Abstract TP56: Endovascular Treatment Decisions in Acute Ischemic Stroke Patients With Low Baseline Aspects: Insights From an International Multidisciplinary Survey

Background and Purpose: Current AHA/ASA guidelines for the early management of patients with acute ischemic stroke restrict level 1A recommendations for endovascular therapy (EVT) to patients with baseline ASPECTS score >5. However, a recent meta-analysis from the HERMES group showed a treatment benefit in patients with ASPECTS ≤5. We aimed to explore how physicians across different specialties and countries approach endovascular treatment decision-making in acute ischemic stroke patients with low baseline ASPECTS. 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, 3 of which involved patients with baseline ASPECTS < 6 (A: 40-year old with ASPECTS 4, B: 33-year old with ASPECTS 2 C: 72-year old with ASPECTS 3), otherwise fulfilling all EVT-eligibility criteria. Participants were 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. without any external (monetary, policy-related or infrastructural) restraints. Overall and scenario-specific decision rates were calculated. Clustered multivariable logistic regression analysis was used to determine variables associated with EVT decision in patients with low baseline ASPECTS. Results: 827/6070 responses were available for the low ASPECTS scenarios. Current and ideal treatment EVT decision rates were 57.1% and 57.6% respectively. Current and ideal decision rates were 69.9% and 60.4% for scenario A, 60.0% and 61.5% for scenario B, 41.3% and 40.2% for scenario C respectively. Annual center EVT volume (OR 1.004,p=.004), annual operator EVT volume (OR 1.009, p=.018) and time since symptom onset (OR 4.543,p<.001) were significantly associated with EVT decision-making under current local resources, while annual operator EVT volume (OR 1.007,p<.029) and time since symptom onset (OR 5.687,p<.001) were associated with decision-making under assumed ideal conditions. Conclusion: A majority of physicians decided to proceed with EVT despite low baseline ASPECTS. Operators and centers doing more EVT per year were more likely to offer EVT to patients with low ASPECTS.