Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
J Neurointerv Surg. 2022 May;14(5):439-43. doi: 10.1136/neurintsurg-2021-017471. Epub 2021 May 25.
Intravenous alteplase is currently the only evidence-based treatment for medium-vessel occlusion stroke (MeVO; M2/3, A2/3, and P2/3 vessel segment occlusions), but due to its limited efficacy, endovascular treatment (EVT) is increasingly performed in these patients. In this case-based survey study, we examined the influence of intravenous alteplase treatment on physicians' decision-making for EVT in primary MeVO stroke.
In an international web-based survey among physicians involved in acute stroke care, participants provided their EVT decision for six quasi-identical fictional MeVO case scenarios (three with and without intravenous alteplase administered). Each scenario showed radiological images and clinical information in the form of a short case vignette. We compared EVT decisions ("immediate EVT", "no EVT", or "wait for alteplase effect" [in case scenarios with alteplase treatment only]) for case scenarios with and without alteplase treatment. Clustered multivariable logistic regression was performed to assess the effect of alteplase on treatment decision.
The survey was completed by 366 physicians from 44 countries, resulting in 2196 responses included in this study. In alteplase-treated cases, 641/1098 (58.4%) responses favored immediate EVT, (279/1098 [25.4%]) favored no EVT and 178/1098 (16.2%) opted to wait for alteplase effect. In non-alteplase-treated case scenarios, 846/1098 (78.7%) were in favor of and 252/1098 (21.3%) against EVT. Intravenous alteplase was associated with a lower chance of a decision in favor of immediate EVT (adjusted OR 0.38 [95%CI 0.31 to 0.46]).
Intravenous alteplase is an important factor in EVT decision-making for MeVO stroke. However, even in alteplase-treated patients, more than half of the physicians decided to proceed with EVT without waiting for alteplase effect.
静脉注射阿替普酶是目前治疗中等大小血管闭塞性卒中（MeVO；M2/3、A2/3 和 P2/3 血管节段闭塞）的唯一循证治疗方法，但由于其疗效有限，越来越多的患者接受血管内治疗（EVT）。在这项基于病例的调查研究中，我们研究了静脉注射阿替普酶治疗对原发性 MeVO 卒中患者进行 EVT 的决策的影响。
在一项针对参与急性卒中治疗的医生的国际网络调查中，参与者对六个近乎相同的虚构 MeVO 病例场景的 EVT 决策进行了评估（其中三个场景接受了静脉注射阿替普酶治疗，三个未接受）。每个场景均以简短的病例简介形式展示了影像学图像和临床信息。我们比较了有和没有阿替普酶治疗的病例场景的 EVT 决策（“立即 EVT”、“不 EVT”或“等待阿替普酶效果”[仅在有阿替普酶治疗的病例场景中]）。采用聚类多变量逻辑回归评估阿替普酶对治疗决策的影响。
这项调查由来自 44 个国家的 366 名医生完成，共有 2196 名医生参与了本研究。在接受阿替普酶治疗的病例中，1098 例中的 641 例（58.4%）倾向于立即 EVT，1098 例中的 279 例（25.4%）倾向于不 EVT，1098 例中的 178 例（16.2%）选择等待阿替普酶效果。在未接受阿替普酶治疗的病例场景中，1098 例中的 846 例（78.7%）赞成 EVT，1098 例中的 252 例（21.3%）反对 EVT。静脉注射阿替普酶与赞成立即 EVT 的决策的可能性降低相关（调整后的比值比 0.38 [95%CI 0.31 至 0.46]）。
静脉注射阿替普酶是 MeVO 卒中 EVT 决策的重要因素。然而，即使在接受阿替普酶治疗的患者中，超过一半的医生决定在等待阿替普酶效果之前进行 EVT。
