J Stroke.
2020 Sep;22(3):377-386. 10.5853/jos.2019.03503.
Decision-Making Visual Aids for Late, Imaging-Guided Endovascular Thrombectomy for Acute Ischemic Stroke
- Affiliations
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- 1Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
- 2Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- 3Department of Radiology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
- 4Department of Neurology, Stanford University, Stanford, CA, USA
- 5Department of Neurology, Emory University, Atlanta, GA, USA
- KMID: 2508041
- DOI: http://doi.org/10.5853/jos.2019.03503
Abstract
- Background and Purpose
Speedy decision-making is important for optimal outcomes from endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Figural decision aids facilitate rapid review of treatment benefits and harms, but have not yet been developed for late-presenting patients selected for EVT based on multimodal computed tomography or magnetic resonance imaging.
Methods
For combined pooled study-level randomized trial (DAWN and DEFUSE 3) data, as well as each trial singly, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of EVT for patients with AIS and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification.
Results
Among imaging-selected patients 6 to 24 hours from last known well, for the full 7-category modified Rankin Scale (mRS), EVT had number needed to treat to benefit 1.9 (interquartile range [IQR], 1.9 to 2.1) and number needed to harm 40.0 (IQR, 29.2 to 58.3). Visual displays of treatment effects among 100 patients showed that, with EVT: 52 patients have better disability outcome, including 32 more achieving functional independence (mRS 0 to 2); three patients have worse disability outcome, including one more experiencing severe disability or death (mRS 5 to 6), mediated by symptomatic intracranial hemorrhage and infarct in new territory. Similar features were present in person-icon figures based on a 6-level mRS (levels 5 and 6 combined) rather than 7-level mRS, and based on the DAWN trial alone and DEFUSE 3 trial alone.
Conclusions
Personograph visual decision aids are now available to rapidly educate patients, family, and healthcare providers regarding benefits and risks of EVT for late-presenting, imaging-selected AIS patients.
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