First-Line Treatment of Symptomatic Subocclusive Large-Vessel Stroke: Results of a Nationwide StrokeNet Survey.

BACKGROUND

Limited evidence is available for the treatment of acute symptomatic sub-occlusive lesions in ischemic stroke. We sought to identify current treatment patterns of stroke teams at academic health centers.

METHODS

We conducted an email survey of the National Institutes of Health (NIH) StrokeNet regional coordinating centers (RCCs). Each RCC principal investigator (PI) was asked to nominate a local stroke interventionalist, or neurologist if the RCC PI was an interventionalist, most aligned with the typical practice pattern of the RCC's lead hospital, to receive a survey. The survey consisted of a clinical vignette and displayed a sub-occlusive lesion in the left middle cerebral artery on CT angiogram followed by subsequent scenarios, revising only one historical, clinical, or radiographic variable at a time. Participants were asked to select initial management for each scenario. Results were reviewed and analyzed by stroke-trained physicians.

RESULTS

Responses were received from 42 (77.8%) of 54 surveyed individuals, representing 25 (92.6%) of 27 RCCs nationwide, including 25 (59.5%) interventionalists. The majority (76.2%) of respondents treated the patient in the primary clinical vignette with mechanical thrombectomy (MT). Among all six clinical scenarios, respondents chose MT with or without medical management as first-line treatment for four (67%) vignettes. Exceptions were low NIH Stroke Scale and known ipsilateral stenosis, where respondents chose medical management as first-line treatment.

CONCLUSIONS

Despite limited evidence to support MT versus other treatment strategies, the majority of StrokeNet RCCs respondents would use MT with or without medical therapy to treat AIS due to intracranial sub-occlusive lesions.