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Decision-making and neurosurgeons’ agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography

  • Original Article - Vascular
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Abstract

Background

To determine the neurosurgeon’s agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater’s level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation.

Method

Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated.

Results

There was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387–0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386–0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398–0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416–235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03–0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044–0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088–0.643; p = 0.005) were associated with a recommendation for endovascular treatment.

Conclusions

Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.

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Funding

No funding was received for this research.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland

    Nicolai Maldaner, Jan-Karl Burkhardt, Martin Nikolaus Stienen, Carlo Serra, Giuseppe Esposito, Marian C. Neidert, Oliver Bozinov & Luca Regli

  2. Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland

    Martin Nikolaus Stienen & Philippe Bijlenga

  3. Department of Neurosurgery, University Hospital Bern, Bern, Switzerland

    Johannes Goldberg & David Bervini

  4. Department of Neurosurgery, Basel University Hospital, Basel, Switzerland

    Davide Croci & Daniel Zumofen

  5. Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel, Switzerland

    Davide Croci & Daniel Zumofen

  6. Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland

    Donato D’Alonzo & Serge Marbacher

  7. Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

    Rodolfo Maduri & Roy Thomas Daniel

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  1. Nicolai Maldaner
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  2. Jan-Karl Burkhardt
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  13. Carlo Serra
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Correspondence to Nicolai Maldaner.

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Conflict of interest

All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Maldaner, N., Burkhardt, JK., Stienen, M.N. et al. Decision-making and neurosurgeons’ agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography. Acta Neurochir 160, 253–260 (2018). https://doi.org/10.1007/s00701-017-3415-6

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  • DOI: https://doi.org/10.1007/s00701-017-3415-6

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