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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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Abstract

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.

Methods

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.

Results

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.

Conclusions

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.

Key Points

• 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.

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Abbreviations

ACA:

Anterior cerebral artery

CI:

Confidence intervals

CTA:

CT angiography

CTP:

CT perfusion

GEEs:

Generalized estimation equations

ICA:

Internal carotid artery

IQR:

Interquartile range

LR:

Logistic regression

MCA:

Middle cerebral artery

MT:

Mechanical thrombectomy

NECT:

Non-enhanced CT

NIHSS:

National Institute of Health Stroke Scale

OR:

Odds ratio

SR:

Stent retriever

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Acknowledgements

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.

Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany

    Aglaé Velasco González, Boris Buerke, Lucas Smagge & Walter Heindel

  2. Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstraße 56, 48149, Muenster, Germany

    Dennis Görlich & Cristina Sauerland

  3. Department of Neuroradiology, Alfried-Krupp Krankenhaus Hospital, Alfried-Krupp Straße 21, 45131, Essen, Germany

    Rene Chapot

  4. University Hospital of the Canary Islands, Carretera de la Cuesta, Taco 0, 38320, Santa Cruz de Tenerife, Spain

    Maria del Valle Velasco

Authors
  1. Aglaé Velasco González
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  2. Boris Buerke
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  3. Dennis Görlich
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  8. Walter Heindel
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Correspondence to Aglaé Velasco González.

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Guarantor

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.

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Written informed consent was waived by the Institutional Review Board.

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Methodology

• cross-sectional study

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Velasco González, A., Buerke, B., Görlich, D. et al. 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. Eur Radiol 29, 6275–6284 (2019). https://doi.org/10.1007/s00330-019-06199-4

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