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.

• Klíčová slova
• MeVO, acute ischemic stroke, aspiration thrombectomy, endovascular thrombectomy, endovascular treatment (EVT), medium vessel occlusions, neurointervention, stroke,
• Publikační typ
• časopisecké články MeSH

PURPOSE: Medium vessel occlusions (MeVOs) can be challenging to detect on imaging. Multiphase computed tomography angiography (mCTA) has been shown to improve large vessel occlusion (LVO) detection and endovascular treatment (EVT) selection. The aims of this study were to determine if mCTA-derived tissue maps can (1) accurately detect MeVOs and (2) predict infarction on 24-h follow-up imaging with comparable accuracy to CT perfusion (CTP). METHODS: Two readers assessed mCTA tissue maps of 116 ischemic stroke patients (58 MeVOs, 58 non-MeVOs) and determined by consensus: (1) MeVO (yes/no) and (2) occlusion site, blinded to clinical or imaging data. Sensitivity, specificity, and area under the curve (AUC) for MeVO detection were estimated in comparison to reference standards of (1) expert readings of baseline mCTA and (2) CTP maps. Volumetric and spatial agreement between mCTA- and CTP-predicted infarcts was assessed using concordance/intraclass correlation and Dice coefficients. Interrater agreement for MeVO detection on mCTA tissue maps was estimated with Cohen's kappa. RESULTS: MeVO detection from mCTA-derived tissue maps had a sensitivity of 91% (95% CI: 80-97), specificity of 82% (95% CI: 70-90), and AUC of 0.87 (95% CI: 0.80-0.93) compared to expert reads of baseline mCTA. Interrater reliability was good (0.72, 95% CI: 0.60-0.85). Compared to CTP maps, sensitivity was 87% (95% CI: 75-95), specificity was 78% (95%CI: 65-88), and AUC was 0.83 (95% CI: 0.76-0.90). The mean difference between mCTA- and CTP-predicted final infarct volume was 4.8 mL (limits of agreement: - 58.5 to 68.1) with a Dice coefficient of 33.5%. CONCLUSION: mCTA tissue maps can be used to reliably detect MeVO stroke and predict tissue fate.

• Klíčová slova
• Acute ischemic stroke, Endovascular treatment, Medium vessel occlusions, Multiphase computed tomography, Treatment selection,
• MeSH
• cévní mozková příhoda * diagnostické zobrazování   terapie   MeSH
• CT angiografie metody   MeSH
• ischemie mozku * terapie   MeSH
• lidé MeSH
• mozková angiografie metody   MeSH
• počítačová rentgenová tomografie metody   MeSH
• reprodukovatelnost výsledků MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

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.

• Klíčová slova
• Acute ischemic stroke, Distal occlusion, Endovascular therapy, Medium vessel occlusion,
• MeSH
• cévní mozková příhoda * diagnostické zobrazování   chirurgie   MeSH
• endovaskulární výkony * MeSH
• ischemická cévní mozková příhoda * MeSH
• ischemie mozku * terapie   MeSH
• lidé MeSH
• průřezové studie MeSH
• senioři MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

BACKGROUND: We aimed to explore the preference of stroke physicians to treat patients with primary medium vessel occlusion (MeVO) stroke with immediate endovascular treatment (EVT) in an international cross-sectional survey, as there is no clear guideline recommendation for EVT in these patients. METHODS: In the survey MeVO-Finding Rationales and Objectifying New Targets for IntervEntional Revascularization in Stroke (MeVO-FRONTIERS), participants were shown four cases of primary MeVOs (six scenarios per case) and asked whether they would treat those patients with EVT. Multivariable logistic regression with clustering by respondent was performed to assess factors influencing the decision to treat. Dominance analysis was performed to assess the influence of factors within the scenarios on decision making. RESULTS: Overall, 366 participants (56 women; 15%) from 44 countries provided 8784 answers to 24 scenarios. Most physicians (59.2%) would treat patients immediately with EVT. Younger patient age (incidence rate ratio (IRR) 1.24, 99% CI 1.19 to 1.30), higher National Institutes of Health Stroke Scale (NIHSS) score (IRR 1.69, 99% CI 1.57 to 1.82), and small core volume (IRR 1.35, 99% CI 1.24 to 1.46) were positively associated with the decision to treat with EVT. Interventionalists (IRR 1.26, 99% CI 1.01 to 1.56) were more likely to treat patients with MeVO immediately with EVT. In the dominance analysis, factors influencing the decision in favor of EVT were (in order of importance): baseline NIHSS, core volume, alteplase use, patients' age, and occlusion site. CONCLUSIONS: Most physicians in this survey were interventionalists and would treat patients with MeVO stroke immediately with EVT. This finding supports the need for robust clinical evidence.

• Klíčová slova
• intervention, stroke, thrombectomy,
• MeSH
• cévní mozková příhoda * chirurgie   MeSH
• endovaskulární výkony * MeSH
• ischemie mozku * terapie   MeSH
• lidé MeSH
• průřezové studie MeSH
• rozhodování MeSH
• trombektomie MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

BACKGROUND AND PURPOSE: The prognosis of medium vessel occlusions (MeVOs), that is, M2/3 middle cerebral artery, A2/3 anterior cerebral artery, and P2/3 posterior cerebral artery occlusions, is generally better compared with large vessel occlusions, since brain ischemia is less extensive. However, in some MeVO patients, infarcts are seen outside the territory of the occluded vessel (MeVO with discrepant infarcts). This study aims to determine the prevalence and clinical impact of discrepant infarct patterns in acute ischemic stroke due to MeVO. METHODS: We pooled data of MeVO patients from INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRove-IT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy)-2 prospective cohort studies of patients with acute ischemic stroke. The combination of occlusion location on baseline computed tomography angiography and infarct location on follow-up computed tomography/magnetic resonance imaging was used to identify MeVOs with discrepant infarct patterns. Two definitions for discrepant infarcts were applied; one was more restrictive and purely based on infarct patterns of the basal ganglia, whereas the second one took cortical infarct patterns into account. Clinical outcomes of patients with versus without discrepant infarcts were summarized using descriptive statistics. Logistic regression was performed to obtain adjusted effect size estimates for the association of discrepant infarcts and good outcome, defined as a modified Rankin Scale score of 0 to 2, and excellent outcome (modified Rankin Scale score 0-1). RESULTS: Two hundred sixty-two patients with MeVO were included in the analysis. The prevalence of discrepant infarcts was 39.7% (definition 1) and 21.0% (definition 2). Patients with discrepant infarcts were less likely to achieve good outcome (definition 1: adjusted odds ratio, 0.48 [95% CI, 0.25-0.91]; definition 2: adjusted odds ratio, 0.47 [95% CI, 0.22-0.99]). When definition 1 was applied, patients with discrepant infarcts were also less likely to achieve excellent outcome (definition 1: adjusted odds ratio, 0.55 [95% CI, 0.31-0.99]; definition 2: adjusted odds ratio, 0.62 [95% CI, 0.31-1.25]). CONCLUSIONS: MeVO patients with discrepant infarcts are common, and they are associated with more severe deficits and poor outcomes.

• Klíčová slova
• brain ischemia, follow-up studies, humans, prevalence, prognosis,
• MeSH
• arteriální okluzní nemoci epidemiologie   terapie   MeSH
• cerebrální infarkt epidemiologie   terapie   MeSH
• cévní mozková příhoda epidemiologie   terapie   MeSH
• CT angiografie MeSH
• fibrinolytika terapeutické užití   MeSH
• ischemie mozku epidemiologie   terapie   MeSH
• kohortové studie MeSH
• lidé středního věku MeSH
• lidé MeSH
• magnetická rezonanční angiografie MeSH
• prevalence MeSH
• prognóza MeSH
• prospektivní studie MeSH
• senioři MeSH
• tkáňový aktivátor plazminogenu terapeutické užití   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• Názvy látek
• fibrinolytika MeSH
• tkáňový aktivátor plazminogenu MeSH