Boisseau W, Benomar A, Ducroux C, Fahed R, Smajda S, Diestro J D B, Charbonnier G, Ognard J, Burel J, Ter Schiphorst A, Boulanger M, Nehme A, Boucherit J, Marnat G, Volders D, Holay Q, Forestier G, Bretzner M, Roy D, Vingadassalom S, Elhorany M, Nico L, Jacquin G, Abdalkader M, Guedon A, Seners P, Janot K, Dumas V, Olatunji R, Gazzola S, Milot G, Zehr J, Darsaut T E, Iancu D, Raymond J
From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France.
Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada.
AJNR Am J Neuroradiol. 2024 Feb 22;45(4):400-5. doi: 10.3174/ajnr.A8149.
The best management of patients with persistent distal occlusion after mechanical thrombectomy with or without IV thrombolysis remains unknown. We sought to evaluate the variability and agreement in decision-making for persistent distal occlusions.
A portfolio of 60 cases was sent to clinicians with varying backgrounds and experience. Responders were asked whether they considered conservative management or rescue therapy (stent retriever, aspiration, or intra-arterial thrombolytics) a treatment option as well as their willingness to enroll patients in a randomized trial. Agreement was assessed using κ statistics.
The electronic survey was answered by 31 physicians (8 vascular neurologists and 23 interventional neuroradiologists). Decisions for rescue therapies were more frequent ( = 1116/1860, 60%) than for conservative management ( = 744/1860, 40%; < .001). Interrater agreement regarding the final management decision was "slight" (κ = 0.12; 95% CI, 0.09-0.14) and did not improve when subgroups of clinicians were studied according to background, experience, and specialty or when cases were grouped according to the level of occlusion. On delayed re-questioning, 23 of 29 respondents (79.3%) disagreed with themselves on at least 20% of cases. Respondents were willing to offer trial participation in 1295 of 1860 (69.6%) cases.
Individuals did not agree regarding the best management of patients with persistent distal occlusion after mechanical thrombectomy and IV thrombolysis. There is sufficient uncertainty to justify a dedicated randomized trial.
对于接受或未接受静脉溶栓的机械取栓术后持续性远端闭塞患者的最佳治疗方案仍不明确。我们试图评估针对持续性远端闭塞进行决策时的变异性和一致性。
向背景和经验各异的临床医生发送了包含60个病例的资料。询问回复者他们是否将保守治疗或挽救性治疗（支架取栓、抽吸或动脉内溶栓）视为一种治疗选择，以及他们让患者参加随机试验的意愿。使用κ统计量评估一致性。
31名医生（8名血管神经科医生和23名介入神经放射科医生）回复了电子调查问卷。挽救性治疗的决策比保守治疗更常见（1116/1860，60% 对比 744/1860，40%；P <.001）。关于最终治疗决策的评分者间一致性为“轻微”（κ = 0.12；95% CI，0.09 - 0.14），并且在根据背景、经验和专业对临床医生亚组进行研究时，或者根据闭塞程度对病例进行分组时，一致性并未改善。在延迟重新询问时，29名受访者中有23名（79.3%）在至少20%的病例上与自己之前的意见不一致。在1860例病例中，有1295例（69.6%）受访者愿意让患者参加试验。
对于机械取栓和静脉溶栓后持续性远端闭塞患者的最佳治疗方案，个体之间意见不一致。存在足够的不确定性，有理由开展一项专门的随机试验。
