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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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.
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Raymond J, Létourneau-Guillon L, Darsaut TE, Findlay JM, Chow MM, Keough MB, Chan AM, Farzin B, Gevry G, Chagnon M, Zehr J. Reply. AJNR Am J Neuroradiol 2022; 43:E4. [PMID: 35241423 PMCID: PMC8910809 DOI: 10.3174/ajnr.a7454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J. Raymond
- Department of Radiology, Neuroradiology Service Centre Hospitalier de l’Université de Montréal (CHUM), Montreal Quebec, CanadaCHUM Research Centre, MontrealQuebec, Canada
| | - L. Létourneau-Guillon
- Department of Radiology, Neuroradiology Service Centre Hospitalier de l’Université de Montréal (CHUM), Montreal Quebec, CanadaCHUM Research Centre, MontrealQuebec, Canada
| | - T E Darsaut
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - J M Findlay
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - M M Chow
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - M B Keough
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - A M Chan
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | | | - G Gevry
- CHUM Research Centre, MontrealQuebec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics Université de Montréal, Montreal Quebec, Canada
| | - J Zehr
- Department of Mathematics and Statistics Université de Montréal, Montreal Quebec, Canada
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Darsaut T, Keough M, Chan A, Farzin B, Findlay J, Chow M, Chagnon M, Zehr J, Gevry G, Raymond J. Transcranial Doppler Velocities and Angiographic Vasospasm after SAH: A Diagnostic Accuracy Study. AJNR Am J Neuroradiol 2022; 43:80-86. [PMID: 34794947 PMCID: PMC8757545 DOI: 10.3174/ajnr.a7347] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE After aneurysmal SAH, transcranial Doppler is commonly used to monitor cerebral vasospasm. The diagnostic accuracy of transcranial Doppler flow velocity values in detecting angiographic vasospasm in patients requiring urgent endovascular intervention has not been established. MATERIALS AND METHODS We performed a retrospective analysis of a consecutive series of patients with aneurysmal SAH who underwent transcranial Doppler (index test) within 24 hours of conventional angiography (reference test). The judgment of 33%, 50%, and 66% degree of vessel narrowing on angiography was independently established by multiple neuroendovascular clinicians. Vessel-specific per-segment and per-patient transcranial Doppler velocities were studied using receiver operating characteristic curves, the Youden index, and minimal acceptable sensitivity models. Optimal mean flow-velocity thresholds were explored to calculate sensitivity and specificity using a per-patient judgment of vasospasm of at least 50% angiographic narrowing in any large arterial segment except A1. RESULTS In 221 patients, vasospasm was found in 15%, 8%, and 4% of arteries when the degree of reference angiographic luminal narrowing was 33%, 50%, and 66%, respectively. Mean flow velocities were significantly higher in vasospastic segments (P = . 001), but per-segment exploratory analyses yielded unsound mean flow velocity thresholds. The Youden and minimal acceptable sensitivity models proposed mean flow velocity thresholds of approximately 160 cm/s for the anterior circulation and 80 cm/s for the posterior circulation in the per-patient diagnosis of angiographic vasospasm (≥50%), yielding a sensitivity of 80%-90% (95% CI, 0.77-0.96), but with a corresponding specificity of 50% (95% CI, 0.40-0.56). CONCLUSIONS In this study, a threshold transcranial Doppler mean flow-velocity value that would accurately diagnose ≥50% angiographic vasospasm remained elusive.
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Affiliation(s)
- T.E. Darsaut
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M.B. Keough
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - A.M. Chan
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - B. Farzin
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - J.M. Findlay
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M.M. Chow
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M. Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Quebec, Canada
| | - J. Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Quebec, Canada
| | - G. Gevry
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - J. Raymond
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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.)
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Darsaut TE, Derksen C, Farzin B, Keough MB, Fahed R, Boisseau W, Letourneau-Guillon L, Januel AC, Weill A, Roy D, Nguyen TN, Finitsis S, Gentric JC, Volders D, Carlson A, Chow MM, O'Kelly C, Rempel JL, Ashforth RA, Chagnon M, Zehr J, Findlay JM, Gevry G, Raymond J. Reliability of the Diagnosis of Cerebral Vasospasm Using Catheter Cerebral Angiography: A Systematic Review and Inter- and Intraobserver Study. AJNR Am J Neuroradiol 2021; 42:501-507. [PMID: 33509923 DOI: 10.3174/ajnr.a7021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the following: 1) to systematically review the literature on the reliability of the diagnosis of cerebral vasospasm using conventional angiography, and 2) to perform an agreement study among clinicians who perform endovascular treatment. MATERIALS AND METHODS Articles reporting a classification system on the degree of cerebral vasospasm on conventional angiography were systematically searched, and agreement studies were identified. We assembled a portfolio of 221 cases of patients with subarachnoid hemorrhage and asked 17 raters with different backgrounds (radiology, neurosurgery, or neurology) and experience (junior ≤10 and senior >10 years) to independently evaluate cerebral vasospasm in 7 vessel segments using a 3-point scale and to evaluate, for each case, whether findings would justify endovascular treatment. Nine raters took part in the intraobserver reliability study. RESULTS The systematic review showed a very heterogeneous literature, with 140 studies using 60 different nomenclatures and 21 different thresholds to define cerebral vasospasm, and 5 interobserver studies reporting a wide range of reliability (κ = 0.14-0.87). In our study, only senior raters reached substantial agreement (κ ≥ 0.6) on vasospasm of the supraclinoid ICA, M1, and basilar segments and only when assessments were dichotomized (presence or absence of ≥50% narrowing). Agreement on whether to proceed with endovascular management of vasospasm was only fair (κ ≤ 0.4). CONCLUSIONS Research on cerebral vasospasm would benefit from standardization of definitions and thresholds. Dichotomized decisions by experienced readers are required for the reliable angiographic diagnosis of cerebral vasospasm.
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Affiliation(s)
- T E Darsaut
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - C Derksen
- Stroke Program (C.D.), Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - B Farzin
- Research Center (B.F., G.G., J.R.)
| | - M B Keough
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - R Fahed
- Department of Medicine (R.F.), Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - W Boisseau
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - L Letourneau-Guillon
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - A-C Januel
- Service de Neuroradiologie (A.-C.J.), Hôpital Purpan, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - A Weill
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - D Roy
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - T N Nguyen
- Service of Interventional Neurology and Neuroradiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - S Finitsis
- Department of Radiology (S.F.), Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - J-C Gentric
- Department of Radiology (J.-C.G.), Division of Neuroradiology, Centre Hospitalier Universitaire Cavale Blanche, Brest, France
| | - D Volders
- Department of Radiology (D.V.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - A Carlson
- Department of Neurosurgery (A.C.), University of New Mexico, Albuquerque, New Mexico
| | - M M Chow
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - C O'Kelly
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - J L Rempel
- Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
| | - R A Ashforth
- Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Province du Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Province du Québec, Canada
| | - J M Findlay
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - G Gevry
- Research Center (B.F., G.G., J.R.)
| | - J Raymond
- Research Center (B.F., G.G., J.R.) .,Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
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Veilleux C, Farzin B, Chaalala C, Labidi M, Raymond J, Bojanowski M. Les anévrismes du segment A1 de l’artère cérébrale antérieure : revue systématique de la littérature. Neurochirurgie 2020. [DOI: 10.1016/j.neuchi.2020.06.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Letourneau-Guillon L, Farzin B, Darsaut TE, Kotowski M, Guilbert F, Chagnon M, Diouf A, Roy D, Weill A, Lemus M, Bard C, Belair M, Landry D, Nico L, Tellier A, Jabre R, Kauffmann C, Raymond J. Reliability of CT Angiography in Cerebral Vasospasm: A Systematic Review of the Literature and an Inter- and Intraobserver Study. AJNR Am J Neuroradiol 2020; 41:612-618. [PMID: 32217551 DOI: 10.3174/ajnr.a6462] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/27/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Computed tomography angiography offers a non-invasive alternative to DSA for the assessment of cerebral vasospasm following subarachnoid hemorrhage but there is limited evidence regarding its reliability. Our aim was to perform a systematic review (Part I) and to assess (Part II) the inter- and intraobserver reliability of CTA in the diagnosis of cerebral vasospasm. MATERIALS AND METHODS In Part I, articles reporting the reliability of CTA up to May 2018 were systematically searched and evaluated. In Part II, 11 raters independently graded 17 arterial segments in each of 50 patients with SAH for the presence of vasospasm using a 4-category scale. Raters were additionally asked to judge the presence of any moderate/severe vasospasm (≥ 50% narrowing) and whether findings would justify augmentation of medical treatment or conventional angiography ± balloon angioplasty. Four raters took part in the intraobserver reliability study. RESULTS In Part I, the systematic review revealed few studies with heterogeneous vasospasm definitions. In Part II, we found interrater reliability to be moderate at best (κ ≤ 0.6), even when results were stratified according to specialty and experience. Intrarater reliability was substantial (κ > 0.6) in 3/4 readers. In the per arterial segment analysis, substantial agreement was reached only for the middle cerebral arteries, and only when senior raters' judgments were dichotomized (presence or absence of ≥50% narrowing). Agreement on the medical or angiographic management of vasospasm based on CTA alone was less than substantial (κ ≤ 0.6). CONCLUSIONS The diagnosis of vasospasm using CTA alone was not sufficiently repeatable among observers to support its general use to guide decisions in the clinical management of patients with SAH.
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Affiliation(s)
- L Letourneau-Guillon
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - B Farzin
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - T E Darsaut
- Department of Surgery (T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - M Kotowski
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - F Guilbert
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - M Chagnon
- Statistical Consultation Services (M.C.), Department of Mathematics and Statistics, Universite de Montreal, Quebec, Canada
| | - A Diouf
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - D Roy
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - A Weill
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - M Lemus
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - C Bard
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - M Belair
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - D Landry
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - L Nico
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - A Tellier
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
| | - R Jabre
- Neurosurgery Division, Surgery Department (R.J.), Centre Hospitalier de l'Universite de Montreal, Universite de Montreal, Montreal, Quebec, Canada
| | - C Kauffmann
- Laboratoire Clinique du Traitement de l'Image (C.K.), Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Universite de Montreal, Montreal, Quebec, Canada
| | - J Raymond
- From the Radiology Department (L.L.-G., B.F., M.K., F.G., A.D., D.R., A.W., M.L., C.B., M.B., D.L., L.N., A.T., J.R.), Centre Hospitalier de l'Universite de Montreal (CHUM), Centre de Recherche du CHUM (CRCHUM), Universite de Montreal, Montreal, Quebec, Canada
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Farzin B, Brosseau L, Jamali S, Salazkin I, Jack A, Darsaut TE, Raymond J. Flow diverters: inter and intra-rater reliability of porosity and pore density measurements. J Neurointerv Surg 2014; 7:734-9. [DOI: 10.1136/neurintsurg-2014-011240] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/11/2014] [Indexed: 11/04/2022]
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