Modeling the Decay in Probability of Receiving Endovascular Thrombectomy on the Basis of Time From Stroke Onset

IF 2.1 Q3 CLINICAL NEUROLOGY Stroke (Hoboken, N.J.) Pub Date : 2023-07-24 DOI:10.1161/svin.123.000932
Daniel A. Paydarfar, J. Holodinsky, M. Mazya, M. Hill, B. Menon, M. Jayaraman, N. Kamal
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Abstract

American Heart Association guidelines specify infarct core volume as 1 determinant of eligibility for endovascular thrombectomy. Therefore, it is important to understand how time‐dependent infarct core growth translates to a patient's declining probability of thrombectomy eligibility. Modeling the probability that a patient with suspected large‐vessel occlusion would qualify for thrombectomy on the basis of their expected time from stroke onset to treatment can help inform the optimal prehospital emergency transport protocols, maximizing the likelihood of an excellent patient outcome. We extended a published physiological model of infarct core growth to derive a decay curve of thrombectomy eligibility (based on a given infarct core volume threshold) as a function of time from stroke onset. We then adapted an existing model of the time‐dependent probability of an excellent outcome to incorporate this decay curve. Using the adapted model, we determined the optimal prehospital emergency transport protocols in Alberta, Canada, and compared these with the protocols that assumed all patients were thrombectomy eligible. The probability of qualifying for thrombectomy decays exponentially as time elapses from stroke onset. We found that the area where mothership is the optimal transport protocol increased by 18.6% after incorporating our decay curve of thrombectomy eligibility into the underlying optimization model. The benefit of mothership versus drip‐and‐ship also increased in the areas where mothership was favored, and in areas where drip‐and‐ship was favored, the benefit of drip‐and‐ship weakened. We also performed a number of sensitivity analyses to observe how these results change on the basis of our assumptions for model parameters. This methodology provides a novel, physiology‐based approach to derive a thrombectomy eligibility curve. These models are necessary to better optimize prehospital transport decisions and consequently improve outcomes of patients with suspected large‐vessel occlusion.
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基于中风发作时间的血管内取栓概率衰减建模
美国心脏协会指南明确将梗死核体积作为血管内血栓切除术的一个决定因素。因此,了解时间依赖性梗死核心生长如何转化为患者血栓切除资格的下降概率是很重要的。基于从中风发作到治疗的预期时间,对疑似大血管闭塞的患者进行取栓的概率进行建模,可以帮助制定最佳院前紧急转运方案,最大限度地提高患者预后的可能性。我们扩展了已发表的梗死核生长的生理模型,得出了血栓切除资格的衰减曲线(基于给定的梗死核体积阈值),作为中风发作时间的函数。然后,我们改编了一个现有的模型,该模型的时间依赖于一个优秀结果的概率,以纳入该衰减曲线。使用调整后的模型,我们确定了加拿大阿尔伯塔省的最佳院前紧急转运方案,并将这些方案与假设所有患者都符合取栓条件的方案进行了比较。随着中风发作时间的推移,符合取栓条件的概率呈指数衰减。我们发现,将我们的血栓切除资格衰减曲线纳入基础优化模型后,母舰是最佳运输协议的区域增加了18.6%。在母舰被偏爱的地区,母舰与滴灌-船的优势也增加了,而在滴灌-船被偏爱的地区,滴灌-船的优势减弱了。我们还进行了一些敏感性分析,以观察这些结果如何根据我们对模型参数的假设而变化。这种方法提供了一种新颖的、基于生理学的方法来得出血栓切除术的资格曲线。这些模型对于更好地优化院前转运决策,从而改善疑似大血管闭塞患者的预后是必要的。
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