Abstract 2601: Neurointerventional Practice Patterns in Acute Ischemic Stroke

Abstract

Background: Intra-arterial therapy (IAT) is increasingly used to treat acute ischemic stroke patients with large vessel occlusions. However, there are minimal consensus guidelines for treatment indications and performance standards. Thus we aimed to gain a better understanding of IAT practice patterns among neurointerventionalists. Methods: An internet-based survey platform ( www.iasurvey.net ) was launched to address five specific areas of IAT in acute strokes: practice setting, operator background, quality and safety, decision-making and treatment strategies. The survey was distributed electronically to members of the major worldwide neurointerventional societies. Results: Of respondents to date, 67 neurointerventionalists based in North America are included in this analysis: 58% neurologists, 27% radiologists, 15% neurosurgeons. Approximately 81% work in academic setting. Across all institutions, the average yearly volume of IA stroke cases is 52 (median 50). Each neurointerventional radiology (NIR) group consists of an average of 3 attendings, with 94% performing IAT. For 43%, activation of the NIR team is on arrival of the patient to the ED, whereas 18 of the 37 with TeleStroke capabilities are alerted after remote evaluation. IAT decisions are made jointly according to 78%, by the NIR team alone for 13% and by the acute stroke service alone for 9%. The minimum NIHSS score for consideration of IAT ranges from 4-13 (median score 8). Imaging evaluation is with CT/CTA in 85%, and with MRI in 45%. Clinical and imaging selection criteria are used in lieu of time in 40% of anterior circulation strokes and 57% of posterior circulation strokes. Despite the emphasis on imaging selection, there is pronounced variability in the specific criteria always used: noncontrast CT (NCCT) hypodensity <1/3rd MCA territory in 55%; NCCT ASPECTS in 15%; CTA source images in 40%; CT perfusion in 33%; MRI mismatch in 12%; and DWI in 22%. For infarct volume determination, 66% use visual estimation alone. Approximately half of operators (54%) prefer conscious sedation if feasible. IAT following full dose IV tPA (ie, bridging therapy) is performed by 72%. For large vessel occlusions (LVO), the Penumbra and Merci devices are the first treatments of choice among 46% and 34%, respectively; for medium sized vessels, Penumbra is preferred by 61%. Local thrombolysis is utilized as first-line therapy in LVO by only 13%, as opposed to rescue therapy for 70%. Case termination is based on time from last seen normal for 75% (range 6-11 hours for anterior circulation). Conclusions: We present a comprehensive study examining real-world practice patterns for IAT in acute ischemic stroke patients. While data collection continues, these early results illustrate the significant variation among neurointerventionalists in the use of this treatment modality. Our findings highlight the need for evidence based practice guidelines.