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Endovascular Treatment Decision Making in Octogenarians and Nonagenarians

Insights from UNMASK EVT an International Multidisciplinary Study

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Abstract

Background

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.

Methods

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.

Results

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).

Conclusion

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

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Acknowledgements

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

Funding

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.

Author information

Authors and Affiliations

  1. Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland

    Johanna Maria Ospel

  2. Department of Radiology, University of Calgary, Calgary, Canada

    Nima Kashani N, Bijoy Menon, Mohammed Almekhlafi, Michael Hill & Mayank Goyal

  3. Department of Clinical Neurosciences, University of Calgary, Calgary, Canada

    Johanna Maria Ospel, Bijoy Menon, Mohammed Almekhlafi, Alexis Wilson, Michael Hill & Mayank Goyal

  4. University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland

    Urs Fischer

  5. Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia

    Bruce Campbell

  6. Department of Neurosurgery, Hyogo College of Medicine 1-1 Mukogawa, Nishinomiya, Hyogo, Japan

    Shinichi Yoshimura

  7. Department of Interventional Neuroradiology at Lyon University Hospital, University of Lyon, Lyon, France

    Francis Turjman

  8. Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India

    Mathew Cherian

  9. Department of Neurology, Yonsei University College of Medicine, Seoul, Korea (Republic of)

    Ji-Hoe Heo

  10. Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Canada

    Gustavo Saposnik

  11. Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, T2N2T9, Calgary, AB, Canada

    Mayank Goyal

Authors
  1. Johanna Maria Ospel
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  2. Nima Kashani N
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  5. Alexis Wilson
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  6. Urs Fischer
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  7. Bruce Campbell
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  8. Shinichi Yoshimura
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  9. Francis Turjman
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  10. Mathew Cherian
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  11. Ji-Hoe Heo
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  12. Michael Hill
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  13. Gustavo Saposnik
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  14. Mayank Goyal
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Corresponding author

Correspondence to Mayank Goyal.

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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.

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Ospel, J.M., Kashani N, N., Menon, B. et al. Endovascular Treatment Decision Making in Octogenarians and Nonagenarians. Clin Neuroradiol 30, 45–50 (2020). https://doi.org/10.1007/s00062-019-00848-3

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  • DOI: https://doi.org/10.1007/s00062-019-00848-3

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