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Endovascular treatment decision-making in acute ischemic stroke patients with large vessel occlusion and low National Institutes of Health Stroke Scale: insights from UNMASK EVT, an international multidisciplinary survey

  • Interventional Neuroradiology
  • Published:
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Abstract

Purpose

Many stroke patients with large vessel occlusion present with a low National Institutes of Health Stroke Scale (NIHSS). There is currently no level 1A recommendation for endovascular treatment (EVT) for this patient subgroup. From a physician’s standpoint, the deficits might only be slight, but they are often devastating from a patient perspective. Furthermore, early neurologic deterioration is common. The purpose of this study was to explore endovascular treatment attitudes of physicians in acute ischemic stroke patients presenting with low admission NIHSS.

Methods

In an international cross-sectional survey among stroke physicians, participants were presented the scenario of a 76-year-old stroke patient with an admission NIHSS of 2. Survey participants were then asked how they would treat the patient (A) given their current local resources, and (B) under assumed ideal conditions, i.e., without external (monetary or infrastructural) constraints. Overall, country-specific and specialty-specific decision rates were calculated and clustered multivariable logistic regression performed to provide adjusted measures of effect size.

Results

Two hundred seventy-five participants (150 neurologists, 84 interventional neuroradiologists, 30 neurosurgeons, 11 affiliated to other specialties) from 33 countries provided their treatment approach to this case scenario. Most physicians favored an endovascular treatment approach, either combined with intravenous alteplase (55.3% under assumed ideal and 52.0% under current working conditions) or as single treatment (11.3% under assumed ideal and 8.4% under current conditions).

Conclusion

Despite the limited evidence for endovascular therapy in acute stroke patients with low NIHSS, most physicians in this survey decided to proceed with endovascular therapy. A randomized controlled trial seems warranted.

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Acknowledgments

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

Funding

The study was funded by Stryker Inc., 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.

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Author notes

  1. GS and MG contributed equally to this work.

Authors and Affiliations

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

    Johanna Maria Ospel, Bijoy Menon, Mohammed Almekhlafi, Andrew Demchuk, Michael Hill & Mayank Goyal

  2. Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland

    Johanna Maria Ospel

  3. Department of Radiology, Severance Stroke Center, Yunsei University College of Medicine, Seoul, South Korea

    Byungmoon Kim

  4. Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea

    Ji-Hoe Heo

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

    Shinichi Yoshimura

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

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

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

    Gustavo Saposnik

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  1. Johanna Maria Ospel
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Corresponding author

Correspondence to Mayank Goyal.

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Conflict of interest

GS is supported by the Heart and Stroke Foundation of Canada Career Scientist Award. MG is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, and Mentice. JO is supported by the University of Basel Research Foundation, the Julia Bangerter Rhyner Foundation, and the “Freiwillige Akademische Gesellschaft Basel”. The other authors have nothing to disclose.

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Ospel, J.M., Kim, B., Heo, JH. et al. Endovascular treatment decision-making in acute ischemic stroke patients with large vessel occlusion and low National Institutes of Health Stroke Scale: insights from UNMASK EVT, an international multidisciplinary survey. Neuroradiology 62, 715–721 (2020). https://doi.org/10.1007/s00234-020-02371-6

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