C Ducroux1, R Fahed1, N N Khoury2, G Gevry3, E Kalsoum4, M-A Labeyrie5, D Ziegler6, C Sauve6, M Chagnon7, T E Darsaut8, J Raymond9. 1. Interventional Neuroradiology Department-Fondation Ophtalmologique Adolphe de Rothschild Hospital, 75019 Paris, France; Radiology Department-Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, H2X 3E4 Montreal, Canada. 2. HSHS Neuroscience Center - HSHS St. John's Hospital, 62769 Springfield, IL, USA. 3. Radiology Department-Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, H2X 3E4 Montreal, Canada. 4. Neuroadiology Department-Henri Mondor Hospital, 94010 Créteil, France. 5. Neuroadiology Department-Lariboisière Hospital, 75010 Paris, France. 6. CHUM Library - Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, H2X 3E4 Montreal-Québec, Canada. 7. Department of Mathematics and Statistic-Université de Montréal, H2X 3E4 Montreal-Québec, Canada. 8. Department of Surgery, Division of Neurosurgery - University of Alberta Hospital, Mackenzie Health Sciences Centre, T6G 2B7 Edmonton-Alberta, Canada. 9. Radiology Department-Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, H2X 3E4 Montreal, Canada. Electronic address: jean.raymond@umontreal.ca.
Abstract
PURPOSE: We aimed to assess agreement on intravenous tissue-plasminogen activator (IV tPA) and mechanical thrombectomy (MT) management decisions in acute ischemic stroke (AIS) patients. Secondary objectives were to assess agreement on Diffusion-Weighted-Imaging-Alberta-Stroke-Program-EArly-CT-Score (DWI-ASPECTS), and clinicians' willingness to recruit patients in a randomized controlled trial (RCT) comparing medical management with or without MT. MATERIALS AND METHODS: Studies assessing agreement of IV tPA and MT were systematically reviewed. An electronic portfolio of 41 AIS patients was sent to randomly selected providers at French stroke centers. Raters were asked 4 questions for each case: (1) What is the DWI-ASPECTS? (2) Would you perform IV tPA? (3) Would you perform MT? (4) Would you include the patient in a RCT comparing standard medical therapy with or without MT? Twenty responders were randomly selected to study intrarater agreement. Agreement was assessed using Fleiss' Kappa statistics. RESULTS: The review yielded two single center studies involving 2-5 raters, with various results. The electronic survey was answered by 86 physicians (60 vascular neurologists and 26 interventional neuroradiologists). The interrater agreement was moderate for IV tPA treatment decisions (κ=0.565 [0.420-0.680]), but only fair for MT (κ=0.383 [0.289-0.491]) and for combined treatment decisions (κ=0.399 [0.320-0.486]). The intrarater agreement was at least substantial for the majority of raters. The interrater agreement for DWI-ASPECTS was fair (κ=0.325 [0.276-0.387]). Physicians were willing to include a mean of 14±9 patients (33.1%±21.7%) in a RCT. CONCLUSION: Disagreements regarding the use of IVtPA or MT in the management of AIS patients remain frequent. Further trials are needed to resolve the numerous areas of uncertainty.
PURPOSE: We aimed to assess agreement on intravenous tissue-plasminogen activator (IV tPA) and mechanical thrombectomy (MT) management decisions in acute ischemic stroke (AIS) patients. Secondary objectives were to assess agreement on Diffusion-Weighted-Imaging-Alberta-Stroke-Program-EArly-CT-Score (DWI-ASPECTS), and clinicians' willingness to recruit patients in a randomized controlled trial (RCT) comparing medical management with or without MT. MATERIALS AND METHODS: Studies assessing agreement of IV tPA and MT were systematically reviewed. An electronic portfolio of 41 AISpatients was sent to randomly selected providers at French stroke centers. Raters were asked 4 questions for each case: (1) What is the DWI-ASPECTS? (2) Would you perform IV tPA? (3) Would you perform MT? (4) Would you include the patient in a RCT comparing standard medical therapy with or without MT? Twenty responders were randomly selected to study intrarater agreement. Agreement was assessed using Fleiss' Kappa statistics. RESULTS: The review yielded two single center studies involving 2-5 raters, with various results. The electronic survey was answered by 86 physicians (60 vascular neurologists and 26 interventional neuroradiologists). The interrater agreement was moderate for IV tPA treatment decisions (κ=0.565 [0.420-0.680]), but only fair for MT (κ=0.383 [0.289-0.491]) and for combined treatment decisions (κ=0.399 [0.320-0.486]). The intrarater agreement was at least substantial for the majority of raters. The interrater agreement for DWI-ASPECTS was fair (κ=0.325 [0.276-0.387]). Physicians were willing to include a mean of 14±9 patients (33.1%±21.7%) in a RCT. CONCLUSION: Disagreements regarding the use of IVtPA or MT in the management of AISpatients remain frequent. Further trials are needed to resolve the numerous areas of uncertainty.
Authors: Caleb Simpeh Edwards; Simon Gashaw Ammanuel; Ogonna N Nnamani Silva; Garret P Greeneway; Katherine M Bunch; Lars W Meisner; Paul S Page; Azam S Ahmed Journal: Surg Neurol Int Date: 2022-09-02