BACKGROUND AND PURPOSE: Patients with acute ischemic stroke due to medium vessel occlusion (MeVO) make up a substantial part of the acute stroke population, though guidelines currently do not recommend endovascular treatment (EVT) for them. A growing body of evidence suggests that EVT is effective in MeVOs, including observational data but no randomized studies. We aimed to explore willingness of physicians worldwide to randomize MeVO stroke patients into a hypothetical trial comparing EVT in addition to best medical management versus best medical management only. METHODS: In an international cross-sectional survey among stroke physicians, participants were presented with 4 cases of primary MeVOs (6 scenarios each). Each subsequent scenario changed one key patient characteristic compared to the previous one, and asked survey participants whether they would be willing to randomize the described patient. Overall, physician- and scenario-specific decision rates were calculated. Multivariable logistic regression with clustering by respondent was performed to assess factors influencing the decision to randomize. RESULTS: Overall, 366 participants (56 women) from 44 countries provided 8784 answers to 24 MeVO case scenarios. The majority of responses (78.3%) were in favor of randomizing. Most physicians were willing to accept patients transferred for EVT from a primary center (82%) and the majority of these (76.5%) were willing to randomize these patients after transfer. Patient age > 65 years, A3 occlusion, small core volume, and patient intravenous alteplase eligibility significantly influenced the physician's decision to randomize (adjOR 1.24, 95%CI 1.13-1.36; adjOR 1.17, 95%CI 1.01-1.34; adjOR 0.98, 95%CI 0.97-0.99 and adjOR 1.38, 95%CI 1.21-1.57, respectively). CONCLUSIONS: Most physicians in this survey were willing to randomize acute MeVO stroke patients irrespective of patient characteristics into a trial comparing EVT in addition to best medical management versus best medical management only, suggesting there is clinical equipoise.

Department of Clinical Neurosciences Foothills Medical Center University of Calgary Foothills Medical Centre 1403 29th St NW Calgary AB T2N 2T9 Canada

Department of Clinical Neurosciences Foothills Medical Center University of Calgary Foothills Medical Centre 1403 29th St NW Calgary AB T2N 2T9 Canada; Department of Diagnostic Imaging Foothills Medical Center University of Calgary Calgary AB Canada

Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Diagnostic Imaging 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 and Interventional Neuroradiology University Medical Center Hamburg Eppendorf Hamburg Germany

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

Department of Neurosurgery Kobe City Medical Centre General Hospital Kobe Japan

Department of Radiology and Nuclear Medicine University of Amsterdam Amsterdam the Netherlands

Division of Neuroradiology Clinic of Radiology and Nuclear Medicine University Hospital Basel University of Basel Basel Switzerland

Neurological Sciences Rush University Medical Center Chicago IL USA

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