Background: Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging. Devices and tools are rapidly evolving. We aimed to gain insight into preferences and global perspectives on the usage of endovascular tools in treating MeVOs. Methods: We conducted an international survey with seven scenarios of patients presenting A3, M2/3, M3, M3/4, or P2/3 occlusions. Respondents were asked for their preferred first-line endovascular approach, and whether they felt that the appropriate endovascular tools were available to them. Answers were analyzed by occlusion location and geographical region of practice, using multinomial/binary logistic regression. Results: A total of 263 neurointerventionists provided 1836 responses. The first-line preferences of physicians were evenly distributed among stent-retrievers, combined approaches, and aspiration only (33.2, 29.8, and 26.8%, respectively). A3 occlusions were more often treated with stent-retrievers (RR 1.21, 95% CI: 1.07-1.36), while intra-arterial thrombolysis was more often preferred in M3 (RR 2.47, 95% CI: 1.53-3.98) and M3/4 occlusions (RR 7.71, 95% CI: 4.16-14.28) compared to M2/3 occlusions. Respondents who thought appropriate tools are currently not available more often chose stent retrievers alone (RR 2.07; 95% CI: 1.01-4.24) or intra-arterial thrombolysis (RR 3.35, 95% CI: 1.26-8.42). Physicians who stated that they do not have access to optimal tools opted more often not to treat at all (RR 3.41, 95% CI: 1.11-10.49). Stent-retrievers alone were chosen more often and contact aspiration alone less often as a first-line approach in Europe (RR 2.12, 95% CI: 1.38-3.24; and RR 0.49, 95% CI 0.34-0.70, respectively) compared to the United States and Canada. Conclusions: In EVT for MeVO strokes, neurointerventionalists choose a targeted vessel specific first-line approach depending on the occlusion location, region of practice, and availability of the appropriate tools.

Department of Clinical Neurosciences Foothills Medical Center University of Calgary Calgary AB Canada

Department of Diagnostic Imaging Foothills Medical Center University of Calgary Calgary AB Canada

Department of Diagnostic Imaging University of Alberta Hospital University of Alberta Edmonton AB Canada

Department of Medical Imaging St Anne's University Hospital Brno and Faculty of Medicine Masaryk University Brno Czech Republic

Department of Neurological Sciences Rush University Medical Center Chicago IL United States

Department of Neuroradiology Toronto Western Hospital Toronto ON Canada

Department of Neuroradiology University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Neuroradiology Vancouver General Hospital Toronto ON Canada

Department of Neurosurgery Kobe City Medical Center General Hospital Kobe Japan

Department of Radiology and Nuclear Medicine Amsterdam University Medical Centers University of Amsterdam Amsterdam Netherlands

Department of Radiology University Hospital of Basel Basel Switzerland

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$a Kashani, Nima $u Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada

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$a Background: Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging. Devices and tools are rapidly evolving. We aimed to gain insight into preferences and global perspectives on the usage of endovascular tools in treating MeVOs. Methods: We conducted an international survey with seven scenarios of patients presenting A3, M2/3, M3, M3/4, or P2/3 occlusions. Respondents were asked for their preferred first-line endovascular approach, and whether they felt that the appropriate endovascular tools were available to them. Answers were analyzed by occlusion location and geographical region of practice, using multinomial/binary logistic regression. Results: A total of 263 neurointerventionists provided 1836 responses. The first-line preferences of physicians were evenly distributed among stent-retrievers, combined approaches, and aspiration only (33.2, 29.8, and 26.8%, respectively). A3 occlusions were more often treated with stent-retrievers (RR 1.21, 95% CI: 1.07-1.36), while intra-arterial thrombolysis was more often preferred in M3 (RR 2.47, 95% CI: 1.53-3.98) and M3/4 occlusions (RR 7.71, 95% CI: 4.16-14.28) compared to M2/3 occlusions. Respondents who thought appropriate tools are currently not available more often chose stent retrievers alone (RR 2.07; 95% CI: 1.01-4.24) or intra-arterial thrombolysis (RR 3.35, 95% CI: 1.26-8.42). Physicians who stated that they do not have access to optimal tools opted more often not to treat at all (RR 3.41, 95% CI: 1.11-10.49). Stent-retrievers alone were chosen more often and contact aspiration alone less often as a first-line approach in Europe (RR 2.12, 95% CI: 1.38-3.24; and RR 0.49, 95% CI 0.34-0.70, respectively) compared to the United States and Canada. Conclusions: In EVT for MeVO strokes, neurointerventionalists choose a targeted vessel specific first-line approach depending on the occlusion location, region of practice, and availability of the appropriate tools.

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$a Cimflova, Petra $u Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada $u Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic

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$a Ospel, Johanna M $u Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada $u Department of Radiology, University Hospital of Basel, Basel, Switzerland

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$a Singh, Nishita $u Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada

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$a Almekhlafi, Mohammed A $u Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada

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$a Rempel, Jeremy $u Department of Diagnostic Imaging, University of Alberta Hospital, University of Alberta, Edmonton, AB, Canada

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$a Fiehler, Jens $u Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

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$a Chen, Michael $u Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States

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$a Sakai, Nobuyuki $u Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan

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$a Agid, Ronit $u Department of Neuroradiology, Toronto Western Hospital, Toronto, ON, Canada

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$a Heran, Manraj $u Department of Neuroradiology, Vancouver General Hospital, Toronto, ON, Canada

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$a Kappelhof, Manon $u Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada $u Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands

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$a Goyal, Mayank $u Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada $u Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada

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