Background: Whether to pursue endovascular therapy (EVT) for LVO acute ischemic stroke patients presenting with large cores is a decisional challenge to patients, families, and clinicians. Though EVT will improve outcomes, rates of severe disability or death will be high and potentially unacceptably to some decision-makers. Further, decisions must be made hyper-urgently. Rapidly legible visual decision aids are needed that enable swift review of potential outcomes tailored to different baseline core volumes. Methods: From patient-level, pooled randomized trial data, 100 person-icon arrays (Kuiper–Marshall personographs) were generated comparing three month functional outcomes with and without EVT for three large core volume ranges: 70–99 cc, 100–149 cc, and ≥150 cc. Also, for educational perspective, arrays were generated for all large core patients combined (70-150+ cc) versus all small-moderate core patients (0-69 cc, HERMES pooled trial dataset). Results: The decision-aide figural displays for patients with large core volumes of 70–99 cc, 100–149 cc, and ≥150 cc are shown in Image 1. The figures accessibly delineate both prognostic (likely disease outcome independent of treatment) and predictive (benefit of therapy) influences of large core volume subcategories. Person-icons shift to increasingly unfavorable rates in both treatment groups as core volume increases but show better outcomes with EVT than medical management within each category. The decision aid figural displays for all large core patients combined (70-150+ cc) and all small-moderate core patients (0-69cc) are shown in Image 2. These displays also well capture core volume prognostic (likely disease outcome independent of treatment) and predictive (benefit of therapy) effects. Unfavorable outcomes are much more common in both treatment groups in the large core vs small-moderate core patients but better outcomes with EVT within each core category are also clearly delineated. Conclusions: Visual decision aids are now available to rapidly educate healthcare providers, patients, and families regarding expected outcomes with and without EVT among patients presenting with large ischemic cores. By representing shifts in survival and independence in rapidly comprehensible comparative displays, these displays can expedite bedside counseling, strengthen shared decision-making, and align emergency stroke interventions with patient and family goals.
Cuesta et al. (Thu,) studied this question.