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Research ArticleNeurointervention

How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT

J.M. Ospel, N. Kashani, U. Fischer, B.K. Menon, M. Almekhlafi, A.T. Wilson, M.M. Foss, G. Saposnik, M. Goyal and M.D. Hill
American Journal of Neuroradiology February 2020, 41 (2) 262-267; DOI: https://doi.org/10.3174/ajnr.A6396
J.M. Ospel
aFrom the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
cDivision of Neuroradiology (J.M.O.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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N. Kashani
bRadiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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U. Fischer
dUniversity Hospital Bern (U.F.), Inselspital, University of Bern, Bern, Switzerland
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B.K. Menon
aFrom the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
bRadiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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M. Almekhlafi
aFrom the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
bRadiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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  • ORCID record for M. Almekhlafi
A.T. Wilson
aFrom the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
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M.M. Foss
aFrom the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
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G. Saposnik
eDivision of Neurology (G.S.), Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada.
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M. Goyal
aFrom the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
bRadiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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M.D. Hill
aFrom the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
bRadiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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  • FIG 1.
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    FIG 1.

    Resources gap (ideal minus current intravenous alteplase rates) in different countries. In green countries, the resources gap was positive (>1%)—ie, physicians would want to treat more patients with intravenous alteplase in an ideal environment than they currently do under their current local resources. Pink countries are those with no resources gap—ie, the intravenous alteplase treatment decision under assumed ideal conditions matched the one under current local resources. In blue countries, the resources gap was negative—ie, physicians are currently treating more patients with intravenous alteplase than they would like to in an ideal environment.

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    FIG 2.

    Changes in decision-making from current local resources (left) to assumed ideal conditions (right). The width of the streams is proportional to the number of changes. tPA, intravenous alteplase; AP/AC, antiplatelet or anticoagulation therapy.

  • FIG 3.
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    FIG 3.

    Percentage of physicians who would drop intravenous alteplase (blue bars) and add intravenous alteplase (green bars) by specialty.

Tables

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    Table 1:

    Participants’ demographic baseline characteristics (n = 607)

    Demographics
    Specialty (No.) (%)
     Neurology326 (53.7)
     Interventional neuroradiology173 (28.5)
     Neurosurgery81 (13.3)
     Others27 (4.2)
    Hospital setting (No.) (%)
     Academic551 (90.8)
     Nonacademic56 (9.2)
    Age (median) (IQR) (yr)44 (39–50)
    Experience (median) (IQR) (yr)13 (8–20)
    Annual personal stroke volume (median) (IQR)100 (50–250)
    Annual personal EVT volume (median) (IQR)30 (15–50)
    Annual center tPA volume (median) (IQR)100 (50–170)
    Annual center EVT volume median (IQR)65 (30–120)
    • Note:—IQR indicates interquartile range; yr, years.

    • View popup
    Table 2:

    Current and ideal decision rates in favor of intravenous alteplase overall and by evidence levela

    EVT Level 1AEVT Level 2BEVT NGTotal
    tPA level 1A
     Current85.1 (1408)85.0 (703)–85.0 (2111)
     Ideal82.1 (1359)83.0 (687)–82.4 (2046)
    tPA level 2B
     Current77.5 (214)84.3 (697)52.0 (143)76.5 (1054)
     Ideal75.0 (207)80.5 (666)52.0 (143)73.7 (1016)
    Total
     Current84.0 (1622)84.6 (1400)52.0 (143)82.0 (3165)
     Ideal81.1 (1566)81.8 (1353)52.0 (143)79.3 (3062)
    • Note:—NG indicates no guideline coverage; –, no responses in this category.

    • ↵a Case scenarios with guideline-based alteplase recommendation only. Data are (%) (No.).

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American Journal of Neuroradiology: 41 (2)
American Journal of Neuroradiology
Vol. 41, Issue 2
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How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT
J.M. Ospel, N. Kashani, U. Fischer, B.K. Menon, M. Almekhlafi, A.T. Wilson, M.M. Foss, G. Saposnik, M. Goyal, M.D. Hill
American Journal of Neuroradiology Feb 2020, 41 (2) 262-267; DOI: 10.3174/ajnr.A6396
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J.M. Ospel, N. Kashani, U. Fischer, B.K. Menon, M. Almekhlafi, A.T. Wilson, M.M. Foss, G. Saposnik, M. Goyal, M.D. Hill
How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT
American Journal of Neuroradiology Feb 2020, 41 (2) 262-267; DOI: 10.3174/ajnr.A6396

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