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Neuroimaging
Original research
Clinical uncertainty in large vessel occlusion ischemic stroke: does automated perfusion imaging make a difference? An intra-rater and inter-rater agreement study
  1. Jose Danilo Bengzon Diestro1,2,3,4,
  2. Robert Fahed5,
  3. Abdelsimar Tan Omar6,
  4. Christine Hawkes7,
  5. Eef J Hendriks8,
  6. Clare Enriquez7,
  7. Muneer Eesa9,
  8. Grant Stotts5,
  9. Hubert Lee10,
  10. Shashank Nagendra11,
  11. Alexandre Poppe12,
  12. Célina Ducroux5,
  13. Timothy Lim13,
  14. Karl Narvacan14,
  15. Michael Rizzuto15,
  16. Afra Alfalahi4,
  17. Hidehisa Nishi4,16,
  18. Pragyan Sarma4,
  19. Ze'ev Itsekson Hayosh4,8,
  20. Katrina Ignacio11,
  21. William Boisseau17,
  22. Eduardo Pimenta Ribeiro Pontes Almeida18,
  23. Anass Benomar19,
  24. Mohammed A Almekhlafi20,
  25. Genvieve Milot21,
  26. Aviraj Deshmukh22,
  27. Kislay Kishore6,
  28. Donatella Tampieri23,
  29. Jeffrey Wang2,
  30. Abhilekh Srivastava24,
  31. Daniel Roy25,
  32. Federico Carpani26,
  33. Nima Kashani27,
  34. Claudia Candale-Radu28,
  35. Nishita Singh28,
  36. Maria Bres Bullrich29,
  37. Robert Sarmiento30,
  38. Ryan T Muir11,
  39. Carmen Parra-Fariñas31,
  40. Stephanie Reiter7,
  41. Yan Deschaintre12,
  42. Ravinder-Jeet Singh22,
  43. Vivek Bodani8,
  44. Aristeidis Katsanos24,
  45. Ronit Agid8,
  46. Atif Zafar2,
  47. Vitor M Pereira3,4,32,
  48. Julian Spears32,
  49. Thomas R Marotta3,4,
  50. Pascal Djiadeu1,33,
  51. Sunjay Sharma1,6,
  52. Forough Farrokhyar1,33,34
  1. 1Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
  2. 2Divison of Neurology, Department of Medicine, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
  3. 3Li Ka Shing Knowledge Insitute, St. Michael's Hospital- Unity Health Toronto, Toronto, Ontario, Canada
  4. 4Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
  5. 5Division Neurology, Department of Medicine, The Ottawa Hospital - Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
  6. 6Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
  7. 7Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  8. 8Division of Interventional Neuroradiology, Joint Department of Medical Imaging (JDMI), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
  9. 9Department of Radiology, University of Calgary, Calgary, Alberta, Canada
  10. 10Division of Neurointerventional Neuroradiology, Division of Neurosurgery, Trillium Health Partners, Mississauga, Ontario, Canada
  11. 11Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  12. 12Department of Neurosciences, Faculté de Médecine, Université de Montréal, Montréal, Quebec, Canada
  13. 13Division of Diagnostic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
  14. 14Department of Medical Imaging, St Michael’s Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
  15. 15Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
  16. 16Department of Neurosurgery, Koseikai Takeda hospital, Kyoto, Japan
  17. 17Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
  18. 18University Health Network - Toronto General Hospital, Toronto, Ontario, Canada
  19. 19Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
  20. 20Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute and O’Brien Institute for Public Health, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
  21. 21Department of Surgery (Neurosurgery), Centre Hospitalier de Quebec, Université Laval, Laval, Quebec, Canada
  22. 22Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
  23. 23Department of Radiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
  24. 24Division of Neurology, Department of Medicine, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
  25. 25Département de Radiologie, Radio-Oncologie et Médecine Nucléaire, Université de Montréal, Montréal, Quebec, Canada
  26. 26Division of Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
  27. 27Department of Medical Imaging, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  28. 28Division of Neurology, Department of Internal Medicine, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada
  29. 29Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
  30. 30Division of Neurology, Department of Medicine, Vancouver General Hospital- University of British Columbia, Vancouver, British Columbia, Canada
  31. 31Divisions of Neuroradiology & Neurointervention, Department of Diagnostic & Interventional Radiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  32. 32Division of Neurosurgery, Department of Surgery, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
  33. 33Department of Global Health, McMaster University, Hamilton, Ontario, Canada
  34. 34Department of Surgery, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to Dr Jose Danilo Bengzon Diestro, Department of Medicine, University of Toronto, Toronto M5B 1W8, Ontario, Canada; danni.diestro{at}gmail.com

Abstract

Background Limited research exists regarding the impact of neuroimaging on endovascular thrombectomy (EVT) decisions for late-window cases of large vessel occlusion (LVO) stroke.

Objective T0 assess whether perfusion CT imaging: (1) alters the proportion of recommendations for EVT, and (2) enhances the reliability of EVT decision-making compared with non-contrast CT and CT angiography.

Methods We conducted a survey using 30 patients drawn from an institutional database of 3144 acute stroke cases. These were presented to 29 Canadian physicians with and without perfusion imaging. We used non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG).

Results The percentage of EVT recommendations differed by 1.1% with or without perfusion imaging. Individual decisions changed in 21.4% of cases (11.3% against EVT and 10.1% in favor). Inter-rater agreement (κG) among the 29 raters was similar between non-perfusion and perfusion CT neuroimaging (κG=0.487; 95% CI 0.327 to 0.647 and κG=0.552; 95% CI 0.430 to 0.675). The 95% CIs overlapped with moderate agreement in both. Intra-rater agreement exhibited overlapping 95% CIs for all 28 raters. κG was either substantial or excellent (0.81–1) for 71.4% (20/28) of raters in both groups.

Conclusions Despite the minimal difference in overall EVT recommendations with either neuroimaging protocol one in five decisions changed with perfusion imaging. Regarding agreement we found that the use of automated CT perfusion images does not significantly impact the reliability of EVT decisions for patients with late-window LVO.

  • Stroke
  • Thrombectomy

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/jnis-2023-021429

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • Twitter @dannidiestro, @CMHawkes, @AnassBenomarMD, @AlmekhlafiMa, @IamAvirajD, @kislaykishore9, @nimakashani, @nishita_singh3, @VitorMendesPer1

    • Contributors All the authors meet the following criteria: 1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; 2. Drafting the work or revising it critically for important intellectual content; 3. Final approval of the version to be published; 4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JBD is the overall guarantor of the study. He accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish

    • Funding JDBD is a recipient of the Fergus Mills Scholarship of McMaster University for the Clinical Uncertainty in Large Vessel Occlusion (CULVO) study.

    • Competing interests JWBD: Honoraria from Medtronic. Travel grant fromMicrovention; MAA: Member of the scientific advisory board of Palmera Medical;TRM: Principal of eVasc Neurovascular.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.