Assessing variability in neurointerventional practice patterns for acute ischemic stroke
- Brijesh Mehta1,2,
- Thabele M Leslie-Mazwi1,2,
- Ronil V Chandra2,
- Zeshan A Chaudhry2,3,
- James D Rabinov2,
- Joshua A Hirsch2,
- Lee H Schwamm1,
- Natalia S Rost1,
- Albert J Yoo2,3
- 1Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- 2Department of Radiology, Division of Interventional Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- 3Department of Radiology, Division of Diagnostic Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Correspondence toDr Brijesh Mehta,Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Gray 241, Boston, MA 02114, USA;
- Received 10 October 2012
- Revised 10 October 2012
- Accepted 12 November 2012
- Published Online First 12 December 2012
Background Intra-arterial therapy (IAT) is increasingly used to treat patients with acute stroke with large vessel occlusions. There are minimal data and guidelines for treatment indications and performance standards. We aimed to gain a better understanding of real-world practice patterns for IAT.
Methods An internet-based survey was launched to address six specific areas of IAT: practice setting, operator background, operational protocols, quality/safety, decision-making and treatment strategies. The survey invitation was distributed to members of multiple neurointerventional societies.
Results Responses from 140 neurointerventionalists worldwide were analyzed. The median annual volume of IAT cases per institution was 40, and the median neurointerventional group size was three staff members. Independent predictors of case volume were presence of comprehensive stroke services and telestroke capability. The median minimum National Institutes of Health Stroke Scale score for treatment consideration was 8, although 60% of respondents reported no minimum score cut-off. There was no strict time window from symptom onset to treatment among 41% of respondents for anterior circulation strokes and among 56% for posterior circulation strokes, instead basing treatment decisions on clinical and imaging findings. Despite the emphasis on imaging-based selection, there was pronounced variability in the criteria used. Only 27% used one imaging approach exclusively. IAT following full- or partial-dose intravenous tissue plasminogen activator was performed by 89%. Mechanical devices were the predominant first-line therapy, but specific device usage depended on practice location. Approximately half preferred conscious sedation during IAT.
Conclusions This survey illustrates significant variation among neurointerventionalists in the real-world use of IAT. Our findings highlight the need for evidence-based practice guidelines.