Variability in the decision-making process of acute ischemic stroke in difficult clinical and radiological constellations: analysis based on a cross-sectional interview-administered stroke questionnaire
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Background and purpose
Notwithstanding guidelines, indications for mechanical thrombectomy (MT) in acute ischemic stroke are multifactorial and can be complex. Our aim was to exploratively evaluate decision-making on the advisability of performing MT in cases presented as an interview-administered questionnaire.
Fifty international raters assessed 12 cases and decided to recommend or exclude MT. Each case contained a brief summary of clinical information and eight representative images of the initial multimodal CT. The demographic characteristics and stroke protocols were recorded for raters. For each case, the reasons for excluding MT were recorded. Uni- and multivariate logistic regression analysis were performed for the different demographic and case characteristics to identify factors that might influence decision-making.
All raters performed MT (median MTs/hospital/year [IQR], 100 [50–141]) with a median of 7 years of experience as first operator (IQR, 4–12). Per case, diversity in decision-making ranged between 1 (case 6, 100% yes MT) and 0.50 (case 12, 54.2% yes MT and 45.8% no MT). The most common reasons for excluding MT were small CBV/CBF mismatch (17%, 102/600), size of infarct core on the CBV map (15.2%, 91/600), and low NIHSS score (National Institute of Health Stroke Scale, 8.3%, 50/600). All clinical and radiological characteristics significantly affected the decision regarding MT, but the general characteristics of the raters were not a factor.
Clinical and imaging characteristics influenced the decision regarding MT in stroke. Nevertheless, a consensus was reached in only a minority of cases, revealing the current divergence of opinion regarding therapeutic decisions in difficult cases.
• This is the first study to explore differences in decision-making in respect of mechanical thrombectomy in ischemic stroke with complex clinical and radiological constellations.
• Fifty experienced international neurointerventionalists answered this interview-administered stroke questionnaire and made decisions as to whether to recommend or disadvise thrombectomy in 12 selected cases.
• Diversity in decision-making for thrombectomy ranged from 1 (100% of raters offered the same answer) to 0.5 (50% indicated mechanical thrombectomy). There was a consensus in only a minority of cases, revealing the current disparity of opinion regarding therapeutic decisions in difficult cases.
KeywordsStroke Decision-making Tomography Thrombectomy Questionnaires
Anterior cerebral artery
Generalized estimation equations
Internal carotid artery
Middle cerebral artery
National Institute of Health Stroke Scale
Aglae Velasco Gonzalez performed this study during a six months fellowship in the Institute of Biostatistics and Clinical Research from the Faculty of Medicine, Westfälische Wilhelms-Universität Münster (WWU). The authors thank the University of Muenster (WWU) for giving us the time to complete this project. We wish to thank all the raters from various countries that participated in this questionnaire and especially Dr. Miguel Castaño (Spain) whose enthusiasm and support enabled us to recruit the ideal number of participants for this stroke questionnaire on mechanical thrombectomy.
The authors state that this work has not received any funding.
Compliance with ethical standards
The scientific guarantor of this publication is Aglaé Velasco González.
Conflict of interest
All authors disclosed no relevant relationships related to the present article. One author (RC) disclosed activities not related to the present article: author received payment from Balt, EV3, and Microvention for consultancy, expert testimony, and payment for lectures.
Statistics and biometry
Two authors of the Institute of Biostatistics and Clinical Research of the University of Muenster conducted the statistical analysis (Dennis Görlich and Cristina Sauerland). One third author (Aglaé Velasco González) participated in the statistical analyses.
Written informed consent was waived by the Institutional Review Board.
Institutional Review Board approval was obtained.
• cross-sectional study
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