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DESTINY-S: attitudes of physicians toward disability and treatment in malignant MCA infarction
Hermann Neugebauer1, Claire J Creutzfeldt, J Claude Hemphill
1Department of Neurology, RKU - University- and Rehabilitation Hospitals Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany, hermann.neugebauer@uni-ulm.de.
Insights
Physician attitudes vary widely on acceptable outcomes and treatment for malignant middle cerebral artery (MCA) infarction. There is a lack of consensus on acceptable disability levels and treatment strategies, highlighting the need for evidence-based patient-centered care.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Decompressive hemicraniectomy (DHC) improves survival in malignant middle cerebral artery (MCA) infarction but often results in severe disability.
- Physician attitudes towards acceptable disability and the impact of aphasia significantly influence treatment decisions.
Purpose of the Study:
- To investigate physician consensus on acceptable outcomes and treatment preferences for malignant MCA infarction.
- To explore factors influencing treatment decisions, including disability grading and stroke hemisphere.
Main Methods:
- A multicenter, international, cross-sectional survey (DESTINY-S) of 1,860 physicians.
- Survey questions focused on acceptable modified Rankin Scale (mRS) scores and preferred treatments for malignant MCA infarction.
Main Results:
- A majority of physicians (79.3%) found mRS scores of 3 or better acceptable; only 5.8% accepted mRS 5.
- Stroke hemisphere (dominant vs. non-dominant) influenced DHC preference (46.9% vs. 72.9%).
- Significant variations in acceptable disability and treatment decisions were observed across geographic regions, medical specialties, and experience levels.
Conclusions:
- Physician consensus on acceptable outcomes and management strategies for malignant MCA infarction is lacking.
- Current physician recommendations may not align with existing scientific evidence.
- A balanced decision-making process incorporating evidence, patient preferences, and clinical expertise is advocated.
Background:
Decompressive hemicraniectomy (DHC) reduces mortality and improves outcome after malignant middle cerebral artery (MCA) infarction but leaves a high number of survivors severely disabled. Attitudes among physicians toward the degree of disability that is considered acceptable and the impact of aphasia may play a major role in treatment decisions.
Methods:
DESTINY-S is a multicenter, international, cross-sectional survey among 1,860 physicians potentially involved in the treatment of malignant MCA infarction. Questions concerned the grade of disability, the hemisphere of the stroke, and the preferred treatment for malignant MCA infarction.
Results:
mRS scores of 3 or better were considered acceptable by the majority of respondents (79.3%). Only few considered a mRS score of 5 still acceptable (5.8%). A mRS score of 4 was considered acceptable by 38.0%. Involved hemisphere (dominant vs. non-dominant) was considered a major clinical symptom influencing treatment decisions in 47.7% of respondents, also reflected by significantly different rates for DHC as preferred treatment in dominant versus non-dominant hemispheric infarction (46.9 vs. 72.9%). Significant differences in acceptable disability and treatment decisions were found among geographic regions, medical specialties, and respondents with different work experiences.
Conclusion:
Little consensus exists among physicians regarding acceptable outcome and therapeutic management after malignant MCA infarction, and physician's recommendations do not correlate with available evidence. We advocate for a decision-making process that balances scientific evidence, patient preference, and clinical expertise.
