Elsevier

Revue Neurologique

Volume 175, Issue 6, June 2019, Pages 380-389
Revue Neurologique

Original article
Intravenous thrombolysis and thrombectomy decisions in acute ischemic stroke: An interrater and intrarater agreement study

https://doi.org/10.1016/j.neurol.2018.10.005Get rights and content

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.

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:

  • original research (review articles, abstracts, editorials and letters were excluded);

  • 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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