Neurointerventional Practice Change Following Distal Medium Vessel Occlusion Randomized Controlled Trials: A Survey

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Abstract
BACKGROUND: Recent randomized trials showed no benefit of mechanical thrombectomy (MT) for ischemic stroke due to distal medium vessel occlusion (DMVO). We sought to understand the use of MT for DMVO stroke treatment before and after the publication of these trials. METHODS: We conducted an email survey of 47 comprehensive stroke centers across the United States, which are participating in a National Institutes of Health–funded randomized controlled trial (RCT; Unique identifier: NCT05948566). The questionnaire was developed and modified with expert feedback. Site principal investigators were asked to discuss the DMVO RCT results with their local clinical teams and to subsequently respond to survey questions in a manner that reflected team-based decision-making regarding MT for DMVO before and after the publication of the RCTs, considering the location of the vessel occlusion (nondominant M2 versus M3/M4/A1/A2). If the site principal investigator was responsible for >1 site with the same stroke team, only 1 survey response was tallied. RESULTS: Of the 43 site principal investigators surveyed representing 47 unique sites, 40 (93%) representing 44 unique sites completed the survey. Before the DMVO RCTs, 95% of respondents were treating nondominant M2 occlusions with MT. Only 15% will continue to be treated with MT, while 57.5% said that treatment was dependent on at least ≥1 variable following presentation of the DMVO RCTs. For all other anterior circulation DMVOs, 50% were treating DMVOs with MT before RCT results’ presentation. Only 7.5% will continue to treat with MT, while 32.5% said that treatment was dependent on at least 1 other variable following presentation of the DMVO RCTs. The most common variable named by survey respondents as important to treatment decision was symptom severity. CONCLUSIONS: In this survey of comprehensive stroke centers, the DMVO RCT results created a significant practice change in how stroke teams approach anterior circulation DMVO stroke with MT.

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