Willingness to randomize primary medium vessel occlusions for endovascular treatment - 30/09/21
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Abstract |
Background and purpose |
Patients with acute ischemic stroke due to medium vessel occlusion (MeVO) make up a substantial part of the acute stroke population, though guidelines currently do not recommend endovascular treatment (EVT) for them. A growing body of evidence suggests that EVT is effective in MeVOs, including observational data but no randomized studies. We aimed to explore willingness of physicians worldwide to randomize MeVO stroke patients into a hypothetical trial comparing EVT in addition to best medical management versus best medical management only.
Methods |
In an international cross-sectional survey among stroke physicians, participants were presented with 4 cases of primary MeVOs (6 scenarios each). Each subsequent scenario changed one key patient characteristic compared to the previous one, and asked survey participants whether they would be willing to randomize the described patient. Overall, physician- and scenario-specific decision rates were calculated. Multivariable logistic regression with clustering by respondent was performed to assess factors influencing the decision to randomize.
Results |
Overall, 366 participants (56 women) from 44 countries provided 8784 answers to 24 MeVO case scenarios. The majority of responses (78.3%) were in favor of randomizing. Most physicians were willing to accept patients transferred for EVT from a primary center (82%) and the majority of these (76.5%) were willing to randomize these patients after transfer. Patient age > 65 years, A3 occlusion, small core volume, and patient intravenous alteplase eligibility significantly influenced the physician's decision to randomize (adjOR 1.24, 95%CI 1.13–1.36; adjOR 1.17, 95%CI 1.01–1.34; adjOR 0.98, 95%CI 0.97–0.99 and adjOR 1.38, 95%CI 1.21–1.57, respectively).
Conclusions |
Most physicians in this survey were willing to randomize acute MeVO stroke patients irrespective of patient characteristics into a trial comparing EVT in addition to best medical management versus best medical management only, suggesting there is clinical equipoise.
Le texte complet de cet article est disponible en PDF.Graphical abstract |
Highlights |
• | Several studies have shown that medium vessel occlusion (MeVO) can cause significant disability. |
• | However, current guidelines do not recommend endovascular treatment (EVT) for MeVO and there are no randomized controlled trials till this date. |
• | In an international cross-sectional survey among stroke physicians comprising of 366 participants (56 women) from 44 countries, majority of responses (78.3%) were in favor of randomizing these patients in a hypothetical trial comparing EVT in addition to best medical management versus best medical management only. |
• | This data suggests that there is clinical equipoise in the stroke community and there is a need for a randomized controlled trial. |
Keywords : Acute ischemic stroke, Medium vessel occlusion, Distal occlusion, Endovascular therapy
Abbreviations : AIS, EVT, MeVO
Plan
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