treatment trial (Medtronic). F. Turjman works as a consultant for Balt and Stryker. G. Saposnik is supported by the Heart and Stroke Foundation of Canada Career Award. M. Goyal is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, Mentice. N. Kashani N, B. Menon, M. Almekhlafi, A. Wilson, B. Campbell, S. Yoshimura, M. Cherian, J.-H. Heo and M. Hill declare that they have no competing interests.

Ethical standards

For this article no studies with human patients or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

Supplementary material

62_2019_848_MOESM1_ESM.docx (18 kb)
Case-scenarios with corresponding evidence levels


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Johanna Maria Ospel
    • 1
    • 3
  • Nima Kashani N
    • 2
  • Bijoy Menon
    • 2
    • 3
  • Mohammed Almekhlafi
    • 2
    • 3
  • Alexis Wilson
    • 3
  • Urs Fischer
    • 4
  • Bruce Campbell
    • 5
  • Shinichi Yoshimura
    • 6
  • Francis Turjman
    • 7
  • Mathew Cherian
    • 8
  • Ji-Hoe Heo
    • 9
  • Michael Hill
    • 2
    • 3
  • Gustavo Saposnik
    • 10
  • Mayank Goyal
    • 2
    • 3
    • 11
    Email author
  1. 1.Department of Radiology, University Hospital BaselUniversity of BaselBaselSwitzerland
  2. 2.Department of RadiologyUniversity of CalgaryCalgaryCanada
  3. 3.Department of Clinical NeurosciencesUniversity of CalgaryCalgaryCanada
  4. 4.University Hospital Bern, InselspitalUniversity of BernBernSwitzerland
  5. 5.Department of Medicine and Neurology, Royal Melbourne HospitalUniversity of MelbourneParkvilleAustralia
  6. 6.Department of NeurosurgeryHyogo College of Medicine 1-1 MukogawaNishinomiyaJapan
  7. 7.Department of Interventional Neuroradiology at Lyon University HospitalUniversity of LyonLyonFrance
  8. 8.Department of RadiologyKovai Medical Center and HospitalCoimbatoreIndia
  9. 9.Department of NeurologyYonsei University College of MedicineSeoulKorea (Republic of)
  10. 10.Division of Neurology, Department of Medicine, St. Michael’s HospitalUniversity of TorontoTorontoCanada
  11. 11.Departments of Radiology and Clinical Neurosciences, Foothills Medical CentreUniversity of CalgaryCalgaryCanada

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