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DESTINY-S: Attitudes of Physicians Toward Disability and Treatment in Malignant MCA Infarction

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Abstract

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.

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Acknowledgment

There is no external funding. The study is exclusively driven by internal means of the Center for Stroke Research Berlin (CSB) and the Institute of Clinical Epidemiology and Biometry, University of Würzburg.

Conflict of interest

H Neugebauer received travel grants from Bristol-Myers Squibb and Boehringer Ingelheim. C. Creutzfeldt reports no disclosures. C. Hemphill received no relevant disclosures but Grant fundings from the NIH/NINDS and Cerebrotech (industry), honoraria from serving on the scientific advisory board of Ornim (stock and stock options), honoraria for writing for Up To Date, and honoraria for expert witness review for several different law firms. P. U. Heuschmann receives/received in the recent years research support from the German Ministry of Research and Education (Center for Stroke Research Berlin; Comprehensive Heart Failure Center Würzburg), the European Union (European Implementation Score Collaboration), the German Stroke Foundation, the Charité – Universitätsmedizin Berlin, the Berlin Chamber of Physicians, and the University Hospital of Würzburg. E. Jüttler received speaker′s honoraria from Bristol-Myers Squibb and from Boehringer Ingelheim. The study was not industry-sponsored. There is no external funding. The study is exclusively driven by internal means of the Center for Stroke Research Berlin (CSB) and the Institute of Clinical Epidemiology and Biometry, University of Würzburg. This study was not industry-sponsored.

Author information

Authors and Affiliations

  1. Department of Neurology, RKU – University- and Rehabilitation Hospitals Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany

    Hermann Neugebauer & Eric Jüttler

  2. Department of Neurology, Harborview Medical Center, Seattle, WA, USA

    Claire J. Creutzfeldt

  3. Department of Neurology, University of California, San Francisco, CA, USA

    J. Claude Hemphill III

  4. Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany

    Peter U. Heuschmann

  5. Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany

    Peter U. Heuschmann

  6. Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany

    Peter U. Heuschmann

  7. Center for Stroke Research Berlin (CSB), Charité – University Medicine Berlin, Berlin, Germany

    Eric Jüttler

Authors
  1. Hermann Neugebauer
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  2. Claire J. Creutzfeldt
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  3. J. Claude Hemphill III
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  4. Peter U. Heuschmann
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  5. Eric Jüttler
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Corresponding author

Correspondence to Hermann Neugebauer.

Additional information

On behalf of the IGNITE Study Group.

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Neugebauer, H., Creutzfeldt, C.J., Hemphill, J.C. et al. DESTINY-S: Attitudes of Physicians Toward Disability and Treatment in Malignant MCA Infarction. Neurocrit Care 21, 27–34 (2014). https://doi.org/10.1007/s12028-014-9956-0

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  • DOI: https://doi.org/10.1007/s12028-014-9956-0

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