1
|
Kim YG, An H, Kim GE, Lee HW, Yang NR. Higher Risk of Mental Illness in Patients With Diagnosed and Untreated Unruptured Intracranial Aneurysm: Findings From a Nationwide Cohort Study. Stroke 2024; 55:2295-2304. [PMID: 39186554 DOI: 10.1161/strokeaha.123.045393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 06/26/2024] [Accepted: 07/09/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND We aimed to investigate the association between a diagnosis of untreated unruptured intracranial aneurysms (UIAs) and the development of mental illness. METHODS This retrospective, propensity-score-matched cohort study was based on the nationwide South Korean database. The UIA diagnosis group included participants newly diagnosed with UIA between 2011 and 2019. For a well-matched control group, patients diagnosed with an acute upper respiratory infection but without UIA during the same period were selected through 1:4 matching based on propensity scores, which were calculated using age, sex, economic status, and comorbidities. The study's outcome measure encompassed the incidence of mental illnesses over a 10-year period, using International Classification of Diseases-Tenth Revision codes for anxiety, stress, depressive, bipolar, and eating disorders, insomnia, and alcohol or drug misuse. RESULTS After propensity score matching, 85 438 participants with untreated UIAs (50.75% male; average age, 56.41 [±13.82] years; follow-up, 4.21 [±2.56] years) and 331 123 controls (49.44% males; average age, 56.69 [±12.92] years; follow-up, 7.48 [±2.12] years) were compared. Incidence rate of mental illness was higher in the UIA group (113.07 versus 90.41 per 1000 person-years; hazard ratio, 1.104 [95% CI, 1.089-1.119]). The risk of mental illness varied slightly by sex (males: hazard ratio, 1.131 [95% CI, 1.108-1.155]; females: hazard ratio, 1.082 [95% CI, 1.063-1.103]). Hazard ratios showed a U-shaped relationship with age, peaking in younger age groups, decreasing in middle-aged groups, and slightly increasing in older age groups, especially in patients with severe mental illness receiving psychotherapy. CONCLUSIONS Our findings indicate a higher risk of mental illness in patients with UIA diagnosis in specific demographic groups, suggesting a possible psychological burden associated with UIAs. Clinicians treating cerebral aneurysms should be aware that the psychological burden caused by the diagnosis of UIA itself could contribute to mental illness and strive to provide comprehensive care for these patients.
Collapse
Affiliation(s)
- Young Goo Kim
- Department of Neurosurgery, Ewha Womans University Mokdong Hospital (Y.G.K., N.R.Y.)
| | - Hyungmi An
- Institute of Convergence Medicine, Ewha Womans University College of Medicine (H.A.)
| | - Ga Eun Kim
- Department of Psychiatry, Ewha Womans University Mokdong Hospital (G.E.K.)
| | - Hyang Woon Lee
- Department of Neurology, Ewha Womans University Mokdong Hospital (H.W.L.), Ewha Womans University College of Medicine, Seoul, Republic of Korea
- Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea (H.W.L.)
- Computational Medicine, System Health Science and Engineering Program, Ewha Womans University, Seoul, Republic of Korea (H.W.L.)
| | - Na Rae Yang
- Department of Neurosurgery, Ewha Womans University Mokdong Hospital (Y.G.K., N.R.Y.)
- Department of Neurosurgery (N.R.Y.), Ewha Womans University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
2
|
Gaub M, Murtha G, Lafuente M, Webb M, Luo A, Birnbaum LA, Mascitelli JR, Al Saiegh F. Flow Diversion for Endovascular Treatment of Intracranial Aneurysms: Past, Present, and Future Directions. J Clin Med 2024; 13:4167. [PMID: 39064207 PMCID: PMC11278297 DOI: 10.3390/jcm13144167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/04/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Flow diversion for intracranial aneurysms emerged as an efficacious and durable treatment option over the last two decades. In a paradigm shift from intrasaccular aneurysm embolization to parent vessel remodeling as the mechanism of action, the proliferation of flow-diverting devices has enabled the treatment of many aneurysms previously considered untreatable. In this review, we review the history and development of flow diverters, highlight the pivotal clinical trials leading to their regulatory approval, review current devices including endoluminal and intrasaccular flow diverters, and discuss current and expanding indications for their use. Areas of clinical equipoise, including ruptured aneurysms and wide-neck bifurcation aneurysms, are summarized with a focus on flow diverters for these pathologies. Finally, we discuss future directions in flow diversion technology including bioresorbable flow diverters, transcriptomics and radiogenomics, and machine learning and artificial intelligence.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229, USA; (M.G.); (G.M.); (M.L.); (M.W.); (A.L.); (L.A.B.); (J.R.M.)
| |
Collapse
|
3
|
Darsaut TE, Rheaume AR, Chagnon M, Raymond J. The use and abuse of survival analysis and Kaplan-Meier curves in surgical trials. Neurochirurgie 2024; 70:101567. [PMID: 38761639 DOI: 10.1016/j.neuchi.2024.101567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Survival analysis based on Cox regression and Kaplan-Meier curves, initially devised for oncology trials, have frequently been used in other contexts where fundamental statistical assumptions (such as a constant hazard ratio) are not satisfied. This is almost always the case in trials that compare surgery with medical management. METHODS We review a trial that compared extracranial-intracranial bypass surgery (EC-IC bypass) with medical management (MM) of patients with symptomatic occlusion of the carotid or middle cerebral artery, where it was claimed that surgery was of no benefit. We discuss a hypothetical study and review other neurovascular trials which have also used survival analysis to compare results. RESULTS The trial comparing EC-IC bypass and MM did not satisfy the fundamental proportional hazard assumption necessary for valid analyses. This was also the case for two prior EC-IC bypass trials, as well as for other landmark neurovascular studies, such as the trials comparing endarterectomy with MM for carotid stenoses, or for the trial that compared intervention and MM for unruptured brain arteriovenous malformations. While minor deviations may have little effect on large trials, it may be impossible to show the benefits of surgery when trial size is small and deviations large. CONCLUSION Survival analyses are inappropriate in RCTs comparing surgery with conservative management, unless survival is calculated after the postoperative period. Alternative ways to compare final clinical outcomes, using for example a fixed follow-up period, should be planned for preventive surgical trials that compare intervention with conservative management.
Collapse
Affiliation(s)
- Tim E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Alan R Rheaume
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, University of Montreal, Montreal, Quebec, Canada
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| |
Collapse
|
4
|
Tjoumakaris SI, Hanel R, Mocco J, Ali-Aziz Sultan M, Froehler M, Lieber BB, Coon A, Tateshima S, Altschul DJ, Narayanan S, El Naamani K, Taussky P, Hoh BL, Meyers P, Gounis MJ, Liebeskind DS, Volovici V, Toth G, Arthur A, Wakhloo AK. ARISE I Consensus Review on the Management of Intracranial Aneurysms. Stroke 2024; 55:1428-1437. [PMID: 38648283 DOI: 10.1161/strokeaha.123.046208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/19/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Intracranial aneurysms (IAs) remain a challenging neurological diagnosis associated with significant morbidity and mortality. There is a plethora of microsurgical and endovascular techniques for the treatment of both ruptured and unruptured aneurysms. There is no definitive consensus as to the best treatment option for this cerebrovascular pathology. The Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts discussed best practices and the most promising approaches to improve the management of brain aneurysms. METHODS A group of experts from academia, industry, and federal regulators convened to discuss updated clinical trials, scientific research on preclinical system models, management options, screening and monitoring, and promising novel device technologies, aiming to improve the outcomes of patients with IA. RESULTS Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts suggested the incorporation of artificial intelligence to capture sequential aneurysm growth, identify predictors of rupture, and predict the risk of rupture to guide treatment options. The consensus strongly recommended nationwide systemic data collection of unruptured IA radiographic images for the analysis and development of machine learning algorithms for rupture risk. The consensus supported centers of excellence for preclinical multicenter trials in areas such as genetics, cellular composition, and radiogenomics. Optical coherence tomography and magnetic resonance imaging contrast-enhanced 3T vessel wall imaging are promising technologies; however, more data are needed to define their role in IA management. Ruptured aneurysms are best managed at large volume centers, which should include comprehensive patient management with expertise in microsurgery, endovascular surgery, neurology, and neurocritical care. CONCLUSIONS Clinical and preclinical studies and scientific research on IA should engage high-volume centers and be conducted in multicenter collaborative efforts. The future of IA diagnosis and monitoring could be enhanced by the incorporation of artificial intelligence and national radiographic and biologic registries. A collaborative effort between academic centers, government regulators, and the device industry is paramount for the adequate management of IA and the advancement of the field.
Collapse
Affiliation(s)
- Stavropoula I Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University at Sidney Kimmel Medical College, Philadelphia, PA (S.I.T., K.E.N.)
| | - Ricardo Hanel
- Baptist Neurological Institute, Jacksonville, FL (R.H.)
| | - J Mocco
- Department of Neurosurgery, Mount Sinai University Hospital, New York, NY (J.M.)
| | - M Ali-Aziz Sultan
- Department of Neurosurgery, Harvard Medical School, Boston, MA (M.A.-A.S.)
| | - Michael Froehler
- Department of Neurology, Vanderbilt University, Nashville, TN (M.F.)
| | - Barry B Lieber
- Department of Neurology, Tufts School of Medicine, Boston, MA (B.B.L.)
| | - Alexander Coon
- Department of Neurosurgery, Carondelet Neurological Institute of St. Joseph's and St. Mary's Hospitals in Tucson, AZ (A.C.)
| | - Satoshi Tateshima
- Department of Radiology (S.T.), University of California, Los Angeles
| | - David J Altschul
- Department of Neurological Surgery, Einstein Montefiore Medical Center, Bronx, NY (D.J.A.)
| | - Sandra Narayanan
- Department of Neurology, Pacific Neuroscience Institute, Santa Monica, CA (S.N.)
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University at Sidney Kimmel Medical College, Philadelphia, PA (S.I.T., K.E.N.)
| | - Phil Taussky
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA (P.T.)
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville (B.L.H.)
| | - Philip Meyers
- Department of Radiology, Saint Luke's Clinic, Boise, ID (P.M.)
| | - Matthew J Gounis
- Department of Radiology, University of Massachusetts, Worcester (M.J.G.)
| | | | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (V.V.)
| | - Gabor Toth
- Department of Neurosurgery, Cleveland Clinic, OH (G.T.)
| | - Adam Arthur
- Department of Neurosurgery, Semmes Murphey Clinic, Memphis, TN (A.A.)
| | - Ajay K Wakhloo
- Department of Radiology, Tufts University School of Medicine, Boston, MA (A.K.W.)
| |
Collapse
|
5
|
Darsaut TE, Findlay JM, Bojanowski MW, Chalaala C, Iancu D, Roy D, Weill A, Boisseau W, Diouf A, Magro E, Kotowski M, Keough MB, Estrade L, Bricout N, Lejeune JP, Chow MMC, O'Kelly CJ, Rempel JL, Ashforth RA, Lesiuk H, Sinclair J, Erdenebold UE, Wong JH, Scholtes F, Martin D, Otto B, Bilocq A, Truffer E, Butcher K, Fox AJ, Arthur AS, Létourneau-Guillon L, Guilbert F, Chagnon M, Zehr J, Farzin B, Gevry G, Raymond J. A Pragmatic Randomized Trial Comparing Surgical Clipping and Endovascular Treatment of Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 2023; 44:634-640. [PMID: 37169541 PMCID: PMC10249696 DOI: 10.3174/ajnr.a7865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/10/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND PURPOSE Surgical clipping and endovascular treatment are commonly used in patients with unruptured intracranial aneurysms. We compared the safety and efficacy of the 2 treatments in a randomized trial. MATERIALS AND METHODS Clipping or endovascular treatments were randomly allocated to patients with one or more 3- to 25-mm unruptured intracranial aneurysms judged treatable both ways by participating physicians. The study hypothesized that clipping would decrease the incidence of treatment failure from 13% to 4%, a composite primary outcome defined as failure of aneurysm occlusion, intracranial hemorrhage during follow-up, or residual aneurysms at 1 year, as adjudicated by a core lab. Safety outcomes included new neurologic deficits following treatment, hospitalization of >5 days, and overall morbidity and mortality (mRS > 2) at 1 year. There was no blinding. RESULTS Two hundred ninety-one patients were enrolled from 2010 to 2020 in 7 centers. The 1-year primary outcome, ascertainable in 290/291 (99%) patients, was reached in 13/142 (9%; 95% CI, 5%-15%) patients allocated to surgery and in 28/148 (19%; 95% CI, 13%-26%) patients allocated to endovascular treatments (relative risk: 2.07; 95% CI, 1.12-3.83; P = .021). Morbidity and mortality (mRS >2) at 1 year occurred in 3/143 and 3/148 (2%; 95% CI, 1%-6%) patients allocated to surgery and endovascular treatments, respectively. Neurologic deficits (32/143, 22%; 95% CI, 16%-30% versus 19/148, 12%; 95% CI, 8%-19%; relative risk: 1.74; 95% CI, 1.04-2.92; P = .04) and hospitalizations beyond 5 days (69/143, 48%; 95% CI, 40%-56% versus 12/148, 8%; 95% CI, 5%-14%; relative risk: 0.18; 95% CI, 0.11-0.31; P < .001) were more frequent after surgery. CONCLUSIONS Surgical clipping is more effective than endovascular treatment of unruptured intracranial aneurysms in terms of the frequency of the primary outcome of treatment failure. Results were mainly driven by angiographic results at 1 year.
Collapse
Affiliation(s)
- T E Darsaut
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - J M Findlay
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | | | | | - D Iancu
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - D Roy
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Weill
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - W Boisseau
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Diouf
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - E Magro
- Service of Neurosurgery (E.M.), Centre Hospitalier Universitaire Cavale Blanche, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1101 LaTIM, Brest, France
| | - M Kotowski
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M B Keough
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - L Estrade
- Interventional Neuroradiology (L.E., N.B.)
| | - N Bricout
- Interventional Neuroradiology (L.E., N.B.)
| | - J-P Lejeune
- Service of Neurosurgery (J.-P.L.), Centre Hospitalier Universitaire de Lille, Lille, France
| | - M M C Chow
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - C J O'Kelly
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - J L Rempel
- Department of Surgery, and Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - R A Ashforth
- Department of Surgery, and Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - H Lesiuk
- Section of Neurosurgery (H.L., J.S.)
| | | | - U-E Erdenebold
- Department of Surgery, and Department of Medical Imaging (U.-E.E.), Section of Interventional Neuroradiology, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J H Wong
- Division of Neurosurgery (J.H.W.), Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - F Scholtes
- Departments of Neurosurgery (F.S., D.M.)
| | - D Martin
- Departments of Neurosurgery (F.S., D.M.)
| | - B Otto
- Medical Physics (B.O.), Division of Medical Imaging, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - A Bilocq
- Service of Neurosurgery (A.B., E.T.), Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - E Truffer
- Service of Neurosurgery (A.B., E.T.), Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - K Butcher
- Clinical Neurosciences (K.B.), Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - A J Fox
- Department of Medical Imaging (A.J.F.), University of Toronto, Toronto, Ontario, Canada
| | - A S Arthur
- Department of Neurosurgery (A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee
| | - L Létourneau-Guillon
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - F Guilbert
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montréal, Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montréal, Québec, Canada
| | - B Farzin
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| | - G Gevry
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| | - J Raymond
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| |
Collapse
|
6
|
Boisseau W, Darsaut TE, Fahed R, Drake B, Lesiuk H, Rempel JL, Gentric JC, Ognard J, Nico L, Iancu D, Roy D, Weill A, Chagnon M, Zehr J, Lavoie P, Nguyen TN, Raymond J. Stent-Assisted Coiling in the Treatment of Unruptured Intracranial Aneurysms: A Randomized Clinical Trial. AJNR Am J Neuroradiol 2023; 44:381-389. [PMID: 36927759 PMCID: PMC10084896 DOI: 10.3174/ajnr.a7815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/16/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND AND PURPOSE Stent-assisted coiling may improve angiographic results of endovascular treatment of unruptured intracranial aneurysms compared with coiling alone, but this has never been shown in a randomized trial. MATERIALS AND METHODS The Stenting in the Treatment of Aneurysm Trial was an investigator-led, parallel, randomized (1:1) trial conducted in 4 university hospitals. Patients with intracranial aneurysms at risk of recurrence, defined as large aneurysms (≥10 mm), postcoiling recurrent aneurysms, or small aneurysms with a wide neck (≥4 mm), were randomly allocated to stent-assisted coiling or coiling alone. The composite primary efficacy outcome was "treatment failure," defined as initial failure to treat the aneurysm; aneurysm rupture or retreatment during follow-up; death or dependency (mRS > 2); or an angiographic residual aneurysm adjudicated by an independent core laboratory at 12 months. The primary hypothesis (revised for slow accrual) was that stent-assisted coiling would decrease treatment failures from 33% to 15%, requiring 200 patients. Primary analyses were intent to treat. RESULTS Of 205 patients recruited between 2011 and 2021, ninety-four were allocated to stent-assisted coiling and 111 to coiling alone. The primary outcome, ascertainable in 203 patients, was reached in 28/93 patients allocated to stent-assisted coiling (30.1%; 95% CI, 21.2%-40.6%) compared with 30/110 (27.3%; 95% CI, 19.4%-36.7%) allocated to coiling alone (relative risk = 1.10; 95% CI, 0.7-1.7; P = .66). Poor clinical outcomes (mRS >2) occurred in 8/94 patients allocated to stent-assisted coiling (8.5%; 95% CI, 4.0%-16.6%) compared with 6/111 (5.4%; 95% CI, 2.2%-11.9%) allocated to coiling alone (relative risk = 1.6; 95% CI, 0.6%-4.4%; P = .38). CONCLUSIONS The STAT trial did not show stent-assisted coiling to be superior to coiling alone for wide-neck, large, or recurrent unruptured aneurysms.
Collapse
Affiliation(s)
- W Boisseau
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - T E Darsaut
- Department of Surgery (T.E.D.), Division of Neurosurgery
| | - R Fahed
- Departments of Neurology (R.F.)
| | - B Drake
- Neurosurgery (B.D., H.L.), University of Ottawa, the Ottawa Hospital, Ottawa, Ontario, Canada
| | - H Lesiuk
- Neurosurgery (B.D., H.L.), University of Ottawa, the Ottawa Hospital, Ottawa, Ontario, Canada
| | - J L Rempel
- Department of Radiology and Diagnostic Imaging (J.L.R.), University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J-C Gentric
- Department of Radiology (J.-C.G., J.O.), University Hospital of Brest, Brest, France
| | - J Ognard
- Department of Radiology (J.-C.G., J.O.), University Hospital of Brest, Brest, France
| | - L Nico
- Departement of Radiology (L.N.), Service of Interventional Neuroradiology, Centre Hospitalo-universitaire de Saint-Etienne, Saint-Etienne, France
| | - D Iancu
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - D Roy
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Weill
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Québec, Canada
| | - P Lavoie
- Department of Neurosurgery (P.L.), Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Canada
| | - T N Nguyen
- Departments of Neurology (T.N.N.)
- Radiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - J Raymond
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| |
Collapse
|
7
|
Collins J, Benomar A, Iancu D, Farzin B, Darsaut TE, Raymond J. Research participants may not recall their participation but have a better understanding of alternative management options than patients in routine care. Neurochirurgie 2023; 69:101392. [PMID: 36669431 DOI: 10.1016/j.neuchi.2022.101392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Patient understanding of care interventions, of the clinical uncertainty, and of their participation in clinical research is often poor. We hypothesized that compared to routine care, patients would better understand the prevailing uncertainty when they participated in research. METHODS A questionnaire was administered to patients at the time they attended a follow-up neurovascular clinic 4 to 52 weeks after a care episode where they did or did not participate in a clinical trial. Patients were not reminded whether they had previously participated in a clinical trial. Questions concerned their understanding of the risks/benefits of interventions, the availability of alternative options, whether their personal opinion was taken into consideration, the reason for the final decision, their confidence at having received the best management, and whether they had been research participants. RESULTS Between June 2019 and June 2020, 167 patients were recruited; 71 had truly been research participants, while 96 had not. A greater proportion of research patients were aware of the existence of management alternatives (65% versus 44%; P=0.008). Patients of both groups believed their personal opinion counted in the final decision (76% versus 70%), and patients were equally confident that they had received the best management (94%). Research patients believed they had participated in research 46% of the time, compared to 12% of routine care patients (P=0.003). CONCLUSION Many patients do not recall that they participated in a clinical trial, but they have a better understanding of the clinical uncertainty and of the availability of alternative management options.
Collapse
Affiliation(s)
- J Collins
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada
| | - A Benomar
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada; Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - D Iancu
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada; Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - B Farzin
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J Raymond
- Interventional Neuroradiology Research laboratory, CHUM Research Centre, Montreal, Quebec, Canada; Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| |
Collapse
|
8
|
Rheaume AR, Olijnyk L, Lecaros NE, Darsaut TE, Raymond J. Understanding how the primary endpoint impacts the interpretation of trial results: The Japanese Adult Moyamoya bypass trial. Neurochirurgie 2023; 69:101408. [PMID: 36701981 DOI: 10.1016/j.neuchi.2023.101408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The meaning of a clinical trial depends to a large extent on the choice of the primary outcome measure, which can be explanatory or pragmatic. METHODS We review the Japanese Adult Moyamoya (JAM) trial, that compared surgical extracranial to intracranial (EC-IC) bypass and medical management of hemorrhagic moyamoya disease. We also review some principles which guide the selection of the primary trial endpoint. DISCUSSION The main component of the primary outcome measure in JAM was rebleeding, a surrogate outcome that allowed investigators to demonstrate that surgical bypass had causal efficacy. However, the number of patients with a poor outcome, defined as those with a modified Rankin score (mRS)>2, would have been a more pragmatic choice. Unfortunately, the trial was too small to show that patients benefited from surgery. CONCLUSION The JAM trial showed that EC-IC bypass can decrease rebleeding in moyamoya patients, but whether patients have better outcomes with surgery remains uncertain. Hard pragmatic clinical primary outcome measures are necessary to guide surgical care.
Collapse
Affiliation(s)
- A R Rheaume
- Division of neurosurgery, department of surgery, university of Alberta Hospital, Mackenzie Health Sciences centre, Edmonton, Alberta, Canada
| | - L Olijnyk
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada
| | - N E Lecaros
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta Hospital, Mackenzie Health Sciences centre, Edmonton, Alberta, Canada
| | - J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
| |
Collapse
|
9
|
Darsaut TE, Chagnon M, Raymond J. Reply. AJNR Am J Neuroradiol 2023; 44:E9-E10. [PMID: 36574315 PMCID: PMC9835901 DOI: 10.3174/ajnr.a7732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- T E Darsaut
- Department of Surgery, Division of NeurosurgeryMackenzie Health Sciences CentreUniversity of Alberta HospitalEdmonton, Alberta, Canada
| | - M Chagnon
- Department of Mathematics and StatisticsUniversité de MontréalMontreal, Quebec, Canada
| | - J Raymond
- Department of Radiology, Service of Interventional NeuroradiologyCentre Hospitalier de l'Université de MontréalMontreal, Quebec, Canada
| |
Collapse
|
10
|
Raymond J, Iancu D, Boisseau W, Diestro JDB, Klink R, Chagnon M, Zehr J, Drake B, Lesiuk H, Weill A, Roy D, Bojanowski MW, Chaalala C, Rempel JL, O'Kelly C, Chow MM, Bracard S, Darsaut TE. Flow Diversion in the Treatment of Intracranial Aneurysms: A Pragmatic Randomized Care Trial. AJNR Am J Neuroradiol 2022; 43:1244-1251. [PMID: 35926886 PMCID: PMC9451626 DOI: 10.3174/ajnr.a7597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Flow diversion is a recent endovascular treatment for intracranial aneurysms. We compared the safety and efficacy of flow diversion with the alternative standard management options. MATERIALS AND METHODS A parallel group, prerandomized, controlled, open-label pragmatic trial was conducted in 3 Canadian centers. The trial included all patients considered for flow diversion. A Web-based platform 1:1 randomly allocated patients to flow diversion or 1 of 4 alternative standard management options (coiling with/without stent placement, parent vessel occlusion, surgical clipping, or observation) as prespecified by clinical judgment. Patients ineligible for alternative standard management options were treated with flow diversion in a registry. The primary safety outcome was death or dependency (mRS > 2) at 3 months. The composite primary efficacy outcome included the core lab-determined angiographic presence of a residual aneurysm, aneurysm rupture, progressive mass effect during follow-up, or death or dependency (mRS > 2) at 3-12 months. RESULTS Between May 2011 and November 2020, three hundred twenty-three patients were recruited: Two hundred seventy-eight patients (86%) had treatment randomly allocated (139 to flow diversion and 139 to alternative standard management options), and 45 (14%) received flow diversion in the registry. Patients in the randomized trial frequently had unruptured (83%), large (52% ≥10 mm) carotid (64%) aneurysms. Death or dependency at 3 months occurred in 16/138 patients who underwent flow diversion and 12/137 patients receiving alternative standard management options (relative risk, 1.33; 95% CI, 0.65-2.69; P = .439). A poor primary efficacy outcome was found in 30.9% (43/139) with flow diversion and 45.6% (62/136) of patients receiving alternative standard management options, with an absolute risk difference of 14.7% (95% CI, 3.3%-26.0%; relative risk, 0.68; 95% CI, 0.50-0.92; P = .014). CONCLUSIONS For patients with mostly unruptured, large, anterior circulation (carotid) aneurysms, flow diversion was more effective than the alternative standard management option in terms of angiographic outcome.
Collapse
Affiliation(s)
- J Raymond
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - D Iancu
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
- Departments of Radiology (D.I.)
| | - W Boisseau
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - J D B Diestro
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - R Klink
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Canada
| | - B Drake
- Surgery (B.D., H.L.), Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
| | - H Lesiuk
- Surgery (B.D., H.L.), Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
| | - A Weill
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - D Roy
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - M W Bojanowski
- Department of Neurosurgery (M.W.B., C.C.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - C Chaalala
- Department of Neurosurgery (M.W.B., C.C.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | | | - C O'Kelly
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M M Chow
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - S Bracard
- Neuroradiology (S.B.), CHRU de Nancy, Nancy, Lorraine, France
| | - T E Darsaut
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| |
Collapse
|
11
|
Lognon P, Gariel F, Marnat G, Darcourt J, Constant Dit Beaufils P, Burel J, Shotar E, Hak JF, Fauché C, Kerleroux B, Guédon A, Ognard J, Forestier G, Pop R, Paya C, Veyrières JB, Sporns P, Girot JB, Zannoni R, Zhu F, Crespy A, L'Allinec V, Mihoc D, Rouchaud A, Gentric JC, Ben Hassen W, Raynaud N, Testud B, Clarençon F, Kaczmarek B, Bourcier R, Bellanger G, Boulouis G, Janot K. Prospective assessment of aneurysmal rupture risk scores in patients with subarachnoid hemorrhage: a multicentric cohort. Neuroradiology 2022; 64:2363-2371. [PMID: 35695927 DOI: 10.1007/s00234-022-02987-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/20/2022] [Indexed: 12/21/2022]
Abstract
PURPOSE The natural evolution of unruptured intracranial aneurysms (UIA) is indeed difficult to predict at the individual level. OBJECTIVE In a large prospective multicentric European cohort, we aimed to evaluate whether the PHASES, UCAS, and ELPASS scores in patients with aneurysmal subarachnoid hemorrhage would have predicted a high risk of aneurysmal rupture or growth. METHODS Academic centers treating patients with intracranial aneurysms were invited to prospectively collect de-identified data from all patients admitted at their institution for a subarachnoid hemorrhage-related to intracranial aneurysmal rupture between January 1 and March 31, 2021 through a trainee-led research collaborative network. Each responding center was provided with an electronic case record form (CRF) which collected all the elements of the PHASES, ELAPSS, and UCAS scores. RESULTS A total of 319 patients with aneurysmal subarachnoid hemorrhage were included at 17 centers during a 3-month period. One hundred eighty-three aneurysms (57%) were less than 7 mm. The majority of aneurysms were located on the anterior communicating artery (n = 131, 41%). One hundred eighty-four patients (57%), 103 patients (32%), and 58 (18%) were classified as having a low risk of rupture or growth, according to the PHASES, UCAS, and ELAPSS scores, respectively. CONCLUSION In a prospective study of European patients with aneurysmal subarachnoid hemorrhage, we showed that 3 common risk-assessment tools designed for patients with unruptured intracranial aneurysms would have not identified most patients to be at high or intermediate risk for rupture, questioning their use for decision-making in the setting of unruptured aneurysms.
Collapse
Affiliation(s)
- P Lognon
- University Hospital of Tours, Tours, France
| | - F Gariel
- University Hospital of Bordeaux, Bordeaux, France
| | - G Marnat
- University Hospital of Bordeaux, Bordeaux, France
| | - J Darcourt
- University Hospital of Toulouse, Toulouse, France
| | - P Constant Dit Beaufils
- L'institut du Thorax, University of Nantes, INSERM, CNRS, Nantes, France.,University Hospital of Nantes, Nantes, France
| | - J Burel
- University Hospital of Rouen, Rouen, France
| | - E Shotar
- Pitié Salpêtrière Hospital, Paris, France
| | - J F Hak
- University Hospital of Marseille, Marseille, France
| | - C Fauché
- University Hospital of Poitiers, Poitiers, France
| | | | - A Guédon
- Lariboisière Hospital, Paris, France
| | - J Ognard
- University Hospital of Brest, Brest, France
| | - G Forestier
- University Hospital of Limoges, Limoges, France
| | - R Pop
- University Hospital of Strasbourg, Strasbourg, France
| | - C Paya
- University Hospital of Saint-Pierre, Saint-Pierre, La Réunion, France
| | - J B Veyrières
- University Hospital of Saint-Pierre, Saint-Pierre, La Réunion, France
| | - P Sporns
- University Hospital of Basel, Basel, Switzerland.,University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
| | - J B Girot
- University Hospital of Angers, Angers, France
| | - R Zannoni
- University Hospital of Saint-Etienne, Saint-Etienne, France
| | - F Zhu
- University Hospital of Nancy, Nancy, France
| | - A Crespy
- University Hospital of Tours, Tours, France
| | - V L'Allinec
- University Hospital of Angers, Angers, France
| | - D Mihoc
- University Hospital of Strasbourg, Strasbourg, France
| | - A Rouchaud
- University Hospital of Limoges, Limoges, France
| | | | | | - N Raynaud
- University Hospital of Poitiers, Poitiers, France
| | - B Testud
- University Hospital of Marseille, Marseille, France
| | | | | | - R Bourcier
- L'institut du Thorax, University of Nantes, INSERM, CNRS, Nantes, France.,University Hospital of Nantes, Nantes, France
| | - G Bellanger
- University Hospital of Toulouse, Toulouse, France
| | - G Boulouis
- University Hospital of Tours, Tours, France
| | - Kevin Janot
- University Hospital of Tours, Tours, France.
| | | |
Collapse
|
12
|
Xie YE, Huang WC, Li YP, Deng JH, Huang JT. Dynamic interaction nursing intervention on functional rehabilitation and self-care ability of patients after aneurysm surgery. World J Clin Cases 2022; 10:4827-4835. [PMID: 35801044 PMCID: PMC9198876 DOI: 10.12998/wjcc.v10.i15.4827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/27/2022] [Accepted: 03/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nursing practices based on the dynamic interaction model have been shown to be superior to generic nursing practices. However, whether this model is effective in patients recovering from intracranial aneurysm surgery is not well studied.
AIM To investigate the effect of nursing based on a dynamic interaction model on functional rehabilitation of patients after aneurysm surgery.
METHODS A total of 86 cases in our hospital with intracranial aneurysm from April 2019 to April 2021, were selected and divided into the study group and the control group, with 43 patients in each group. The control group received routine nursing, and the research group received nursing intervention based on a dynamic interaction model. The daily living ability (activities of daily living, ADL), cognitive function (Simple Intelligent Mental State Scale, MMSE), quality of life (Generic Quality of Life Inventory-74, GQOL-74), self-care ability (Exercise of Self-Care Agency scale), incidence of complications, and nursing satisfaction were recorded before and after intervention.
RESULTS Before intervention, ADL (52.09 ± 6.44), MMSE (18.03 ± 4.11), and GQOL-74 (53.68 ± 4.34) scores in the study group were not significantly different from those in the control group (ADL: 50.97 ± 7.32, MMSE: 17.59 ± 3.82, GQOL-74: 55.06 ± 3.98) (P > 0.05). After intervention, ADL (86.12 ± 5.07), MMSE (26.64 ± 2.66), and GQOL-74 (83.13 ± 5.67) scores in the study group were higher than those in the control group (ADL: 79.81 ± 6.35, MMSE: 24.51 ± 3.00, and GQOL-74: 77.96 ± 6.27) (P < 0.05). Before intervention, self-concept (17.46 ± 4.44), self-care skills (25.22 ± 4.20), self-care knowledge (22.35 ± 4.74), and self-care responsibility (15.06 ± 3.29) scores in the study group was similar to those in the control group (self-concept: 16.89 ± 5.53, self-care skills: 24.59 ± 4.46, self-care knowledge: 21.80 ± 3.61, and self-care responsibility: 14.83 ± 3.11) (P > 0.05). After the intervention, self-concept (26.01 ± 3.18), self-care skills (37.68 ± 6.05), self-care knowledge (45.56 ± 5.83), and self-care responsibility (22.01 ± 3.77) scores in the study group were higher than those in the control group (self-concept: 22.97 ± 3.46, self-care skills: 33.02 ± 5.65, self-care skills knowledge: 36.81 ± 5.54, and self-care responsibility: 17.97 ± 3.56 points) (P < 0.05). The incidence of complications in the study group (4.65%) was lower than that in the control group (18.60%) (P < 0.05). Nursing satisfaction in the study group (95.35%) was higher than that in the control group (81.40%) (P < 0.05).
CONCLUSION Nursing intervention based on a dynamic interaction model can improve postoperative cognitive function, daily living ability, self-care ability, quality of life, and patient satisfaction, while reducing the risk of complications.
Collapse
Affiliation(s)
- Yan-E Xie
- The First Neurological Department, Central People’s Hospital of Huizhou City, Huizhou 516001, Guangdong Province, China
| | - Wei-Cheng Huang
- The First Neurological Department, Central People’s Hospital of Huizhou City, Huizhou 516001, Guangdong Province, China
| | - Yu-Ping Li
- The First Neurological Department, Central People’s Hospital of Huizhou City, Huizhou 516001, Guangdong Province, China
| | - Jia-Huan Deng
- The First Neurological Department, Central People’s Hospital of Huizhou City, Huizhou 516001, Guangdong Province, China
| | - Jian-Ting Huang
- The First Neurological Department, Central People’s Hospital of Huizhou City, Huizhou 516001, Guangdong Province, China
| |
Collapse
|
13
|
Iancu D, Collins J, Farzin B, Darsaut TE, Eneling J, Boisseau W, Olijnyk L, Boulouis G, Chaalala C, Bojanowski MW, Weill A, Roy D, Raymond J. Recruitment in a pragmatic randomized trial on the management of unruptured intracranial aneurysms. World Neurosurg 2022; 163:e413-e419. [PMID: 35395427 DOI: 10.1016/j.wneu.2022.03.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The Comprehensive Aneurysm Management (CAM) study is a pragmatic trial designed to manage UIA patients within a care research framework. METHOD CAM is an all-inclusive study. Management options are allocated according to an algorithm combining pre-randomization and clinical judgment. Eligible patients are offered 1:1 randomized allocation of intervention versus conservative management and 1:1 randomization allocation of surgical versus endovascular treatment. Ineligible patients are registered. The primary outcome is survival without dependency (mRS<3) at 10 years. All UIA patients at one center are reported. RESULTS Between February 2020 and July 2021, 403 UIA patients were recruited: 179 (44%) in one of the RCTs and 224 (56%) in one of the registries. Conservative management was recommended for 205/403 patients (51%); of 198 (49%) patients considered for curative treatment, 159 (80%) were randomly allocated conservative (n=81) or curative treatment (n=78). These patients were younger and had larger aneurysms than those in the observation registry (P = .004). In 39/198 patients (20%), conservative management was not considered reasonable (17 patients were recommended endovascular, 2 surgery, and 20 the RCT comparing endovascular with surgical treatment). In total, 70 patients were recruited in the RCT comparing surgery and endovascular treatment. After informed discussion at time of consent, 141/159 patients (89%) agreed with the randomly allocated management plan, while 11% crossed-over to the alternative management option. CONCLUSION CAM was successfully integrated into routine practice. Meaningful conclusions can be obtained if multiple centers actively participate in the trial.
Collapse
Affiliation(s)
- Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Jennifer Collins
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Behzad Farzin
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, Edmonton, Alberta, Canada
| | - Johanna Eneling
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Leonardo Olijnyk
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Grégoire Boulouis
- Neuroradiology Department, Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, France
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada.
| |
Collapse
|
14
|
Darsaut TE, Keough MB, Boisseau W, Findlay JM, Bojanowski MW, Chaalala C, Iancu D, Weill A, Roy D, Estrade L, Lejeune JP, Januel AC, Carlson AP, Sauvageau E, Al-Jehani H, Orlov K, Aldea S, Piotin M, Gaberel T, Gevry G, Raymond J. Middle Cerebral Artery Aneurysm Trial (MCAAT): A randomized care trial comparing surgical and endovascular management of MCA aneurysm patients. World Neurosurg 2021; 160:e49-e54. [PMID: 34971833 DOI: 10.1016/j.wneu.2021.12.083] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multi-center, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is 'Treatment Success': i) occlusion or exclusion of the aneurysm using the allocated treatment modality; ii) no intracranial hemorrhage during follow-up; iii) no retreatment of the target aneurysm during follow-up, iv) no residual aneurysm on angiographic follow-up and v) independence (mRS <3) at 1 year. The trial tests two versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared to endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1 year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSION Patients with MCA aneurysms can be optimally managed within a care trial protocol.
Collapse
Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, CHU de Lille, Hôpital Salengro, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, CHU de Lille, Hôpital Salengro, Lille, France
| | - Anne-Christine Januel
- Department of Interventional Neuroradiology, CHU de Toulouse, Hôpital Purpan, Toulouse, France
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida, USA
| | - Hosam Al-Jehani
- Department of Neurosurgery and Radiology, King Fahad University Hospital, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Kirill Orlov
- Endovascular Neurosurgery Research Center, Federal Center of Brain Research and Neurotechnologies of the Federal Medical Biological Agency of Russia, Moscow, Russia
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | | | - Guylaine Gevry
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| |
Collapse
|
15
|
Benomar A, Farzin B, Gevry G, Boisseau W, Roy D, Weill A, Iancu D, Guilbert F, Létourneau-Guillon L, Jacquin G, Chaalala C, Bojanowski MW, Labidi M, Fahed R, Volders D, Nguyen TN, Gentric JC, Magro E, Boulouis G, Forestier G, Hak JF, Ghostine JS, Kaderali Z, Shankar JJ, Kotowski M, Darsaut TE, Raymond J. Noninvasive Angiographic Results of Clipped or Coiled Intracranial Aneurysms: An Inter- and Intraobserver Reliability Study. AJNR Am J Neuroradiol 2021; 42:1615-1620. [PMID: 34326106 DOI: 10.3174/ajnr.a7236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/28/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND PURPOSE Noninvasive angiography is commonly used to assess the outcome of surgical or endovascular treatment of intracranial aneurysms in clinical series or randomized trials. We sought to assess whether a standardized 3-grade classification system could be reliably used to compare the CTA and MRA results of both treatments. MATERIALS AND METHODS An electronic portfolio composed of CTAs of 30 clipped and MRAs of 30 coiled aneurysms was independently evaluated by 24 raters of diverse experience and training backgrounds. Twenty raters performed a second evaluation 1 month later. Raters were asked which angiographic grade and management decision (retreatment; close or long-term follow-up) would be most appropriate for each case. Agreement was analyzed using the Krippendorff α (αK) statistic, and the relationship between angiographic grade and clinical management choice, using the Fisher exact and Cramer V tests. RESULTS Interrater agreement was substantial (αK = 0.63; 95% CI, 0.55-0.70); results were slightly better for MRA results of coiling (αK = 0.69; 95% CI, 0.56-0.76) than for CTA results of clipping (αK = 0.58; 95% CI, 0.44-0.69). Intrarater agreement was substantial to almost perfect. Interrater agreement regarding clinical management was moderate for both clipped (αK = 0.49; 95% CI, 0.32-0.61) and coiled subgroups (αK = 0.47; 95% CI, 0.34-0.54). The choice of clinical management was strongly associated with the size of the residuum (mean Cramer V = 0.77 [SD, 0.14]), but complete occlusions (grade 1) were followed more closely after coiling than after clipping (P = .01). CONCLUSIONS A standardized 3-grade scale was found to be a reliable and clinically meaningful tool to compare the results of clipping and coiling of aneurysms using CTA or MRA.
Collapse
Affiliation(s)
- A Benomar
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - B Farzin
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - G Gevry
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - W Boisseau
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - D Roy
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - A Weill
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - D Iancu
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - F Guilbert
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - L Létourneau-Guillon
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| | - G Jacquin
- Department of Medicine, Division of Neurology (G.J.)
| | - C Chaalala
- Division of Neurosurgery (C.C., M.W.B., M.L.), Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - M W Bojanowski
- Division of Neurosurgery (C.C., M.W.B., M.L.), Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - M Labidi
- Division of Neurosurgery (C.C., M.W.B., M.L.), Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - R Fahed
- Division ofNeurology (R.F.), The Ottawa Hospital Ottawa, Ontario, Canada
| | - D Volders
- Department of Diagnostic Radiology (D.V.), Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - T N Nguyen
- Departments of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - J-C Gentric
- Departments of Interventional Neuroradiology (J.-C.G.)
| | - E Magro
- Neurosurgery (E.M.), Hôpital de la Cavale Blanche, Centre Hospitalier Régional et Universitaire de Brest, Brest, France
| | - G Boulouis
- Department of Neuroradiology (G.B.), Centre Hospitalier Régional et Universitaire de Tours, Tours, France
| | - G Forestier
- Department of Neuroradiology (G.F.), University Hospital of Limoges, Limoges, France
| | - J-F Hak
- Department of Medical Imaging (J.-F.H.), University Hospital Timone Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - J S Ghostine
- Department of Radiology (J.S.G.), Jean-Talon Hospital, Montreal, Quebec, Canada
| | | | - J J Shankar
- Department of Radiology (J.J.S.), Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - M Kotowski
- Department of Neurosurgery (M.K.), Hôpital de la Providence, Neuchâtel, Switzerland
| | - T E Darsaut
- Department of Surgery (T.E.D.), Division of Neurosurgery,Walter C. Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - J Raymond
- From the Department of Radiology (A.B., B.F., G.G., W.B., D.R., A.W., D.I., F.G., L.L.-G., J.R.)
| |
Collapse
|
16
|
Darsaut TE, Fahed R, Raymond J. Unruptured aneurysms: Why observational studies fall short no matter how "Big" the Data. Neurochirurgie 2021; 67:330-335. [PMID: 33713661 DOI: 10.1016/j.neuchi.2021.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/09/2020] [Accepted: 02/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The best management of unruptured intracranial aneurysms (UIAs) remains unknown, despite multiple observational studies. A randomized trial (RCT) is in order. Yet, a National Institute Neurological Disorders and Stroke workshop has once again proposed to use prospective observational studies (POS) of large databases to address such problems. METHODS We review the historical misconceptions that have been associated with observations of UIAs and their treatments. We critically examine some recent methods that have been proposed to address shortcomings of observational studies. We finally review the ethical principles underlying the use of trial methods in the care of patients. RESULTS Replacing RCTs with POS submits patients to management options that have never been proven beneficial, while making them involuntary research subjects of studies that are inevitably biased. A science of practice cannot be an outsider's examination of the behavior of clinicians incapable of questioning their practice. The thesis we propose is that a science of practice must not only eventually determine what best practice will be; It must engage agents involved in medical practice to transparently reveal the uncertainty that calls for management options to be offered under the guidance of declared and controlled care research, to optimize patient outcomes in spite of the uncertainty. CONCLUSION To use POS rather than RCTs in medical practice is to renege on scientific and ethical principles that characterize modern medicine. Instead, we must learn to integrate care research into our practice to provide optimal medical care in real time.
Collapse
Affiliation(s)
- T E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Center, University of Alberta hospital, 8440 112th Street, Edmonton, T6G 2B7 Alberta, Canada.
| | - R Fahed
- Division of Neurology, Department of Medicine, The Ottawa Hospital-Civic Campus, 1053, Carling Avenue, K1Y 4E9 Ottawa, Ontario, Canada.
| | - J Raymond
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal, 1000, Saint-Denis, D03.5462B, H2X 0C1 Montreal, Quebec, Canada.
| |
Collapse
|
17
|
Angiographic results of surgical or endovascular treatment of intracranial aneurysms: a systematic review and inter-observer reliability study. Neuroradiology 2021; 63:1511-1519. [PMID: 33625550 DOI: 10.1007/s00234-021-02676-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Results of surgical or endovascular treatment of intracranial aneurysms are often assessed using angiography. A reliable method to report results irrespective of treatment modality is needed to enable comparisons. Our goals were to systematically review existing classification systems, and to propose a 3-point classification applicable to both treatments and assess its reliability. METHODS We conducted two systematic reviews on classification systems of angiographic results after clipping or coiling to select a simple 3-category scale that could apply to both treatments. We then circulated an electronic portfolio of angiograms of clipped (n=30) or coiled (n=30) aneurysms, and asked raters to evaluate the degree of occlusion using this scale. Raters were also asked to choose an appropriate follow-up management for each patient based on the degree of occlusion. Agreement was assessed using Krippendorff's α statistics (αK), and relationship between occlusion grade and clinical management was analyzed using Fisher's exact and Cramer's V tests. RESULTS The systematic reviews found 70 different grading scales with heterogeneous reliability (kappa values from 0.12 to 1.00). The 60-patient portfolio was independently evaluated by 19 raters of diverse backgrounds (neurosurgery, radiology, and neurology) and experience. There was substantial agreement (αK=0.76, 95%CI, 0.67-0.83) between raters, regardless of background, experience, or treatment used. Intra-rater agreement ranged from moderate to almost perfect. A strong relationship was found between angiographic grades and management decisions (Cramer's V: 0.80±0.12). CONCLUSION A simple 3-point scale demonstrated sufficient reliability to be used in reporting aneurysm treatments or in evaluating treatment results in comparative randomized trials.
Collapse
|
18
|
Houdart E. Commentary about a 20th meta-analysis. J Neurointerv Surg 2021; 13:e19. [PMID: 33514610 DOI: 10.1136/neurintsurg-2020-017234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 11/04/2022]
|
19
|
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]
|
20
|
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.
Collapse
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
| |
Collapse
|