Clinical uncertainty in large vessel occlusion ischemic stroke: does automated perfusion imaging make a difference? An intra-rater and inter-rater agreement study

Jose Danilo Bengzon Diestro; Robert Fahed; Abdelsimar Tan Omar; Christine Hawkes; Eef J Hendriks; Clare Enriquez; Muneer Eesa; Grant Stotts; Hubert Lee; Shashank Nagendra; Alexandre Poppe; Célina Ducroux; Timothy Lim; Karl Narvacan; Michael Rizzuto; Afra Alfalahi; Hidehisa Nishi; Pragyan Sarma; Ze'ev Itsekson Hayosh; Katrina Ignacio; William Boisseau; Eduardo Pimenta Ribeiro Pontes Almeida; Anass Benomar; Mohammed A Almekhlafi; Genvieve Milot; Aviraj Deshmukh; Kislay Kishore; Donatella Tampieri; Jeffrey Wang; Abhilekh Srivastava; Daniel Roy; Federico Carpani; Nima Kashani; Claudia Candale-Radu; Nishita Singh; Maria Bres Bullrich; Robert Sarmiento; Ryan T Muir; Carmen Parra-Fariñas; Stephanie Reiter; Yan Deschaintre; Ravinder-Jeet Singh; Vivek Bodani; Aristeidis Katsanos; Ronit Agid; Atif Zafar; Vitor M Pereira; Julian Spears; Thomas R Marotta; Pascal Djiadeu; Sunjay Sharma; Forough Farrokhyar

doi:10.1136/jnis-2023-021429

Clinical uncertainty in large vessel occlusion ischemic stroke: does automated perfusion imaging make a difference? An intra-rater and inter-rater agreement study

J Neurointerv Surg. 2024 Mar 21:jnis-2023-021429. doi: 10.1136/jnis-2023-021429. Online ahead of print.

Authors

Jose Danilo Bengzon Diestro^{1

2

3

4}, Robert Fahed⁵, Abdelsimar Tan Omar⁶, Christine Hawkes⁷, Eef J Hendriks⁸, Clare Enriquez⁷, Muneer Eesa⁹, Grant Stotts⁵, Hubert Lee¹⁰, Shashank Nagendra¹¹, Alexandre Poppe¹², Célina Ducroux⁵, Timothy Lim¹³, Karl Narvacan¹⁴, Michael Rizzuto¹⁵, Afra Alfalahi⁴, Hidehisa Nishi^{4

16}, Pragyan Sarma⁴, Ze'ev Itsekson Hayosh^{4

8}, Katrina Ignacio¹¹, William Boisseau¹⁷, Eduardo Pimenta Ribeiro Pontes Almeida¹⁸, Anass Benomar¹⁹, Mohammed A Almekhlafi²⁰, Genvieve Milot²¹, Aviraj Deshmukh²², Kislay Kishore⁶, Donatella Tampieri²³, Jeffrey Wang², Abhilekh Srivastava²⁴, Daniel Roy²⁵, Federico Carpani²⁶, Nima Kashani²⁷, Claudia Candale-Radu²⁸, Nishita Singh²⁸, Maria Bres Bullrich²⁹, Robert Sarmiento³⁰, Ryan T Muir¹¹, Carmen Parra-Fariñas³¹, Stephanie Reiter⁷, Yan Deschaintre¹², Ravinder-Jeet Singh²², Vivek Bodani⁸, Aristeidis Katsanos²⁴, Ronit Agid⁸, Atif Zafar², Vitor M Pereira^{3

4

32}, Julian Spears³², Thomas R Marotta^{3

4}, Pascal Djiadeu^{33

34}, Sunjay Sharma^{33

6}, Forough Farrokhyar^{33

34

35}

Affiliations

¹ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada danni.diestro@gmail.com.
² Divison of Neurology, Department of Medicine, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.
³ Li Ka Shing Knowledge Insitute, St. Michael's Hospital- Unity Health Toronto, Toronto, Ontario, Canada.
⁴ Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.
⁵ Division Neurology, Department of Medicine, The Ottawa Hospital - Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
⁶ Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
⁷ Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
⁸ Division of Interventional Neuroradiology, Joint Department of Medical Imaging (JDMI), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
⁹ Department of Radiology, University of Calgary, Calgary, Alberta, Canada.
¹⁰ Division of Neurointerventional Neuroradiology, Division of Neurosurgery, Trillium Health Partners, Mississauga, Ontario, Canada.
¹¹ Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
¹² Department of Neurosciences, Faculté de Médecine, Université de Montréal, Montréal, Quebec, Canada.
¹³ Division of Diagnostic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
¹⁴ Department of Medical Imaging, St Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.
¹⁵ Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
¹⁶ Department of Neurosurgery, Koseikai Takeda hospital, Kyoto, Japan.
¹⁷ Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France.
¹⁸ University Health Network - Toronto General Hospital, Toronto, Ontario, Canada.
¹⁹ Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada.
²⁰ Departments 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 Department of Surgery (Neurosurgery), Centre Hospitalier de Quebec, Université Laval, Laval, Quebec, Canada.
²² Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada.
²³ Department of Radiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada.
²⁴ Division of Neurology, Department of Medicine, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada.
²⁵ Département de Radiologie, Radio-Oncologie et Médecine Nucléaire, Université de Montréal, Montréal, Quebec, Canada.
²⁶ Division of Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
²⁷ Department of Medical Imaging, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
²⁸ Division of Neurology, Department of Internal Medicine, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada.
²⁹ Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
³⁰ Division of Neurology, Department of Medicine, Vancouver General Hospital- University of British Columbia, Vancouver, British Columbia, Canada.
³¹ Divisions of Neuroradiology & Neurointervention, Department of Diagnostic & Interventional Radiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
³² Division of Neurosurgery, Department of Surgery, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.
³³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
³⁴ Department of Global Health, McMaster University, Hamilton, Ontario, Canada.
³⁵ Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

PMID: 38453461
DOI: 10.1136/jnis-2023-021429

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 (κ_G).

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 (κ_G) among the 29 raters was similar between non-perfusion and perfusion CT neuroimaging (κ_G=0.487; 95% CI 0.327 to 0.647 and κ_G=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. κ_G 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.

Keywords: Stroke; Thrombectomy.