David Leander Rimmele1, Axel Larena-Avellaneda1, Anna C Alegiani1, Michael Rosenkranz1, Nils Ole Schmidt1, Jan Regelsberger1, Friedhelm C Hummel1, Tim Magnus1, Eike Sebastian Debus1, Jens Fiehler1, Christian Gerloff1, Götz Thomalla2. 1. From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland. 2. From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland. thomalla@uke.de.
Abstract
OBJECTIVE: To describe our experience with consensus-based decision-making for treatment of internal carotid artery (ICA) stenosis by neurologists, interventional neuroradiologists, vascular surgeons, and neurosurgeons in a multidisciplinary neurovascular board and to study adherence to treatment recommendations in the context of uncertainty with respect to the best treatment option. METHODS: We established a multidisciplinary neurovascular board meeting twice a week with structured documentation of consensus decisions. Over a time period of 53 months, 614 cases with ICA stenosis were discussed, with 285 (46%) symptomatic and 279 (45%) asymptomatic cases. RESULTS: Recommendation for symptomatic ICA stenosis was revascularization in 76%, medical management alone in 8%, and further diagnostics in 16%. For asymptomatic ICA stenosis, recommendation was randomization in a clinical trial in 29%, revascularization in 27%, medical management alone in 23%, and further diagnostics in 22%. Treatment recommendations were followed in 94% of symptomatic ICA stenosis and 69% of asymptomatic ICA stenosis. Patients in whom carotid artery stenting was recommended for revascularization were younger and showed a higher rate of severe (≥70%) ICA stenosis. CONCLUSIONS: Interdisciplinary board decisions are a helpful and transparent tool to assure adherence to guideline recommendations, and to provide consensus-based individualized treatment strategies in clinical practice in the absence of unequivocal evidence.
OBJECTIVE: To describe our experience with consensus-based decision-making for treatment of internal carotid artery (ICA) stenosis by neurologists, interventional neuroradiologists, vascular surgeons, and neurosurgeons in a multidisciplinary neurovascular board and to study adherence to treatment recommendations in the context of uncertainty with respect to the best treatment option. METHODS: We established a multidisciplinary neurovascular board meeting twice a week with structured documentation of consensus decisions. Over a time period of 53 months, 614 cases with ICA stenosis were discussed, with 285 (46%) symptomatic and 279 (45%) asymptomatic cases. RESULTS: Recommendation for symptomatic ICA stenosis was revascularization in 76%, medical management alone in 8%, and further diagnostics in 16%. For asymptomatic ICA stenosis, recommendation was randomization in a clinical trial in 29%, revascularization in 27%, medical management alone in 23%, and further diagnostics in 22%. Treatment recommendations were followed in 94% of symptomatic ICA stenosis and 69% of asymptomatic ICA stenosis. Patients in whom carotid artery stenting was recommended for revascularization were younger and showed a higher rate of severe (≥70%) ICA stenosis. CONCLUSIONS: Interdisciplinary board decisions are a helpful and transparent tool to assure adherence to guideline recommendations, and to provide consensus-based individualized treatment strategies in clinical practice in the absence of unequivocal evidence.