Original articleIntravenous thrombolysis and thrombectomy decisions in acute ischemic stroke: An interrater and intrarater agreement study
Introduction
Intravenous thrombolysis with tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT) have been proven effective in reducing morbidity in AIS patients in multiple randomized controlled trials (RCTs) [1], [2]. Most RCTs have used restrictive selection criteria, leaving multiple clinical uncertainties in spite of published guidelines [3], [4]. This uncertainty may translate into diverging clinical practices.
Agreement in making clinical decisions on individual AIS patients has rarely been studied [5]. Our first aim was to assess the inter- and intrarater agreement on the use of IV tPA and/or MT in the management of diverse AIS patients using a portfolio of selected cases.
More inclusive future trials may address remaining uncertainties; a secondary aim was to document how often clinicians would propose participation in a RCT comparing standard medical therapy (including IV tPA) with or without MT.
Finally, computed tomography (CT) and the Alberta-Stroke-Program-EArly-CT-Score (ASPECTS) [6] were used in most thrombectomy trials. However, in the “THrombectomie des Artères CErébrales” (THRACE) trial [7], most patients underwent brain MRI, thought to be more reliable for the detection and grading of early ischemic lesions, [8] in accordance with French guidelines [9]. Another secondary aim of this study was to evaluate the inter- and intrarater agreement of the Diffusion-Weighted-Imaging-ASPECTS (DWI-ASPECTS) [10] in AIS candidates for IV tPA or MT.
Section snippets
Literature systematic review
We initially performed a systematic review on management decisions regarding AIS patients. The protocol and search strategy, written in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA), [11] are provided in Appendix A. We included all articles that met the following selection criteria:
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original research (review articles, abstracts, editorials and letters were excluded);
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estimates of reliability or agreement of IV tPA or MT decisions for a group of
Systematic review
Two pertinent studies [20], [21] were identified (flow diagram provided in Fig. 1): one study involving 5 raters and 25 confirmed AIS patients found a fair-to-moderate agreement for the decision to perform MT; [20] while the other, involving 2 to 3 raters and 60 patients with a suspected AIS found substantial agreement for IV tPA and MT decisions [21].
Agreement study
The electronic survey was distributed and answered between November 2016 and April 2017. Eighty-six clinicians participated in the study (60
Discussion
This study found that disagreements are frequent in the management of AIS patients. Clinicians were more likely to disagree on decisions that concerned categories of patients that were excluded from past trials, and clinicians were willing to offer participation in a new RCT in approximately one third of patients. Agreement on the DWI-ASPECTS was moderate at best, raising concerns regarding its use for making clinical recommendations.
There have been few agreement studies on the management of
Conclusion
Disagreements regarding the use of IV tPA or MT in the management of AIS patients remain frequent. Further trials are needed to resolve the numerous areas of uncertainty.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Disclosure of interest
The authors declare that they have no competing interest.
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Cited by (7)
Intra- and inter-rater consistency of dual assessment by radiologist and neurologist for evaluating DWI-ASPECTS in ischemic stroke
2022, Revue NeurologiqueCitation Excerpt :Interrater agreement is assumed to be higher for DWI-ASPECTS [5,14–16]. Concerns were raise for evaluations performed by standalone evaluators, leading to comparison of neuroradiologists and vascular neurologists performances [17,18]. We hypothesized that double-reading by neurologists and radiologists would increase the reliability of DWI-ASPECTS evaluation.
Patients’ selection for mechanical thrombectomy and the wrong axis comparisons
2019, Journal of NeuroradiologyMeasuring clinical uncertainty as a preliminary step to randomized controlled trials
2019, Journal of Clinical EpidemiologyEFFICACY OF INTRAVENOUS THROMBOLYSIS COMBINED WITH MECHANICAL STENT INTERVENTIONAL THROMBECTOMY ON ACUTE ISCHEMIC STROKE
2022, Journal of Medical BiochemistryAcademics versus the Internet: Evaluating the readability of patient education materials for cerebrovascular conditions from major academic centers
2022, Surgical Neurology InternationalPhysician, know thyself: Implicit and explicit decision-making for mechanical thrombectomy in stroke
2020, Journal of NeuroInterventional Surgery
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FAMOUS collaborative group members (90 physicians):Philippe NICLOT, Alain AMERI, Jérôme HODEL, Jean-Christophe GENTRIC, François-Mathias MERRIEN, Aurore JOURDAIN, François ROUHART, Irina VIAKHIREVA, Serge TIMSIT, Frédéric CLARENÇON, Silvia PISTOCCHI, Charlotte ROSSO, Chiara ZAVANONE, Emmanuel HOUDART, Marc-Antoine LABEYRIE, Peggy REINER, Benjamin GORY, Roberto RIVA, Norbert NIGHOGHOSSIAN, Tae-Hee CHO, Laurent DEREX, François EUGÈNE, Jean-Christophe FERRÉ, Anthony LE BRAS, Stéphane VANNIER, Maria LASSALLE, Cyril CHIVOT, Audrey ARNOUX, Philippe ALLA, Jean-Brice VEYRIERES, Gaultier MARNAT, Jérôme BERGE, Stéphane OLINDO, Igor SIBON, Bertrand LAPERGUE, Adrien WANG, Arturo CONSOLI, Federico DI MARIA, Michael OBADIA, Candice SABBEN, Mikael MAZIGHI, Hocine REDJEM, Michel PIOTIN, William BOISSEAU, Lilia RAZLOG, Raoul POP, Rémy BEAUJEUX, Dan MIHOC, Sébastian RICHTER, Monica MANISOR, Valérie WOLFF, Véronique QUENARDELLE, Lisa ZINCHENKO, Mihaela DIACONU, Marion YGER, Stephen DELORME, Christina IOSIF, Thierry MOULIN, Hatem ZEKRI, François LALLEMENT, Olivier VERCRUYSSE, Christanthi PAPAGIANNAKI, Ozlem OZKUL-WERMESTER, Cyril DARGAZANLI, Vincent COSTALAT, Nicolas GAILLARD, Caroline ARQUIZAN, Mireille CAYRE-CASTEL, Serge BRACARD, Anne-Laure DERELLE, Sébastien RICHARD, Lisa HUMBERTJEAN, Yann HERVÉ, Pascal FAVROLE, Patrick LE COZ, Thomas DE BROUKER, Marie-Isabelle FORCE, Serge AKONO, Serkan CAKMAK, Alexandru FLOREA, Thibault LALU, Grégory TAURIN, Duc Long DUONG, Marie-Laure CHADENAT, Fernando PICO, Rémi ALLIBERT, Sarah EVAIN, Philippe TASSAN, Eric BERTHIER, Xavier DUCROCQ, Matthieu RIGAL, Marion BOULANGER.