Endovascular Therapy or Alteplase in Patients with Comorbidities: Insights from UNMASK EVT

Abstract

Objective: Decisions to treat large-vessel occlusion with endovascular therapy (EVT) or intravenous alteplase depend on how physicians weigh benefits against risks when considering patients’ comorbidities. We explored EVT/alteplase decision-making by stroke experts in the setting of comorbidity/disability. Methods: In an international multi-disciplinary survey, experts chose treatment approaches under current resources and under assumed ideal conditions for 10 of 22 randomly assigned case scenarios. Five included comorbidities (cancer, cardiac/respiratory/renal disease, mild cognitive impairment [MCI], physical dependence). We examined scenario/respondent characteristics associated with EVT/alteplase decisions using multivariable logistic regressions. Results: Among 607 physicians (38 countries), EVT was chosen less often in comorbidity-related scenarios (79.6% under current resources, 82.7% assuming ideal conditions) versus six “level-1A” scenarios for which EVT/alteplase was clearly indicated by current guidelines (91.1% and 95.1%, respectively, odds ratio [OR] [current resources]: 0.38, 95% confidence interval 0.31–0.47). However, EVT was chosen more often in comorbidity-related scenarios compared to all other 17 scenarios (79.6% versus 74.4% under current resources, OR: 1.34, 1.17–1.54). Responses favoring alteplase for comorbidity-related scenarios (e.g. 75.0% under current resources) were comparable to level-1A scenarios (72.2%) and higher than all others (60.4%). No comorbidity independently diminished EVT odds when considering all scenarios. MCI and dependence carried higher alteplase odds; cancer and cardiac/respiratory/renal disease had lower odds. Being older/female carried lower EVT odds. Relevant respondent characteristics included performing more EVT cases/year (higher EVT-, lower alteplase odds), practicing in East Asia (higher EVT odds), and in interventional neuroradiology (lower alteplase odds vs neurology). Conclusion: Moderate-to-severe comorbidities did not consistently deter experts from EVT, suggesting equipoise about withholding EVT based on comorbidities. However, alteplase was often foregone when respondents chose EVT. Differences in decision-making by patient age/sex merit further study.

Clinical predictors of stroke prognosis after endovascular therapy

“…EVT is highly e cacious for acute ischemic stroke due to large-vessel occlusion, up to 24-hours post-onset in select cases [4]. Recently advances in AIS, which is caused by large vessel occlusion and treated with EVT, have reduced the severity of the disability, morbidity, and mortality rates of stroke [5]. In our medical center, the ratio of AIS which suffered an EVT was 52% (154/302).…”

Application Safety of Alteplase in the Treatment of Acute Cerebral Infarction

“…Observation index: Record NIHSS score of two groups of acute cerebral infarction patients before and after treatment, as well as adverse reactions of patients during treatment [5][6][7] . Efficacy evaluation index: With a view on NIHSS score of acute cerebral infarction, clinical efficacy of this study is divided into three levels, namely, effective, ineffective and markedly effective [8][9][10][11] . Markedly effective: After treatment, various vital clinical signs of the patients were improved significantly and recovered to normal, the biochemical indicators also returned to normal, NIHSS score decreased more than 90 % [12] , effective: after treatment, various vital clinical signs of the patients were further improved, the biochemical indicators were also basically returned to normal, NIHSS score decreased by about 40 %-70 %.…”

Acute Reperfusion Decision-Making in Stroke Patients with Comorbidities: Further Unmasking UNMASK-EVT

“…However in real life, it is probably more likely that acute stroke patients who are otherwise eligible for reperfusion also have various combinations of such comorbidities. 9,10 While the authors have acknowledged this deficiency in their discussion and included several https://doi.org/10.1017/cjn.2020.176…”

“…9 Ganesh et al explored reperfusion decisions in the setting of such comorbidities in an international cross-sectional web-based survey (UNMASK-EVT). 10 The study examined 6070 scenariobased responses in a convenience sample of 607 physicians across 38 countries including various physician specialties. They presented respondents with 10 randomly assigned anterior circulation large vessel occlusion (LVO) case scenarios from a pool of 22.…”

“…However, in real-life, it is probably more likely that acute stroke patients who are otherwise eligible for reperfusion also have various combinations of such comorbidities. 9,10 While the authors have acknowledged this deficiency in their discussion and included several other covariates in their models, this could limit the generalizability of results. 11 While some of the comorbidities have been addressed in this survey, other relevant ones that may impact clinical decisions are missing.…”