BACKGROUND: The proper imaging modality for use in the selection of patients for endovascular thrombectomy (EVT) presenting in the late window remains controversial, despite current guidelines advocating the use of advanced imaging in this population. We sought to understand if clinicians with different specialty training differ in their approach to patient selection for EVT in the late time window. METHODS: We conducted an international survey of stroke and neurointerventional clinicians between January and May 2022 with questions focusing on imaging and treatment decisions of large vessel occlusion (LVO) patients presenting in the late window. Interventional neurologists, interventional neuroradiologists, and endovascular neurosurgeons were defined as interventionists whereas all other specialties were defined as non-interventionists. The non-interventionist group was defined by all other specialties of the respondents: stroke neurologist, neuroradiologist, emergency medicine physician, trainee (fellows and residents) and others. RESULTS: Of 3000 invited to participate, 1506 (1027 non-interventionists, 478 interventionists, 1 declined to specify) physicians completed the study. Interventionist respondents were more likely to proceed directly to EVT (39.5% vs. 19.5%; p < 0.0001) compared to non-interventionist respondents in patients with favorable ASPECTS (Alberta Stroke Program Early CT Score). Despite no difference in access to advanced imaging, interventionists were more likely to prefer CT/CTA alone (34.8% vs. 21.0%) and less likely to prefer CT/CTA/CTP (39.1% vs. 52.4%) for patient selection (p < 0.0001). When faced with uncertainty, non-interventionists were more likely to follow clinical guidelines (45.1% vs. 30.2%) while interventionists were more likely to follow their assessment of evidence (38.7% vs. 27.0%) (p < 0.0001). CONCLUSION: Interventionists were less likely to use advanced imaging techniques in selecting LVO patients presenting in the late window and more likely to base their decisions on their assessment of evidence rather than published guidelines. These results reflect gaps between interventionists and non-interventionists reliance on clinical guidelines, the limits of available evidence, and clinician belief in the utility of advanced imaging.

Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy

Boston University Chobanian and Avedisian School of Medicine Boston Medical Center 85 East Concord Street 02118 Boston MA USA

Center of Neurology Vilnius University Vilnius Lithuania

Cooper Neurological Institute Camden USA

Department of Neurology University Hospital Carl Gustav Carus an der Technischen Universität Dresden Dresden Germany

Department of Neurology Xinqiao Hospital and The 2nd Affiliated Hospital Army Medical University Chongqing China

Diagnostic and Interventional Neuroradiology University Hospital Bern Bern Switzerland

Diagnostic and Therapeutic Neuroradiology St Michael's Hospital University of Toronto Toronto Canada

Dresden Neurovascular Center University Hospital Carl Gustav Carus an der Technischen Universität Dresden Dresden Germany

Interventional Neuroradiology Beijing Tiantan Hospital Beijing China

Interventional Neuroradiology Centre Hospitalier de l'Universite de Montreal Montreal Canada

Interventional Neuroradiology Nottingham University Hospitals Nottingham UK

Interventionelle Neuroradiologie Universitätsklinikum Hamburg Eppendorf Hamburg Germany

Klinik für Neurologie Universitätsklinikum Hamburg Eppendorf Hamburg Germany

Morriston Hospital Swansea Hospital Swansea Wales UK

Neuroendovascular Massachusetts General Hospital Boston USA

Neurointervention Texas Stroke Institute Dallas Fort Worth USA

Neurointerventional London Health Sciences Centre London Canada

Neurology Affiliated Hangzhou 1st People's Hospital Hangzhou China

Neurology Ajou University Hospital Suwon Korea

Neurology Akershus University Hospital Akershus Norway

Neurology Attikon University Hospital Athens Greece

Neurology Basel University Hospital Basel Switzerland

Neurology Beijing Tiantan Hospital Beijing China

Neurology Boston Medical Center Boston USA

Neurology Bufalini Hospital Cesena Italy

Neurology Emory University Atlanta USA

Neurology Erasmus MC University Medical Center Rotterdam The Netherlands

Neurology Foshan Sanshui District People's Hospital Foshan China

Neurology General Hospital of Northern Theatre Command Shenyang China

Neurology Heidelberg University Hospital Heidelberg Germany

Neurology Helsinki University Hospital and University of Helsinki Helsinki Finland

Neurology Hopital Foch Suresnes France

Neurology Hospital de Egas Moniz Lisbon Portugal

Neurology Klinikum Ludwigshafen Ludwigshafen Germany

Neurology Leuven University Hospital Leuven Belgium

Neurology Osaka National Hospital Osaka Japan

Neurology Oslo University Hospital Oslo Norway

Neurology Rhode Island Hospital Providence USA

Neurology St Anne's University Hospital Brno Czech Republic

Neurology St Antonius Hospital Nieuwegein The Netherlands

Neurology St Elizabeth's Medical Center Boston USA

Neurology SUNY Upstate Syracuse USA

Neurology The 903rd Hospital of The Chinese People's Liberation Army Hangzhou China

Neurology University of British Columbia Vancouver Canada

Neurology University of Calgary Calgary Canada

Neurology University of Pittsburgh Medical Center Pittsburgh USA

Neurology Vietnam National University of Medicine and Pharmacy Hanoi Vietnam

Neurology Xuanwu Hospital Beijing China

Neuroradiology University Hospital 'San Giovanni di Dio e Ruggi d'Aragona' Salerno Italy

Neuroscience Mercy Health St Vincent Hospital Toledo OH USA

Neurosurgery Boston Medical Center Boston USA

Neurosurgery Changhai Hospital Shanghai China

Neurosurgery St Elizabeth's Medical Center Boston USA

Neurosurgery Xuanwu Hospital Beijing China

Radiology Boston Medical Center Boston USA

Radiology University of Calgary Calgary Canada

Royal Melbourne Hospital Melbourne Australia

Royal North Shore Hospital Sydney Australia

South Western Sydney Clinical School Liverpool Hospital Liverpool Australia

Stroke Center Bach Mai Hospital Hanoi Viet Nam

Stroke Center Neurology Lausanne University Hospital Lausanne Switzerland

Stroke Center The 1st Affiliated Hospital of USTC Hefei China

Stroke Department of Acute Medicine Nottingham University Hospitals NHS Trust Nottingham UK

Stroke Medicine Imperial College Healthcare London UK

Stroke Outcomes and Decision Neuroscience Research Unit University of Toronto Toronto Canada

Universidade Federal de São Paulo and Hospital Israelita Albert Einstein São Paulo Brazil

University of Melbourne Melbourne Australia

Urgent Neurology University Clinic of Neurology Skopje Macedonia

Zeenat Qureshi Stroke Institute University of Missouri Columbia USA

See more in PubMed

Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11–21. doi: 10.1056/NEJMoa1706442. PubMed DOI

Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart RA, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378:708–718. doi: 10.1056/NEJMoa1713973. PubMed DOI PMC

Yoshimura S, Sakai N, Yamagami H, Uchida K, Beppu M, Toyoda K, Matsumaru Y, Matsumoto Y, Kimura K, Takeuchi M, et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med. 2022;386:1303–1313. doi: 10.1056/NEJMoa2118191. PubMed DOI

Huo X, Ma G, Tong X, Zhang X, Pan Y, Nguyen TN, Yuan G, Han H, Chen W, Wei M, et al. Trial of endovascular therapy for acute ischemic stroke with large infarct. N Engl J Med. 2023 doi: 10.1056/NEJMoa2213379. PubMed DOI

Sarraj A, Hassan AE, Abraham MG, Ortega-Gutierrez S, Kasner SE, Hussain MS, Chen M, Blackburn S, Sitton CW, Churilov L, et al. Trial of endovascular thrombectomy for large ischemic strokes. n Engl J Med. 2023 doi: 10.1056/NEJMoa2214403. PubMed DOI

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, et al. Guidelines for the early management of patients with acute Ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke. 2019;50:e344–e418. doi: 10.1161/STR.0000000000000211. PubMed DOI

Turc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M, Schellinger PD, Toni D, de Vries J, White P, et al. European stroke organisation (ESO)—European society for minimally invasive neurological therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischaemic strokeendorsed by stroke alliance for europe (SAFE) Eur Stroke J. 2019;4:6–12. doi: 10.1177/2396987319832140. PubMed DOI PMC

Eskey CJ, Meyers PM, Nguyen TN, Ansari SA, Jayaraman M, McDougall CG, DeMarco JK, Gray WA, Hess DC, Higashida RT, et al. Indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American heart association. Circulation. 2018;137:e661–e689. doi: 10.1161/CIR.0000000000000567. PubMed DOI

Nguyen TN, Castonguay AC, Siegler JE, Nagel S, Lansberg MG, de Havenon A, Sheth SA, Abdalkader M, Tsai J, Albers GW, et al. Mechanical thrombectomy in the late presentation of anterior circulation large vessel occlusion stroke: guideline recommendations from the society of vascular and Interventional neurology guidelines and practice standards (GAPS) committee. Stroke: Vasc Interv Neurol. 2023 doi: 10.1161/SVIN.122.000512. DOI

Roushdy T, Aref H, Kesraoui S, Temgoua M, Nono KP, Gebrewold MA, Peter W, Gopaul U, Belahsen MF, Ben-Adji D, et al. Stroke services in Africa: what is there and what is needed. Int J Stroke. 2022;17(9):972–982. doi: 10.1177/17474930211066416. PubMed DOI

Nguyen TN, Raymond J, Nogueira RG, Fischer U, Siegler JE. The problem of restrictive thrombectomy trial eligibility criteria. Stroke. 2022;53:2988–2990. doi: 10.1161/STROKEAHA.122.040006. PubMed DOI

Abdalkader M, Siegler JE, Lee JS, Yaghi S, Qiu Z, Huo X, Miao Z, Campbell BCV, Nguyen TN. Neuroimaging of acute ischemic stroke: multimodal imaging approach for acute endovascular therapy. J Stroke. 2023;25:55–71. doi: 10.5853/jos.2022.03286. PubMed DOI PMC

Nguyen TN, Abdalkader M, Nagel S, Qureshi MM, Ribo M, Caparros F, Haussen DC, Mohammaden MH, Sheth SA, Ortega-Gutierrez S, et al. Noncontrast computed tomography vs computed tomography perfusion or magnetic resonance imaging selection in late presentation of stroke with large-vessel occlusion. JAMA Neurol. 2022;79:22–31. doi: 10.1001/jamaneurol.2021.4082. PubMed DOI PMC

Seker F, Qureshi MM, Möhlenbruch MA, Nogueira RG, Abdalkader M, Ribo M, Caparros F, Haussen DC, Mohammaden MH, Sheth SA, et al. Reperfusion without functional independence in late presentation of stroke with large vessel occlusion. Stroke. 2022;53:3594–3604. doi: 10.1161/STROKEAHA.122.039476. PubMed DOI

Sheth KN, Terry JB, Nogueira RG, Horev A, Nguyen TN, Fong AK, Gandhi D, Prabhakharan S, et al. Advanced modality imaging evaluation in acute ischemic stroke may lead to delayed endovascular reperfusion therapy without improvement in clinical outcomes. J NeuroIntervent Surg. 2013;5:62–65. doi: 10.1136/neurintsurg-2012-010512. PubMed DOI PMC

Sun Chung-Huan J, Ribo M, Goyal M, Yoo AJ, Jovin T, Cronin CA, Zaidat O, Nogueira R, Nguyen TN, Hussain S, et al. Door-to-puncture: a&nbsp;practical metric for capturing and enhancing system processes associated with endovascular stroke care, preliminary results from the rapid reperfusion registry. J Am Heart Assoc. 2014;3:e000859. doi: 10.1161/JAHA.114.000859. PubMed DOI PMC

Siegler JE, Ortega-Gutierrez S, Hester T, Haussen DC, Nogueira RG, Liebeskind DS, Zaidat OO, Vora N, Desai S, Jadhav AP, et al. Interaction of ethnicity and arrival method on thrombectomy delay: the society of vascular and interventional neurology collaboration. Stroke Vasc Interv Neurol. 2022;2:e000217.

Raymaekers V, Demeestere J, Bellante F, De Blauwe S, De Raedt S, Dusart A, Jodaitis L, Lemmens R, Loos C, Noémie L, et al. The impact of COVID-19 on acute stroke care in Belgium. Acta Neurol Belg. 2021;121:1251–1258. doi: 10.1007/s13760-021-01726-x. PubMed DOI PMC

Siegler JE, Zha AM, Czap AL, Ortega-Gutierrez S, Farooqui M, Liebeskind DS, Desai SM, Hassan AE, Starosciak AK, Linfante I, et al. Influence of the COVID-19 pandemic on treatment times for acute Ischemic stroke: the society of vascular and Interventional neurology multicenter collaboration. Stroke. 2021;52:40–47. doi: 10.1161/STROKEAHA.120.032789. PubMed DOI PMC

Fischer U, Branca M, Bonati LH, Carrera E, Vargas MI, Platon A, Kulcsar Z, Wegener S, Luft A, Seiffge DJ, et al. Magnetic resonance imaging or computed tomography for suspected acute stroke: association of admission image modality with acute recanalization therapies, workflow metrics, and outcomes. Ann Neurol. 2022;92:184–194. doi: 10.1002/ana.26413. PubMed DOI PMC

Mohammaden MH, Doheim MF, Elfil M, Al-Bayati AR, Pinheiro A, Nguyen TN, Bhatt NR, Haussen DC, Nogueira RG. Direct to angiosuite versus conventional imaging in suspected large vessel occlusion: a systemic review and meta-analysis. Stroke. 2022;53:2478–2487. doi: 10.1161/STROKEAHA.121.038221. PubMed DOI

Nguyen TN, Abdalkader M, Jovin TG, Nogueira RG, Jadhav AP, Haussen DC, Hassan AE, Novakovic R, Sheth SA, Ortega-Gutierrez S, et al. Mechanical thrombectomy in the era of the COVID-19 pandemic: emergency preparedness for neuroscience teams: a guidance statement from the society of vascular and interventional neurology. Stroke. 2020;51:1896–1901. doi: 10.1161/STROKEAHA.120.030100. PubMed DOI PMC

Drumm B, Banerjee S, Qureshi MM, Schonewille WJ, Klein P, Huo X, Chen Y, Strbian D, Fischer U, Puetz V, et al. Current opinions on optimal management of basilar artery occlusion: after the BEST of BASICS survey. Stroke Vasc Interv Neurol. 2022;2:e000538.

Edwards C, Drumm B, Siegler JE, Schonewille WJ, Klein P, Huo X, Chen Y, Abdalkader M, Qureshi MM, Strbian D, et al. Basilar artery occlusion management: specialist perspectives from an international survey. J Neuroimaging. 2023 doi: 10.1111/jon.13084. PubMed DOI

Nguyen TN, Klein P, Berberich A, Nagel S, Abdalkader M, Herning A, Chen Y, Huo X, Miao Z, Sheth SA, et al. Late window imaging selection for endovascular therapy of large vessel occlusion stroke: an international survey. Stroke Vasc Interv Neurol. 2023 doi: 10.1161/SVIN.122.000595. DOI

Nagel S, Herweh C, Pfaff JAR, Schieber S, Schönenberger S, Möhlenbruch MA, Bendszus M, Ringleb PA. Simplified selection criteria for patients with longer or unknown time to treatment predict good outcome after mechanical thrombectomy. J Neurointerv Surg. 2019;11:559–562. doi: 10.1136/neurintsurg-2018-014347. PubMed DOI

Jovin TG, Nogueira RG, Lansberg MG, Demchuk AM, Martins SO, Mocco J, Ribo M, Jadhav AP, Ortega-Gutierrez S, Hill MD, et al. Thrombectomy for anterior circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis. Lancet. 2022;399:249–258. doi: 10.1016/S0140-6736(21)01341-6. PubMed DOI

Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, Cheripelli B, Cho T-H, Fazekas F, Fiehler J, et al. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018;379:611–622. doi: 10.1056/NEJMoa1804355. PubMed DOI

Masoud H, Havenon A, Castonguay AC, Asif KS, Nguyen TN, Mehta B, Abdalkader M, Ortega-Gutierrez S, Leslie-Mazwi TM, Mansour OY, et al. Brief practice update on intravenous thrombolysis before thrombectomy in patients with large vessel occlusion acute ischemic stroke. Stroke Vasc Interv Neurol. 2021;2022(2):e000276. doi: 10.1161/SVIN.121.000276. DOI

Fischer U, Kaesmacher J, Strbian D, Eker O, Cognard C, Plattner PS, Bütikofer L, Mordasini P, Deppeler S, Pereira VM, et al. Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trial. Lancet. 2022;400:104–115. doi: 10.1016/S0140-6736(22)00537-2. PubMed DOI

Huo X, Ma G, Zhang X, Pan Y, Tong X, Sun D, Liu L, Wang Y, Liebeskind DS, Wang Y, et al. Endovascular therapy in acute anterior circulation large vessel occlusive patients with a large infarct core (ANGEL-ASPECT): protocol of a multicentre randomised trial. Stroke Vasc Neurol. 2022 doi: 10.1136/svn-2022-001865. PubMed DOI PMC

Campbell BCV, Nguyen TN. Advances in stroke: treatments-interventional. Stroke. 2022;53:264–267. doi: 10.1161/STROKEAHA.121.037039. PubMed DOI

Sarraj A, Hassan AE, Abraham M, Ribo M, Blackburn S, Chen M, Hussain MS, Pereira VM, Ortega-Gutierrez S, Sitton C, et al. A randomized controlled trial to optimize patient’s selection for endovascular treatment in acute ischemic stroke (SELECT2): study protocol. Int J Stroke. 2022;17:689–693. doi: 10.1177/17474930211035032. PubMed DOI

Castonguay AC, de Havenon A, Leslie-Mazwi TM, Kenmuir C, Sheth SA, Asif KS, Nguyen TN, Janardhan V, Mansour OY, Novakovic R, et al. Society of vascular and Interventional neurology standards and parameters for guideline development and publication. Stroke Vasc Interv Neurol. 2021;1:e000112. doi: 10.1161/SVIN.121.000112. DOI

Mai DT, Dao XC, Luong NK, Nguyen TK, Nguyen HT, Nguyen TN. Current state of stroke care in Vietnam. Stroke Vasc Interv Neurol. 2022;2:e000331.

Olthuis SGH, Pirson FAV, Pinckaers FME, Hinsenveld WH, Nieboer D, Ceulemans A, Knapen RRM, Quirien Robbe MM, Berkhemer OA, van Walderveen MAA, et al. Endovascular treatment versus no endovascular treatment after 6–24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial. Lancet. 2023. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00575-5/fulltext PubMed

Campbell BCV, Hill MD, Nguyen TN, Broderick JP. Acute and interventional treatments. Stroke. 2023;54:591–594. doi: 10.1161/STROKEAHA.122.041254. PubMed DOI

Siegler JE, Qureshi MM, Nogueira RG, Tanaka K, Nagel S, Michel P, Vigilante N, Ribo M, Yamagami H, Yoshimura S, et al. Endovascular vs medical management for late anterior large vessel occlusion with prestroke disability: analysis of CLEAR and RESCUE-Japan. Neurology. 2022 doi: 10.1212/WNL.0000000000201543. PubMed DOI PMC