Factors influencing thrombectomy decision making for primary medium vessel occlusion stroke

Cimflová, Petra; Kappelhof, Manon; Singh, Nishita; Kashani, Nima; Ospel, Johanna M.; McDonough, Rosalie; Demchuk, Andrew M.; Menon, Bijoy K; Sakai, Nobuyuki; Chen, M; Fiehler, Jens; Goyal, Mayank

doi:10.1136/neurintsurg-2021-017472

Cited by 14 publications

(14 citation statements)

References 13 publications

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“…We conducted a clinical case-vignette-based, international, online, cross-sectional survey to assess stroke physicians' current practice and preferences with regard to EVT for MeVO stroke. 7 The survey consisted of seven cases, each comprising a brief clinical case-vignette and exemplary computed tomography (CT) or angiography imaging findings. Four of these cases were primary MeVOs, three were secondary MeVOs, i.e.…”

Section: Survey Designmentioning

confidence: 99%

Worldwide anaesthesia use during endovascular treatment for medium vessel occlusion stroke

et al. 2021

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Introduction The optimal anaesthesia approach for endovascular treatment (EVT) in acute ischaemic stroke is currently unknown. In stroke due to medium vessel occlusions (MeVO), the occluded vessels are particularly small and more difficult to access, especially in restless or uncooperative patients. In these patients, general anaesthesia (GA) may be preferred by physicians to prevent complications due to patient movement. We investigated physicians’ approaches to anaesthesia during EVT for MeVO stroke. Methods In a worldwide, case-based, online survey, physicians’ preferred anaesthesia approach during EVT for MeVO stroke was categorized as “initial GA”, “initial GA if necessary” (depending on patient cooperation), “no initial GA, but conversion if necessary” (start with local anaesthesia or conscious sedation), and “no GA”. Preferred anaesthesia approaches were reported overall and stratified by physician and patient characteristics. Results A total of 366 survey participants provided 1464 responses to 4 primary MeVO EVT case-scenarios. One-third of responses (489/1464 [33%]) favoured no initial GA, but conversion if necessary. Both initial GA and initial GA if necessary were preferred in 368/1464 (25%) of responses respectively. No GA was favoured in 244/1464 (17%). Occlusion location, respondent specialization (interventional neuroradiology), higher age, and female respondent sex were significantly associated with GA preference. GA was more often used in Europe than in other parts of the world ( p < 0.001). Conclusions Anaesthesia approaches in MeVO EVT vary across world regions and patient and physician factors. Most physicians in this survey preferred to start with local anaesthesia or conscious sedation and convert to GA if necessary.

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Section: Survey Designmentioning

confidence: 99%

Worldwide anaesthesia use during endovascular treatment for medium vessel occlusion stroke

et al. 2021

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“…In contrast from M1 occlusions, where the general current approach appears to be IVT and MT, a patient’s eligibility for intravenous thrombolysis seems to play a greater role in MT decision-making for M2 occlusions [ 32 ]. In a survey by Kappelhof et al, even in IVT patients more than half of the physicians stated that they would perform MT without waiting for the alteplase effect [ 32 ] and many (59%) neurointerventionalists would even immediately proceed to MT without prior IVT [ 33 ]. Treatment decision-making is further complicated by the diversity of clinical symptoms patients can present with, which are dependent on the eloquence of the affected area [ 31 ].…”

Section: Discussionmentioning

confidence: 99%

Middle Cerebral Artery M2 Thrombectomy: Safety and Technical Considerations in the German Stroke Registry (GSR)

Herzberg

Dorn

Trumm

et al. 2022

JCM

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There is ongoing debate concerning the safety and efficacy of various mechanical thrombectomy (MT) approaches for M2 occlusions. We compared these for MT in M2 versus M1 occlusions. Subgroup analyses of different technical approaches within the M2 MT cohort were also performed. Patients were included from the German Stroke Registry (GSR), a multicenter registry of consecutive MT patients. Primary outcomes were reperfusion success events. Secondary outcomes were early clinical improvement (improvement in NIHSS score > 4) and independent survival at 90 days (mRS 0–2). Out of 3804 patients, 2689 presented with M1 (71%) and 1115 with isolated M2 occlusions (29%). The mean age was 76 (CI 65–82) and 77 (CI 66–83) years, respectively. Except for baseline NIHSS (15 (CI 10–18) vs. 11 (CI 6–16), p < 0.001) and ASPECTS (9 (CI 7–10) vs. 9 (CI 8–10, p < 0.001), baseline demographics were balanced. Apart from a more frequent use of dedicated small vessel stent retrievers (svSR) in M2 (17.4% vs. 3.0; p < 0.001), intraprocedural aspects were balanced. There was no difference in ICH at 24 h (11%; p = 1.0), adverse events (14.4% vs. 18.1%; p = 0.63), clinical improvement (62.5% vs. 61.4 %; p = 0.57), mortality (26.9% vs. 22.9%; p = 0.23). In M2 MT, conventional stent retriever (cSR) achieved higher rates of mTICI3 (54.0% vs. 37.7–42.0%; p < 0.001), requiring more MT-maneuvers (7, CI 2–8) vs. 2 (CI 2–7)/(CI 2–2); p < 0.001) and without impact on efficacy and outcome. Real-life MT in M2 can be performed with equal safety and efficacy as in M1 occlusions. Different recanalization techniques including the use of svSR did not result in significant differences regarding safety, efficacy and outcome.

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“…[12][13][14] Together with the high efficacy and safety of EVT in LVO stroke, this finding has led many physicians to routinely offer EVT for MeVO stroke. [4][5][6] To offer the appropriate treatment, it is, however, necessary that MeVOs are quickly and reliably identified on imaging. Missing a MeVO on baseline imaging can lead to a delayed diagnosis or misdiagnosis, which may result in a patient not receiving intravenous thrombolysis or not getting transferred to a comprehensive stroke center for EVT.…”

Section: Discussionmentioning

confidence: 99%

Interrater Agreement and Detection Accuracy for Medium-Vessel Occlusions Using Single-Phase and Multiphase CT Angiography

Ospel

Bala²,

McDonough³

et al. 2021

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Accurate and reliable detection of medium-vessel occlusions is important to establish the diagnosis of acute ischemic stroke and initiate appropriate treatment with intravenous thrombolysis or endovascular thrombectomy. However, medium-vessel occlusions are often challenging to detect, especially for unexperienced readers. We aimed to evaluate the accuracy and interrater agreement of the detection of medium-vessel occlusions using single-phase and multiphase CTA.MATERIALS AND METHODS: Single-phase and multiphase CTA of 120 patients with acute ischemic stroke (20 with no occlusion, 44 with large-vessel occlusion, and 56 with medium-vessel occlusion in the anterior and posterior circulation) were assessed by 3 readers with varying levels of experience (session 1: single-phase CTA; session 2: multiphase CTA). Interrater agreement for occlusion type (large-vessel occlusion versus medium-vessel occlusion versus no occlusion) and for detailed occlusion sites was calculated using the Fleiss k with 95% confidence intervals. Accuracy for the detection of medium-vessel occlusions was calculated for each reader using classification tables. RESULTS:Interrater agreement for occlusion type was moderate for single-phase CTA (k ¼ 0.58; 95% CI, 0.56-0.62) and almost perfect for multiphase CTA (k ¼ 0.81; 95% CI, 0.78-0.83). Interrater agreement for detailed occlusion sites was moderate for singlephase CTA (k ¼ 0.55; 95% CI, 0.53-0.56) and substantial for multiphase CTA (k ¼ 0.71; 95% CI, 0.67-0.74). On single-phase CTA, readers 1, 2, and 3 classified 33/56 (59%), 34/56 (61%), and 32/56 (57%) correctly as medium-vessel occlusions. On multiphase CTA, 48/56 (86%), 50/56 (89%), and 50/56 (89%) medium-vessel occlusions were classified correctly. CONCLUSIONS:Interrater agreement for medium-vessel occlusions is moderate when using single-phase CTA and almost perfect with multiphase CTA. Detection accuracy is substantially higher with multiphase CTA compared with single-phase CTA, suggesting that multiphase CTA might be a valuable tool for assessment of medium-vessel occlusion stroke.ABBREVIATIONS: EVT ¼ endovascular treatment; LVO ¼ large-vessel occlusion; mCTA ¼ multiphase CTA; MeVO ¼ medium-vessel occlusion M edium-vessel occlusions (MeVOs) are defined as occlusions of the M2 and M3/4 segments of the MCA, A2 and A3/4 segments of the anterior cerebral artery, and P2 and P3/4 segments of the posterior cerebral artery. 1 MeVOs account for approximately 25%-40% of all acute ischemic strokes, and although they have traditionally been thought to cause only minor symptoms, MeVO strokes frequently result in disabling deficits. 2,3 This outcome has led to a paradigm shift in treatment: An increasing number of physicians now routinely offers endovascular treatment (EVT) as a stand-alone therapy instead of or in addition to intravenous thrombolysis for MeVO stroke. 4-6 Furthermore, 2 randomized trials, ESCAPE-MeVO and DISTAL, are being planned to generate level 1A evidence for EVT in MeVO stroke (personal communication: Ma...

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Factors influencing thrombectomy decision making for primary medium vessel occlusion stroke

Cited by 14 publications

References 13 publications

Worldwide anaesthesia use during endovascular treatment for medium vessel occlusion stroke

Worldwide anaesthesia use during endovascular treatment for medium vessel occlusion stroke

Middle Cerebral Artery M2 Thrombectomy: Safety and Technical Considerations in the German Stroke Registry (GSR)

Interrater Agreement and Detection Accuracy for Medium-Vessel Occlusions Using Single-Phase and Multiphase CT Angiography

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