Johanna Maria Ospel1,2, Nima Kashani N3, Bijoy Menon3,2, Mohammed Almekhlafi3,2, Alexis Wilson2, Urs Fischer4, Bruce Campbell5, Shinichi Yoshimura6, Francis Turjman7, Mathew Cherian8, Ji-Hoe Heo9, Michael Hill3,2, Gustavo Saposnik10, Mayank Goyal11,12,13. 1. Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland. 2. Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. 3. Department of Radiology, University of Calgary, Calgary, Canada. 4. University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland. 5. Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. 6. Department of Neurosurgery, Hyogo College of Medicine 1-1 Mukogawa, Nishinomiya, Hyogo, Japan. 7. Department of Interventional Neuroradiology at Lyon University Hospital, University of Lyon, Lyon, France. 8. Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India. 9. Department of Neurology, Yonsei University College of Medicine, Seoul, Korea (Republic of). 10. Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada. 11. Department of Radiology, University of Calgary, Calgary, Canada. mgoyal@ucalgary.ca. 12. Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. mgoyal@ucalgary.ca. 13. Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, T2N2T9, Calgary, AB, Canada. mgoyal@ucalgary.ca.
Abstract
BACKGROUND: Evidence for efficacy and safety in stroke patients≥80 years is limited, since they were underrepresented in randomized thrombectomy trials. This study sought to explore how physicians approach endovascular therapy (EVT) decision making in octogenarians and nonagenarians under their current local resources under assumed ideal conditions, i.e. without external (monetary or infrastructural) limitations. METHODS: In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 out of a pool of 22 case scenarios with different evidence levels for EVT, 4 of which involved octogenarians and 2 nonagenarians, and asked how they would treat the patient in the given scenario A) under their current local resources and B) under assumed ideal conditions, i.e. with no external restraints. Decision rates were calculated and clustered multivariable regression analysis performed to determine adjusted measures of effect size for patient age. RESULTS: In octogenarians, physicians decided in favor of EVT in 76.7% (all of which were level 2B evidence scenarios) under current local resources and in 80.2% under assumed ideal conditions. In nonagenarians, 74.0% decided in favor of EVT under current local resources (level 1A scenarios: 87.7%, level 2B scenarios: 60.3%) and 79.2% would offer EVT under assumed ideal conditions (level 1A scenarios: 91.3%, level 2B scenarios: 67.2%). Age was not a significant predictor for treatment decision under current local resources (adjusted odds ratio, OR: 0.99, confidence interval, CI: 0.96-1.02 per decile increase) and under assumed ideal conditions (adjusted OR: 1.00, CI 0.97-1.03 per decile increase). CONCLUSION: The vast majority of physicians participating in this survey would offer EVT to acute ischemic stroke patients above 80 years.
RCT Entities:
BACKGROUND: Evidence for efficacy and safety in strokepatients ≥80 years is limited, since they were underrepresented in randomized thrombectomy trials. This study sought to explore how physicians approach endovascular therapy (EVT) decision making in octogenarians and nonagenarians under their current local resources under assumed ideal conditions, i.e. without external (monetary or infrastructural) limitations. METHODS: In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 out of a pool of 22 case scenarios with different evidence levels for EVT, 4 of which involved octogenarians and 2 nonagenarians, and asked how they would treat the patient in the given scenario A) under their current local resources and B) under assumed ideal conditions, i.e. with no external restraints. Decision rates were calculated and clustered multivariable regression analysis performed to determine adjusted measures of effect size for patient age. RESULTS: In octogenarians, physicians decided in favor of EVT in 76.7% (all of which were level 2B evidence scenarios) under current local resources and in 80.2% under assumed ideal conditions. In nonagenarians, 74.0% decided in favor of EVT under current local resources (level 1A scenarios: 87.7%, level 2B scenarios: 60.3%) and 79.2% would offer EVT under assumed ideal conditions (level 1A scenarios: 91.3%, level 2B scenarios: 67.2%). Age was not a significant predictor for treatment decision under current local resources (adjusted odds ratio, OR: 0.99, confidence interval, CI: 0.96-1.02 per decile increase) and under assumed ideal conditions (adjusted OR: 1.00, CI 0.97-1.03 per decile increase). CONCLUSION: The vast majority of physicians participating in this survey would offer EVT to acute ischemic strokepatients above 80 years.
Authors: Eric S Sussman; Blake Martin; Michael Mlynash; Michael P Marks; David Marcellus; Gregory Albers; Maarten Lansberg; Robert Dodd; Huy M Do; Jeremy J Heit Journal: J Neurointerv Surg Date: 2019-07-26 Impact factor: 5.836
Authors: Alicia C Castonguay; Osama O Zaidat; Roberta Novakovic; Thanh N Nguyen; M Asif Taqi; Rishi Gupta; Chung-Huan J Sun; Coleman Martin; William E Holloway; Nils Mueller-Kronast; Joey E English; Italo Linfante; Guilherme Dabus; Tim W Malisch; Franklin A Marden; Hormozd Bozorgchami; Andrew Xavier; Ansaar T Rai; Michael T Froehler; Aamir Badruddin; Michael G Abraham; Vallabh Janardhan; Hashem Shaltoni; Albert J Yoo; Alex Abou-Chebl; Peng R Chen; Gavin W Britz; Ritesh Kaushal; Ashish Nanda; Mohammad A Issa; Raul G Nogueira Journal: Stroke Date: 2014-10-30 Impact factor: 7.914