Background Mechanical thrombectomy (MT) is the standard-of-care treatment for stroke patients with emergent large vessel occlusions. Despite this, little is known about physician decision making regarding MT and prognostic accuracy.
Methods A prospective multicenter cohort study of patients undergoing MT was performed at 11 comprehensive stroke centers. The attending neurointerventionalist completed a preprocedure survey prior to arterial access and identified key decision factors and the most likely radiographic and clinical outcome at 90 days. Post hoc review was subsequently performed to document hospital course and outcome.
Results 299 patients were enrolled. Good clinical outcome (modified Rankin Scale (mRS) score of 0–2) was obtained in 38% of patients. The most frequently identified factors influencing the decision to proceed with thrombectomy were site of occlusion (81%), National Institutes of Health Stroke Scale score (74%), and perfusion imaging mismatch (43%). Premorbid mRS score determination in the hyperacute setting accurately matched retrospectively collected data from the hospital admission in only 140 patients (46.8%). Physicians correctly predicted the patient’s 90 day mRS tertile (0–2, 3–4, or 5–6) and final modified Thrombolysis in Ischemic Cerebral Infarction score preprocedure in only 44.2% and 44.3% of patients, respectively. Clinicians tended to overestimate the influence of occlusion site and perfusion imaging on outcomes, while underestimating the importance of pre-morbid mRS.
Conclusions This is the first prospective study to evaluate neurointerventionalists’ ability to accurately predict clinical outcome after MT. Overall, neurointerventionalists performed poorly in prognosticating patient 90 day outcomes, raising ethical questions regarding whether MT should be withheld in patients with emergent large vessel occlusions thought to have a poor prognosis.
- CT perfusion
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Collaborators SATIN research group contributors: Muhammad Ubaid Hafeez, MD, Jeremiah Johnson, MD, Andrew F Ducruet, MD, Joshua S Catapano, MD, Ashutosh P Jadhav, MD, PhD, Italo Linfante, MD, Robert W Regenhardt, MD, PhD, Christopher J Stapleton, MD, Sami Al Kasab, MD, Ramez N Abdalla, MD, MSc, Yazan Radaideh, MD, Joseph Morrison, MD, Webster Crowley, MD, Stephan Munich, MD, Ahmed Abdelsalam, MD, Vasu Saini, MD, Joshua D Burkes, MD, Shail Thanki, MD, Waldo Guerrero, MD, SoHyun Boo, MD, Abdul Tarabishy, MD, Phong Vu, MD, Jennifer Domico, RN, CCRP.
Contributors Concept: KMF. Data acquisition: all authors and SATIN contributors. Statistical analysis: CK. Manuscript composition: KMF, BPC, CK, TML-M, and JAH. Final approval: all authors. Guarantor: KMF.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.
Competing interests KMF, MC, JAH, FCA, MM, and PK serve on the editorial board of JNIS.
Provenance and peer review Not commissioned; externally peer reviewed.
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