Visual aids that use arrays of human outlines or “personographs” to paint a picture of thrombectomy’s relative risks and benefits in treating acute ischemic stroke recently were developed by a team of researchers. The aids are now available as a tool to help rapidly educate healthcare providers, patients, and their families, according to a paper published online December 8, 2017, ahead of print in Stroke.
“The authors are a group of well-known experts in the field of acute stroke management,” Maxim Mokin, MD, PhD (University of South Florida, Tampa, FL), told Neurovascular Exchange in an email. “In the past,” he added, “such graphs have been used by stroke neurologists to make it easier to explain to patients and families risks versus benefits of IV tPA.”
Those sorts of educational tools are sorely needed, said Mokin. “Physicians often report difficulty explaining to families whether IV tPA or thrombectomy should be considered, especially if done by those who are not necessarily the experts in this field.”
Lead author Ivie Tokunboh, BA (University of California Los Angeles, Los Angeles, CA), pointed out in an email to NVX that endovascular thrombectomy is a highly time-dependent therapy. Thus, tools are needed that can help hasten decision-making. “Better outcomes will occur if patients, families, and physicians can make well-informed, go/no-go treatment decisions very quickly,” she said. “Current approaches vary widely from hospital to hospital and doctor to doctor, and are often informal and verbally based. This causes great variation in practice and slow transmission of information.”
Two Tools Based on IV tPA Eligibility
Tokunboh and colleagues used patient-level, pooled randomized trial data to develop Kuiper-Marshall personographs, which consisted of 100 person-icon arrays that depict the beneficial and adverse effects of endovascular thrombectomy for patients with acute cerebral ischemia and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification.
They developed two personographs, one for IV tPA-eligible and another for IV tPA ineligible patients. For tPA eligible patients, they calculated that the addition of thrombectomy to IV tPA had a number needed to treat (NNT) of 2.9 and a number needed to harm (NNH) of 68.9. Thus, the personograph depicts that the addition of thrombectomy results in 34 patients having a better disability outcome, including 14 more with normal or near normal outcome, defined as an mRS 0-1.
Among patients ineligible for IV tPA, the addition of thrombectomy was calculated to have an NNT of 2. and NNH of 100.This translates to 44 of 100 patients having a better disability outcome, including 16 more with normal or nearly normal outcomes, with the addition of thrombectomy. The personographs also depict the risk of early side effects.
“The study shows that there is substantial long-term benefit of endovascular therapy, reducing disability in 34-44% of treated patients, and minimal long-term harm, with only increasing disability in 1% of patients,” said Tokunboh.
According to Mokin, the graphics “can help both families and physicians less familiar with stroke revascularization therapies to understand the risk/benefit of modern therapies.”
Tokunboh added that “these displays may also be useful in public education and in education of policy makers to facilitate understanding of the magnitude of benefit and harm of thrombectomy for stroke.”
Yet one obvious limitation, Mokin added, is that as new data on endovascular therapy arrives on the scene, the graphics will have to be updated.
He pointed out, for instance, that the current personographs do not include data from the most recent DAWN or DEFUSE3 studies of endovascular therapy. In their current incarnation, though, the personographs “would still provide an overall idea of greater benefit (near or complete independence) versus low risk of harm (bleed/death),” Mokin said.
Another constraint, Tokunboh added, is that these visual aids were “generated from pooled randomized clinical trial data. The benefits and harms displayed may not be fully generalizable to patients who would not meet have trial entry criteria or patients being treated at less experienced endovascular centers.”
Tokunboh I, Vales Montero M, Zopelaro Almeida MF, et al. Visual Aids for patient, family, and physician decision making about endovascular thrombectomy for acute ischemic stroke. Stroke. 2017;Epub ahead of print.
Mokin and Tokunboh report no relevant conflicts of interest.