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Equipoise dumbbell
  1. David F Kallmes1,
  2. Kevin Kallmes2,
  3. Mayank Goyal3,
  4. Joshua A Hirsch4,
  5. Alejandro A Rabinstein5,
  6. Waleed Brinjikji1,
  7. Colin Derdeyn6
  1. 1 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 Duke University School of Law, Durham, North Carolina, USA
  3. 3 Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
  4. 4 Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
  5. 5 Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
  6. 6 Department of Radiology and Interventional Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  1. Correspondence to Kevin Kallmes, Duke University School of Law, Durham, NC 27708, USA; kall0156{at}

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‘Clinical equipoise’—what an appealing concept, which has come to dominate our conversations about clinical trials in the cerebrovascular community.1 In its early years, the neurointerventional field moved forward empowered by case series and by the confidence that skilled operators using minimally invasive techniques attained better results than the alternatives—including doing nothing. The lack of personal ‘equipoise’ meant that many well-meaning practitioners thought it unnecessary and even unethical to subject their patients to randomization away from a treatment they thought was best. As was the case for neurosurgeons who promoted extracranial–intracranial bypass2 and carotid endarterectomy,3 alternatives to ‘clinical equipoise’ such as ‘community equipoise’ took shape for interventionalists. Recognizing that disparate perspectives across the community of experts could demonstrate a larger scale metric of uncertainty eased the discomfort of randomization of many practitioners by balancing their certainty against those that lacked equipoise but from the ‘other’ side. Recent trials in endovascular therapy for ischemic stroke exemplify the evidence-based medicine this concept has allowed in a community where few individual physicians had true personal equipoise.4–7

In articulating the concept of ‘community equipoise’ in 1987,8 Benjamin Freedman created a system that enabled clinical researchers to randomize their patients …

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