Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Tufts Medical Center, Boston, Massachusetts, United States of America.
Center for Outcomes Research & Evaluation, Maine Medical Center Research Institute, Portland, Maine, United States of America.
PLoS One. 2018 Mar 29;13(3):e0194971. doi: 10.1371/journal.pone.0194971. eCollection 2018.
While silent brain infarcts (SBIs) in screened cohorts are associated with risk of symptomatic stroke and dementia, the clinical significance of incidentally discovered SBIs (id-SBIs) is unknown. Detection may offer an opportunity to initiate prevention measures, but uncertainties about id-SBIs may impede clinicians from addressing them and complicate further study of this condition.
This study used semi-structured interviews of practicing clinicians. Interviews were audio recorded, transcribed, and analyzed using a grounded theory approach. A constant comparative method was used to organize emergent themes and examine new themes. Purposeful sampling was employed to achieve participant diversity. Fifteen clinicians were interviewed. Emergent themes centered on uncertainty about id-SBIs, clinical decision making in response to uncertainty, and evidence needed to resolve uncertainty. All clinicians reported uncertainty about id-SBIs: diagnostic, prognostic, or therapeutic. Differential responses to uncertainties resulted in practice variation within and between specialties. Diagnostic and prognostic uncertainty discouraged disclosure of imaging findings to patients. Vascular neurologists viewed the prognostic significance of id-SBIs as similar to symptomatic stroke. Therapeutic uncertainty was common, but most participants endorsed using stroke secondary prevention strategies. Regarding future research, all internists indicated they would consider changing practices in response to observational studies, whereas half of the neurologists expressed reluctance to modify practices based on non-randomized data. Several expressed concerns about clinical trial feasibility and lack of equipoise.
id-SBIs are a focus of uncertainty for clinicians, leading to practice variation. Future studies must address diagnostic and prognostic uncertainty to facilitate implementation of prevention strategies.
虽然筛查队列中的无症状性脑梗死（SBI）与症状性中风和痴呆的风险相关，但偶然发现的 SBI（id-SBI）的临床意义尚不清楚。检测可能提供了一个启动预防措施的机会，但 id-SBI 存在的不确定性可能会阻碍临床医生解决这些问题，并使进一步研究这一情况变得复杂。
本研究采用了对执业临床医生的半结构式访谈。访谈内容进行了录音、转录，并使用扎根理论方法进行了分析。采用恒定比较法对新出现的主题进行组织和检查。采用有目的的抽样来实现参与者的多样性。共对 15 名临床医生进行了访谈。出现的主题集中在 id-SBI 的不确定性、对不确定性的临床决策以及解决不确定性所需的证据上。所有临床医生都报告了对 id-SBI 的不确定性：诊断、预后或治疗。对不确定性的不同反应导致了不同专业内部和之间的实践差异。诊断和预后的不确定性阻止了向患者透露成像结果。血管神经病学家认为 id-SBI 的预后意义与症状性中风相似。治疗的不确定性很常见，但大多数参与者都赞成使用中风二级预防策略。关于未来的研究，所有内科医生都表示，如果观察性研究显示需要改变实践，他们会考虑这样做，而一半的神经科医生则表示不愿意根据非随机数据改变实践。一些人对临床试验的可行性和缺乏平衡表示担忧。
id-SBI 是临床医生关注的焦点，导致了实践的差异。未来的研究必须解决诊断和预后的不确定性，以促进预防策略的实施。
