Mechanical thrombectomy decision making and prognostication: Stroke treatment Assessments prior to Thrombectomy In Neurointervention (SATIN) study

Abstract

BackgroundMechanical 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.MethodsA 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.Results299 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.ConclusionsThis 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.

The Charlotte Large artery occlusion Endovascular therapy Outcome Score predicts independent outcome after thrombectomy

“…We recognize the limitations of any clinical prediction rule, as previously described, 5,6 and do not advocate making a definitive prognosis based on any single scale. However, incorporating an objective measure into an individual patient scenario may be better than using clinical subjectivity alone, given the previously reported poor prognostications of stroke physicians in case‐based scenarios versus a validated risk score 28,29 and prior to thrombectomy 30 …”

Evaluation of computed tomography perfusion and angiogram use in stroke evaluation for thrombectomy at a community emergency department setting

“…This consideration is in agreement with the claim made by DAWN author Dr. Raul Nogueira, who suggests that the selection criteria used are more useful as predictors of outcome rather than hardline decisionmaking parameters, and that to adhere to the boundaries provided by the DAWN or DEFUSE-3 protocols would be to deny an effective treatment to many other deserving stroke patients [6]. Also, a recent study of neuro-interventionists' prognostic ability to predict post-mechanical thrombectomy outcomes revealed low accuracy given pre-procedure information [7]. Of note, there is currently no posited target for a hit or miss rate associated with the radiographic procedure.…”

Large core stroke thrombectomy: paradigm shift or futile exercise?

“…Large core stroke thrombectomy: paradigm shift or futile exercise? Michael Chen , 1 Thabele M Leslie-Mazwi, 2 Joshua A Hirsch , 3 Felipe C Albuquerque 4 Predicting treatment effect is a popular topic among recent Journal of Neurointerventional Surgery stroke thrombectomy publications. [1][2][3] The primary outcome measure is often functional independence, that is, a modified Rankin Scale (mRS) score of 0-2, which may lead practitioners to ruminate on the probability of this outcome during stroke triage, instead of treating patients with thrombectomy.…”

“…In fact, the recent Stroke treatment Assessments prior to Thrombectomy In Neurointervention (SATIN) study demonstrated that neurointerventionalists were only accurate in predicting outcomes 44% of the time, including being overly pessimistic at times when outcomes were better than expected. 4 It is no wonder that the majority of malpractice lawsuits related to acute stroke treatment allege failure to treat. 5 From the patient's perspective, the most terrifying, costly and overlooked outcome of ischemic stroke is an mRS of 5.…”

“…They generally prefer us to attend to providing their loved ones with even a slim chance at neurological improvement. In fact, the recent Stroke treatment Assessments prior to Thrombectomy In Neurointervention (SATIN) study demonstrated that neurointerventionalists were only accurate in predicting outcomes 44% of the time, including being overly pessimistic at times when outcomes were better than expected 4. It is no wonder that the majority of malpractice lawsuits related to acute stroke treatment allege failure to treat 5…”