Optimization of Endovascular Therapy in the Neuroangiography Suite to Achieve Fast and Complete (Expanded Treatment in Cerebral Ischemia 2c-3) Reperfusion

Goyal

2021

J NeuroIntervent Surg

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Medium-vessel occlusions (MeVOs), that is, occlusions of the M2/3 middle cerebral artery, A2/3 anterior cerebral artery, and P2/3 posterior cerebral artery segments, account for 25%–40% of all acute ischemic stroke cases. Clinical outcomes of MeVO stroke with intravenous thrombolysis, which is the current standard of care, are moderate at best. With improving imaging technologies and a growing literature, MeVOs are increasingly recognized as a target for endovascular treatment (EVT). For the time being, there is limited but promising evidence for the safety and efficacy of MeVO EVT, and many neurointerventionists are already routinely offering EVT for MeVO stroke, despite the lack of clear guideline recommendations. In this article, we review the evidence on endovascular treatment for MeVO stroke and summarize the available literature on current imaging strategies, commonly used EVT selection criteria, EVT techniques, and outcome assessment for MeVO stroke.

Section: Outcomes For Evt In Primary Vs Secondary Mevosmentioning

confidence: 99%

A review of endovascular treatment for medium vessel occlusion stroke

Goyal

2021

J NeuroIntervent Surg

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“…However, new techniques, smaller devices, and more flexible catheters specifically designed for distal thrombectomy have improved procedural safety. [16][17][18] EVT decision rates in this study differed based on occlusion location. In scenarios with A2/3 occlusion, immediate EVT was favored only by 51% (alteplase-eligible patients)/71% (alteplaseineligible patients) of respondents, while these numbers were much higher for scenarios with M2/3 occlusion (57%/83%) and P2/3 occlusion (82/67%).…”

Section: Ischemic Strokementioning

confidence: 84%

Influence of intravenous alteplase on endovascular treatment decision-making in acute ischemic stroke due to primary medium-vessel occlusion: a case-based survey study

Kappelhof

Kashani

et al. 2021

J NeuroIntervent Surg

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BackgroundIntravenous alteplase is currently the only evidence-based treatment for medium-vessel occlusion stroke (MeVO; M2/3, A2/3, and P2/3 vessel segment occlusions), but due to its limited efficacy, endovascular treatment (EVT) is increasingly performed in these patients. In this case-based survey study, we examined the influence of intravenous alteplase treatment on physicians’ decision-making for EVT in primary MeVO stroke.MethodsIn an international web-based survey among physicians involved in acute stroke care, participants provided their EVT decision for six quasi-identical fictional MeVO case scenarios (three with and without intravenous alteplase administered). Each scenario showed radiological images and clinical information in the form of a short case vignette. We compared EVT decisions (“immediate EVT”, “no EVT”, or “wait for alteplase effect” [in case scenarios with alteplase treatment only]) for case scenarios with and without alteplase treatment. Clustered multivariable logistic regression was performed to assess the effect of alteplase on treatment decision.ResultsThe survey was completed by 366 physicians from 44 countries, resulting in 2196 responses included in this study. In alteplase-treated cases, 641/1098 (58.4%) responses favored immediate EVT, (279/1098 [25.4%]) favored no EVT and 178/1098 (16.2%) opted to wait for alteplase effect. In non-alteplase-treated case scenarios, 846/1098 (78.7%) were in favor of and 252/1098 (21.3%) against EVT. Intravenous alteplase was associated with a lower chance of a decision in favor of immediate EVT (adjusted OR 0.38 [95%CI 0.31 to 0.46]).ConclusionsIntravenous alteplase is an important factor in EVT decision-making for MeVO stroke. However, even in alteplase-treated patients, more than half of the physicians decided to proceed with EVT without waiting for alteplase effect.

“…39 Fortunately in stroke, some key treatment-related variables are modifiable, like time-to-treatment 40,41 and completeness of reperfusion. 42 For instance, in the MR-CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry, all prediction models performed poorly in predicting good reperfusion and 90-day mRS score of 0 to 2 when only baseline variables were used (with area under the curve of 0.53-0.57 and 0.77-0.79, respectively), with better-but still quite imperfect-performance when treatment-related variables were also considered (AUC, 0.88-0.91 for mRS). 43 The quality of postacute care also matters 44 ; in the ESCAPE trial (Endovascular Treatment for Small Core and Anterior circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times), poststroke complications were a key determinant of whether patients ended up with a poor outcome despite small infarcts or vice versa.…”

Section: What Variables Are Included In the Model?mentioning

confidence: 99%

Challenges of Outcome Prediction for Acute Stroke Treatment Decisions

Goyal

Kappelhof

et al. 2021

Stroke

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Physicians often base their decisions to offer acute stroke therapies to patients around the question of whether the patient will benefit from treatment. This has led to a plethora of attempts at accurate outcome prediction for acute ischemic stroke treatment, which have evolved in complexity over the years. In theory, physicians could eventually use such models to make a prediction about the treatment outcome for a given patient by plugging in a combination of demographic, clinical, laboratory, and imaging variables. In this article, we highlight the importance of considering the limits and nuances of outcome prediction models and their applicability in the clinical setting. From the clinical perspective of decision-making about acute treatment, we argue that it is important to consider 4 main questions about a given prediction model: (1) what outcome is being predicted, (2) what patients contributed to the model, (3) what variables are in the model (considering their quantifiability, knowability at the time of decision-making, and modifiability), and (4) what is the intended purpose of the model? We discuss relevant aspects of these questions, accompanied by clinically relevant examples. By acknowledging the limits of outcome prediction for acute stroke therapies, we can incorporate them into our decision-making more meaningfully, critically examining their contents, outcomes, and intentions before heeding their predictions. By rigorously identifying and optimizing modifiable variables in such models, we can be empowered rather than paralyzed by them.