Sara Jamali MD, Presenter: Nothing to Disclose

Tim E. Darsaut MD, Abstract Co-Author: Nothing to Disclose

Max Findlay MD, Abstract Co-Author: Nothing to Disclose

Jean Raymond MD, Abstract Co-Author: Nothing to Disclose

The management of Unruptured Intracranial Aneurysms (UIAs) remains controversial. The goal of this study was to evaluate the clinical community agreement in decision making regarding UIAs.

A portfolio of 41 cases of UIAs with angiographic images, along with a short description of the patient presentation, was sent to 28, mainly Canadian, clinicians with various years of experience in the management of UIAs (15 radiologists and 13 surgeons). Five clinicians responded twice at least 3 months apart. Nineteen cases were selected from patients recruited in a randomized trial comparing coiling and clipping, the Cures trial. For each case, the responder was to choose between 3 treatment options (observation, surgical clipping, or endovascular coiling) and indicate their level of certainty on a quantitative scale. The variability was studied using k statistics from 0 to 1, 0 meaning no agreement, 1 perfect and 0.6 substantial agreement.

Decisions to coil were more frequent (612 or 53%) than decisions to clip (289 or 25%) or to observe (259 or 22%). Inter-judge agreement was only fair (k= 0.31 +/- 0.02) for all cases and all judges, despite the fact that intra-judge agreements were substantial (between 0.44 and 0.83 +/- 0.1) and mean certainty levels high for each case (from 6.5 to 9.4 +/- 2.0 on a scale of 10). Agreement was no better within specialties (surgeons or radiologists), within groups proficient in endovascular coiling, surgical clipping or both, or within strata of years of experience. There was no link between certainty levels and years of experience. Agreement was lower (k= 0.18 +/- 0.2) in cases selected from the randomized trial than others (0.35 +/- 0.2).

There is poor agreement in decisions regarding the management of UIAs, even between individuals sharing a similar experience or the same specialty. In the absence of reliable evidence decision making is variable.

Decision making can perhaps be improved by concerted efforts to provide reliable evidence.

Jamali, S, Darsaut, T, Findlay, M, Raymond, J, Uncertainty and Discordance in the Management of Unruptured Intracranial Aneurysms.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13025205.html