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Original research
Mechanical thrombectomy decision making and prognostication: Stroke treatment Assessments prior to Thrombectomy In Neurointervention (SATIN) study
  1. Kyle M Fargen1,
  2. Carol Kittel2,
  3. Brian P Curry3,
  4. Connor W Hile1,
  5. Stacey Q Wolfe1,
  6. Patrick Brown1,
  7. Maxim Mokin4,
  8. Ansaar T Rai5,
  9. Michael Chen6,
  10. Robert M Starke7,
  11. Felipe C Albuquerque8,
  12. Sameer A Ansari9,
  13. Peter Kan10,
  14. Alejandro M Spiotta11,
  15. Guilherme Dabus12,
  16. Thabele M Leslie-Mazwi13,
  17. Joshua A Hirsch14
  18. SATIN Research Group
    1. 1Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
    2. 2Division of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
    3. 3Neurological Surgery, Walter Reed Army Medical Center, Bethesda, Maryland, USA
    4. 4Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
    5. 5Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
    6. 6Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
    7. 7Department of Neurosurgery and Radiology, University of Miami School of Medicine, Miami, Florida, USA
    8. 8Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
    9. 9Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
    10. 10Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
    11. 11Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
    12. 12Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, Miami, Florida, USA
    13. 13Neurology, University of Washington, Seattle, Washington, USA
    14. 14NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
    1. Correspondence to Dr Kyle M Fargen, Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina 27157, USA; kylefargen{at}gmail.com

    Abstract

    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
    • Intervention
    • Stroke
    • Thrombectomy

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Twitter @Ansaar_Rai, @dr_mchen, @PeterKa80460001, @JoshuaAHirsch

    • 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.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.