Surgical or endovascular management of ruptured intracranial aneurysms

An agreement study

Tim E. Darsaut, Robert Fahed, R. Loch Macdonald, Adam Arthur, M. Yashar S. Kalani, Fuat Arikan, Daniel Roy, Alain Weill, Alain Bilocq, Jeremy L. Rempel, Michael M. Chow, Robert A. Ashforth, J. Max Findlay, Luis H. Castro-Afonso, Miguel Chagnon, Guylaine Gevry, Jean Raymond

Research output: Contribution to journalArticle

Abstract

Objective: Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA. Methods: The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non-middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage patients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0-10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics. Results: Eighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8%] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8%) than for ISAT (26.2%) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95% CI 0.158-0.276) for all cases and judges, despite high confidence levels (mean score > 8 for all cases). Agreement was no better within subgroups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (abil- ity to clip or coil, or both). When agreement was defined as > 80% of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred. Conclusions: Agreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.

Original languageEnglish (US)
Pages (from-to)25-31
Number of pages7
JournalJournal of neurosurgery
Volume131
Issue number1
DOIs
StatePublished - Jan 1 2019

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Ruptured Aneurysm
Intracranial Aneurysm
Aneurysm
Surgical Instruments
Cerebral Arteries

All Science Journal Classification (ASJC) codes

  • Surgery
  • Clinical Neurology

Cite this

Darsaut, T. E., Fahed, R., Macdonald, R. L., Arthur, A., Kalani, M. Y. S., Arikan, F., ... Raymond, J. (2019). Surgical or endovascular management of ruptured intracranial aneurysms: An agreement study. Journal of neurosurgery, 131(1), 25-31. https://doi.org/10.3171/2018.1.JNS172645

Surgical or endovascular management of ruptured intracranial aneurysms : An agreement study. / Darsaut, Tim E.; Fahed, Robert; Macdonald, R. Loch; Arthur, Adam; Kalani, M. Yashar S.; Arikan, Fuat; Roy, Daniel; Weill, Alain; Bilocq, Alain; Rempel, Jeremy L.; Chow, Michael M.; Ashforth, Robert A.; Findlay, J. Max; Castro-Afonso, Luis H.; Chagnon, Miguel; Gevry, Guylaine; Raymond, Jean.

In: Journal of neurosurgery, Vol. 131, No. 1, 01.01.2019, p. 25-31.

Research output: Contribution to journalArticle

Darsaut, TE, Fahed, R, Macdonald, RL, Arthur, A, Kalani, MYS, Arikan, F, Roy, D, Weill, A, Bilocq, A, Rempel, JL, Chow, MM, Ashforth, RA, Findlay, JM, Castro-Afonso, LH, Chagnon, M, Gevry, G & Raymond, J 2019, 'Surgical or endovascular management of ruptured intracranial aneurysms: An agreement study', Journal of neurosurgery, vol. 131, no. 1, pp. 25-31. https://doi.org/10.3171/2018.1.JNS172645
Darsaut, Tim E. ; Fahed, Robert ; Macdonald, R. Loch ; Arthur, Adam ; Kalani, M. Yashar S. ; Arikan, Fuat ; Roy, Daniel ; Weill, Alain ; Bilocq, Alain ; Rempel, Jeremy L. ; Chow, Michael M. ; Ashforth, Robert A. ; Findlay, J. Max ; Castro-Afonso, Luis H. ; Chagnon, Miguel ; Gevry, Guylaine ; Raymond, Jean. / Surgical or endovascular management of ruptured intracranial aneurysms : An agreement study. In: Journal of neurosurgery. 2019 ; Vol. 131, No. 1. pp. 25-31.
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abstract = "Objective: Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA. Methods: The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non-middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage patients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0-10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics. Results: Eighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8{\%}] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8{\%}) than for ISAT (26.2{\%}) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95{\%} CI 0.158-0.276) for all cases and judges, despite high confidence levels (mean score > 8 for all cases). Agreement was no better within subgroups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (abil- ity to clip or coil, or both). When agreement was defined as > 80{\%} of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred. Conclusions: Agreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.",
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T1 - Surgical or endovascular management of ruptured intracranial aneurysms

T2 - An agreement study

AU - Darsaut, Tim E.

AU - Fahed, Robert

AU - Macdonald, R. Loch

AU - Arthur, Adam

AU - Kalani, M. Yashar S.

AU - Arikan, Fuat

AU - Roy, Daniel

AU - Weill, Alain

AU - Bilocq, Alain

AU - Rempel, Jeremy L.

AU - Chow, Michael M.

AU - Ashforth, Robert A.

AU - Findlay, J. Max

AU - Castro-Afonso, Luis H.

AU - Chagnon, Miguel

AU - Gevry, Guylaine

AU - Raymond, Jean

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Objective: Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA. Methods: The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non-middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage patients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0-10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics. Results: Eighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8%] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8%) than for ISAT (26.2%) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95% CI 0.158-0.276) for all cases and judges, despite high confidence levels (mean score > 8 for all cases). Agreement was no better within subgroups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (abil- ity to clip or coil, or both). When agreement was defined as > 80% of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred. Conclusions: Agreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.

AB - Objective: Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA. Methods: The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non-middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage patients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0-10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics. Results: Eighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8%] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8%) than for ISAT (26.2%) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95% CI 0.158-0.276) for all cases and judges, despite high confidence levels (mean score > 8 for all cases). Agreement was no better within subgroups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (abil- ity to clip or coil, or both). When agreement was defined as > 80% of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred. Conclusions: Agreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.

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