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Boisseau W, Benomar A, Ducroux C, Fahed R, Smajda S, Diestro JDB, Charbonnier G, Ognard J, Burel J, Ter Schiphorst A, Boulanger M, Nehme A, Boucherit J, Marnat G, Volders D, Holay Q, Forestier G, Bretzner M, Roy D, Vingadassalom S, Elhorany M, Nico L, Jacquin G, Abdalkader M, Guedon A, Seners P, Janot K, Dumas V, Olatunji R, Gazzola S, Milot G, Zehr J, Darsaut TE, Iancu D, Raymond J. The Management of Persistent Distal Occlusions after Mechanical Thrombectomy and Thrombolysis: An Inter- and Intrarater Agreement Study. AJNR Am J Neuroradiol 2024:ajnr.A8149. [PMID: 38388684 DOI: 10.3174/ajnr.a8149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/24/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE The best management of patients with persistent distal occlusion after mechanical thrombectomy with or without IV thrombolysis remains unknown. We sought to evaluate the variability and agreement in decision-making for persistent distal occlusions. MATERIALS AND METHODS A portfolio of 60 cases was sent to clinicians with varying backgrounds and experience. Responders were asked whether they considered conservative management or rescue therapy (stent retriever, aspiration, or intra-arterial thrombolytics) a treatment option as well as their willingness to enroll patients in a randomized trial. Agreement was assessed using κ statistics. RESULTS The electronic survey was answered by 31 physicians (8 vascular neurologists and 23 interventional neuroradiologists). Decisions for rescue therapies were more frequent (n = 1116/1860, 60%) than for conservative management (n = 744/1860, 40%; P < .001). Interrater agreement regarding the final management decision was "slight" (κ = 0.12; 95% CI, 0.09-0.14) and did not improve when subgroups of clinicians were studied according to background, experience, and specialty or when cases were grouped according to the level of occlusion. On delayed re-questioning, 23 of 29 respondents (79.3%) disagreed with themselves on at least 20% of cases. Respondents were willing to offer trial participation in 1295 of 1860 (69.6%) cases. CONCLUSIONS Individuals did not agree regarding the best management of patients with persistent distal occlusion after mechanical thrombectomy and IV thrombolysis. There is sufficient uncertainty to justify a dedicated randomized trial.
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Affiliation(s)
- W Boisseau
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - A Benomar
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - C Ducroux
- Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
| | - R Fahed
- Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
| | - S Smajda
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
| | - J D B Diestro
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - G Charbonnier
- Interventional Neuroradiology Department (G.C.), Besançon University Hospital, Besançon, France
| | - J Ognard
- Interventional Neuroradiology Department (J.O.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - J Burel
- Department of Radiology (J. Burel), Rouen University Hospital, Rouen, France
| | - A Ter Schiphorst
- Neurology Department (A.T.S.), CHRU Gui de Chauliac, Montpellier, France
| | - M Boulanger
- Department of Neurology (M. Boulanger, A.N.), Caen University Hospital, Caen, France
| | - A Nehme
- Department of Neurology (M. Boulanger, A.N.), Caen University Hospital, Caen, France
| | - J Boucherit
- Department of Radiology (J. Boucherit), Rennes University Hospital, Rennes, France
| | - G Marnat
- Department of Neuroradiology (G. Marnat), University Hospital of Bordeaux, Bordeaux, France
| | - D Volders
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
| | - Q Holay
- Radiology Department (Q.H.), Hôpital d'Instruction des armées Saint-Anne, Toulon, France
| | - G Forestier
- Neuroradiology Department (G.F.), University Hospital of Limoges, Limoges, France
| | - M Bretzner
- Neuroradiology Department (M. Bretzner), CHU Lille, University Lille, Inserm, U1172 Lille Neuroscience & Cognition, F-59000, Lille, France
| | - D Roy
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - S Vingadassalom
- Interventional Neuroradiology Department (S.V.), CHRU Marseille, La Timone, France
| | - M Elhorany
- Department of Neuroradiology (M.E.), Groupe Hospitalier de Pitié Salpêtrière, Paris, France
- Department of Neurology (M.E.), Tanta University, Tanta, Egypt
| | - L Nico
- Department of Radiology (L.N.), University Hospital of Padova, Padova, Italy
| | - G Jacquin
- Neurovascular Health Program (G.J.), Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - M Abdalkader
- Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - A Guedon
- Department of Neuroradiology (A.G.), Lariboisière Hospital, Paris, France
| | - P Seners
- Neurology Department (P.S.), Hôpital Fondation A. de Rothschild, Fondation Rothschild Hospital, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (P.S.), UMR_S1266, INSERM, Université de Paris, Paris, France
| | - K Janot
- Interventional Neuroradiology (K.J.), University Hospital of Tours, Tours, France
| | - V Dumas
- Radiology Department (V.D.), University Hospital of Poitiers, Poitiers, France
| | - R Olatunji
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - S Gazzola
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
- From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France
| | - G Milot
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - J Zehr
- Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
- Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
| | - T E Darsaut
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D Iancu
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
| | - J Raymond
- Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada
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Boisseau W, Darsaut TE, Fahed R, Findlay JM, Bourcier R, Charbonnier G, Smajda S, Ognard J, Roy D, Gariel F, Carlson AP, Shotar E, Ciccio G, Marnat G, Sporns PB, Gaberel T, Jecko V, Weill A, Biondi A, Boulouis G, Bras AL, Aldea S, Passeri T, Boissonneau S, Bougaci N, Gentric JC, Diestro JDB, Omar AT, Al-Jehani HM, Hage GE, Volders D, Kaderali Z, Tsogkas I, Magro E, Holay Q, Zehr J, Iancu D, Raymond J. Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study. AJNR Am J Neuroradiol 2022; 43:1437-1444. [PMID: 36137654 PMCID: PMC9575541 DOI: 10.3174/ajnr.a7648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later. RESULTS Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time. CONCLUSIONS Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.
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Affiliation(s)
- W Boisseau
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - T E Darsaut
- Department of Surgery (T.E.D., J.M.F.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - R Fahed
- Department of Medicine (R.F.), Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - J M Findlay
- Department of Surgery (T.E.D., J.M.F.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - R Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - G Charbonnier
- Departments of Interventional Neuroradiology (G. Charbonnier, A.B.)
| | - S Smajda
- Departments of Interventional Neuroradiology (S.S.)
| | - J Ognard
- Department of Interventional Neuroradiology (J.O., J.C.G.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - D Roy
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - F Gariel
- Departments of Neuroradiology (F.G., G.M.)
| | - A P Carlson
- Department of Neurosurgery (A.P.C.), University of New Mexico Hospital, Albuquerque, New Mexico
| | - E Shotar
- Department of Neuroradiology (E.S.), Groupe Hospitalier de Pitié Salpêtrière, Paris, France
| | - G Ciccio
- Department of Interventional Neuroradiology (G. Ciccio), Centre Hospitalier de Bastia, Bastia, Corse, France
| | - G Marnat
- Departments of Neuroradiology (F.G., G.M.)
| | - P B Sporns
- Department of Neuroradiology (P.B.S., I.T.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology (P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Gaberel
- Department of Neurosurgery (T.G.), University Hospital of Caen, Caen, France
| | - V Jecko
- Neurosurgery (V.J.), University Hospital of Bordeaux, Bordeaux, France
| | - A Weill
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - A Biondi
- Departments of Interventional Neuroradiology (G. Charbonnier, A.B.)
| | - G Boulouis
- Department of Neuroradiology (G.B.), University Hospital of Tours, Tours, Indre et Loire, France
| | - A L Bras
- Department of Radiology (A.L.B.), Groupement Hospitaliser Bretagne Atlantique-Hôpital Chubert, Vannes, Bretagne, France
| | - S Aldea
- Neurosurgery (S.A.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - T Passeri
- Department of Neurosurgery (T.P.), Lariboisière Hospital, Assistance Publique Hôpitaux de Paris, University of Paris, Paris, France
| | - S Boissonneau
- Department of Neurosurgery (S.B.), La Timone Hospital
- L'Institut National de la Santé et de la Recherche Médicale (S.B.), Institut de Neurosciences des Systèmes, Aix Marseille University, Marseille, France
| | - N Bougaci
- Neurosurgery (N.B.), Besançon University Hospital, Besançon, France
| | - J C Gentric
- Department of Interventional Neuroradiology (J.O., J.C.G.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - J D B Diestro
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A T Omar
- Division of Neurosurgery (A.T.O.), Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - H M Al-Jehani
- Department of Neurosurgery, Radiology and Critical Care Medicine (H.M.A.-J.), King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Alkhobar, Saudi Arabia
| | - G El Hage
- Department of Neurosurgery (G.E.H.), Centre Hospitalier de l'Université de Montréal,Montreal, Québec, Canada
| | - D Volders
- Department of Radiology (D.V.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Z Kaderali
- Division of Neurosurgery (Z.K.), GB1-Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - I Tsogkas
- Department of Neuroradiology (P.B.S., I.T.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - E Magro
- Department of Neurosurgery (E.M.), Centre Hospitalier Universitaire Cavale Blanche, UBO L'Institut National de la Santé et de la Recherche Médicale, LaTIM UMR 1101, Brest, France
| | - Q Holay
- Department of Radiology (Q.H.), Hôpital d'Instruction des Armées Saint-Anne, Toulon, France
| | - J Zehr
- Department of Mathematics and Statistics (J.Z.), Pavillon André-Aisenstadt,Montreal, Québec, Canada
| | - D Iancu
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - J Raymond
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
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Patel M, Au K, Davis FG, Easaw JC, Mehta V, Broad R, Chow MMC, Hockley A, Kaderali Z, Magro E, Nataraj A, Scholtes F, Chagnon M, Gevry G, Raymond J, Darsaut TE. Clinical Uncertainty and Equipoise in the Management of Recurrent Glioblastoma. Am J Clin Oncol 2021; 44:258-263. [PMID: 33782334 DOI: 10.1097/coc.0000000000000812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A significant proportion of glioblastoma (GBM) patients are considered for repeat resection, but evidence regarding best management remains elusive. Our aim was to measure the degree of clinical uncertainty regarding reoperation for patients with recurrent GBM. METHODS We first performed a systematic review of agreement studies examining the question of repeat resection for recurrent GBM. An electronic portfolio of 37 pathologically confirmed recurrent GBM patients including pertinent magnetic resonance images and clinical information was assembled. To measure clinical uncertainty, 26 neurosurgeons from various countries, training backgrounds, and years' experience were asked to select best management (repeat surgery, other nonsurgical management, or conservative), confidence in recommended management, and whether they would include the patient in a randomized trial comparing surgery with nonsurgical options. Agreement was evaluated using κ statistics. RESULTS The literature review did not reveal previous agreement studies examining the question. In our study, agreement regarding best management of recurrent GBM was slight, even when management options were dichotomized (repeat surgery vs. other options; κ=0.198 [95% confidence interval: 0.133-0.276]). Country of practice, years' experience, and training background did not change results. Disagreement and clinical uncertainty were more pronounced within clinicians with (κ=0.167 [0.055-0.314]) than clinicians without neuro-oncology fellowship training (κ=0.601 [0.556-0.646]). A majority (51%) of responders were willing to include the patient in a randomized trial comparing repeat surgery with nonsurgical alternatives in 26/37 (69%) of cases. CONCLUSION There is sufficient uncertainty and equipoise regarding the question of reoperation for patients with recurrent glioblastoma to support the need for a randomized controlled trial.
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Affiliation(s)
- Mukt Patel
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Karolyn Au
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | | | - Jacob C Easaw
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, AB
| | - Vivek Mehta
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Robert Broad
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Michael M C Chow
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Aaron Hockley
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Zul Kaderali
- Section of Neurosurgery, GB1-Health Sciences Centre, Winnipeg, MB, Canada
| | - Elsa Magro
- Neurosurgery service, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Boulevard Tanguy-Prigent Brest, France
| | - Andrew Nataraj
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | | | - Miguel Chagnon
- Department of Mathematics and Statistics, André-Aisenstadt Pavillon (AA-5190)
| | - Guylaine Gevry
- Department of Radiology, Centre Hospitalier of University of Montreal (CHUM), Montreal, QC, Canada
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier of University of Montreal (CHUM), Montreal, QC, Canada
| | - Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
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Darsaut T, Raymond J. Experience using pragmatic care trials to guide neurovascular practice under uncertainty. Neurochirurgie 2020; 66:423-428. [DOI: 10.1016/j.neuchi.2020.06.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 01/04/2023]
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Darsaut TE, Raymond J. Practicing outcome-based medical care using pragmatic care trials. Trials 2020; 21:899. [PMID: 33121523 PMCID: PMC7599099 DOI: 10.1186/s13063-020-04829-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 10/17/2020] [Indexed: 12/23/2022] Open
Abstract
The current separation between medical research and care is an obstacle to essential aspects of good medical practice: the verification that care interventions actually deliver the good outcomes they promise, and the use of scientific methods to optimize care under uncertainty. Pragmatic care trials have been designed to address these problems. Care trials are all-inclusive randomized trials integrated into care. Every item of trial design is selected in the best medical interest of participating patients. Care trials can eventually show what constitutes good medical practice based on patient outcomes. In the meantime, care trials give clinicians and patients the scientific methods necessary for optimization of medical care when no one really knows what to do.We report the progress of 9 randomized care trials that were used to guide the endovascular or surgical management of 1212 patients with acute stroke, intracranial aneurysms, and arteriovenous malformations in a single center in an elective or acute care context. Care trials were used to address long-standing dilemmas regarding rival medical, surgical, or endovascular management options or to offer innovative instead of standard treatments. The trial methodology, by replacing unrepeatable treatment decisions by 1:1 randomized allocation whenever reliable knowledge was not available, had an immediate impact, transforming unverifiable dogmatic medical practice into verifiable outcome-based medical care. We believe the approach is applicable to all medical or surgical domains, but widespread adoption may require the revision of many currently prevalent views regarding the role of research in clinical practice.
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Affiliation(s)
- Tim E. Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 - 112 Street, Edmonton, Alberta T6G 2B7 Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l’Université de Montréal – CHUM, 1000 Saint-Denis street, room D03-5462B, Montreal, QC H2X 0C1 Canada
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