Visual Aids for Patient, Family, and Physician Decision Making About Endovascular Thrombectomy for Acute Ischemic Stroke

Abstract

I n acute cerebral ischemia because of large vessel occlusion (LVO), endovascular thrombectomy is a highly effective treatment that is now standard of care. [1][2][3][4] Moreover, the degree of benefit from endovascular thrombectomy is highly time dependent.5 For every 1 minute that therapy is delayed in a typical large artery ischemic stroke, 2 million more brain cells die 5 ; for every 4 minutes that therapy is delayed between emergency department arrival and reperfusion, 1 of every 100 patients has a worse disability outcome. 6 For this reason, the national ideal target for the time interval from patient arrival in the emergency department to arterial puncture is <60 minutes. 7Background and Purpose-Rapid decision making optimizes outcomes from endovascular thrombectomy for acute cerebral ischemia. Visual displays facilitate swift review of potential outcomes and can accelerate decision processes. Methods-From patient-level, pooled randomized trial data, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of endovascular thrombectomy for patients with acute cerebral ischemia and large vessel occlusion using (1) automated (algorithmic) and (2) expert-guided joint outcome table specification. Results-For the full 7-category modified Rankin Scale, thrombectomy added to IV tPA (intravenous tissue-type plasminogen activator) alone had number needed to treat to benefit 2.9 (95% confidence interval, 2.6-3.3) and number needed to harm 68.9 (95% confidence interval, 40-250); thrombectomy for patients ineligible for IV tPA had number needed to treat to benefit 2.3 (95% confidence interval, 2.1-2.5) and number needed to harm 100 (95% confidence interval, 62.5-250). Visual displays of treatment effects on 100 patients showed: with thrombectomy added to IV tPA alone, 34 patients have better disability outcome, including 14 more normal or near normal (modified Rankin Scale, 0-1); with thrombectomy for patients ineligible for IV tPA, 44 patients have a better disability outcome, including 16 more normal or nearly normal. Displays also showed that harm (increased modified Rankin Scale final disability) occurred in 1 of 100 patients in both populations, mediated by increased new territory infarcts. The person-icon figures integrated these outcomes, and early side-effects, in a single display. Conclusions-Visual decision aids are now available to rapidly educate healthcare providers, patients, and families about benefits and risks of endovascular thrombectomy, both when added to IV tPA in tPA-eligible patients and as the sole reperfusion treatment in tPA-ineligible patients. (Stroke. 2018;49:90-97.

Decision-Making Visual Aids for Late, Imaging-Guided Endovascular Thrombectomy for Acute Ischemic Stroke

“…The magnitude of EVT shift effects in the late-presenting, imaging-selected EVT patients is comparable to the effects of early EVT in largely under 6-hour patients ineligible for intravenous thrombolytic therapy, and the net benefits substantially exceed that of intravenous thrombolysis alone in under 3-hour patients. 6,7 This accords with the greater reperfusion efficacy of EVT over intravenous thrombolysis and with the capacity of multimodal imaging to identify those late-presenting patients who are similar to the preponderance of early-presenting patients in still harboring substantial salvageable penumbra. Producing visual decision aids delineating dichotomized end points is relatively straightforward, but figural displays are more challenging to develop for ordinal outcomes that are ar-rayed along a range of disability.…”

“…An automated, expert-independent technique, algorithmic min-max population of the joint outcome table, was utilized to calculate ordinal net BPH. 7,9,10 In order to generate the expert joint outcome table method, seven content experts, including noninvasive vascular neurologists (4) and neuro-interventionalists (3) independently populated joint outcome tables. All participants were members of academic institutions who had extensive research and clinical experience in neurothrombectomy.…”

“…Figural displays are powerful tools to help patients, family, and healthcare providers rapidly understand response patterns to therapy. 6,7 We sought to use the methods for creating rapidly understandable figural displays from ordinal disability outcomes in parallel group trials 6,7 to develop visual guides for decision-making regarding ordinal outcome of EVT among late-presenting, imaging-guided, ischemic stroke patients based on data from the two salient pivotal randomized trials, DAWN (Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3).…”

Rosiglitazone ameliorates tissue plasminogen activator‐induced brain hemorrhage after stroke

“…Early reestablishment of cerebral blood flow is crucial for the functional recovery of acute ischemic stroke patients . The latest guideline of acute stroke treatment still recommends tPA as the first‐line of effective thrombolytic treatment to achieve early reperfusion of the ischemic brain . However, the current therapeutic window of 4.5 hours after the onset of stroke remarkably limits the clinical use of tPA thrombolysis .…”

“…28,29 The latest guideline of acute stroke treatment still recommends tPA as the first-line of effective thrombolytic treatment to achieve early reperfusion of the ischemic brain. 2,3,30 However, the current therapeutic window of 4.5 hours after the onset of stroke remarkably limits the clinical use of tPA thrombolysis. [31][32][33] BBB disruption is a fundamental pathological feature of intracerebral HT induced by tPA thrombolysis.…”