The Management of Persistent Distal Occlusions after Mechanical Thrombectomy and Thrombolysis: An Inter- and Intrarater Agreement Study

W Boisseau; A Benomar; C Ducroux; R Fahed; S Smajda; J D B Diestro; G Charbonnier; J Ognard; J Burel; A Ter Schiphorst; M Boulanger; A Nehme; J Boucherit; G Marnat; D Volders; Q Holay; G Forestier; M Bretzner; D Roy; S Vingadassalom; M Elhorany; L Nico; G Jacquin; M Abdalkader; A Guedon; P Seners; K Janot; V Dumas; R Olatunji; S Gazzola; G Milot; J Zehr; T E Darsaut; D Iancu; J Raymond

doi:10.3174/ajnr.A8149

The Management of Persistent Distal Occlusions after Mechanical Thrombectomy and Thrombolysis: An Inter- and Intrarater Agreement Study

AJNR Am J Neuroradiol. 2024 Feb 22;45(4):400-405. doi: 10.3174/ajnr.A8149. Online ahead of print.

Authors

W Boisseau^{1

2}, A Benomar², C Ducroux³, R Fahed³, S Smajda¹, J D B Diestro⁴, G Charbonnier⁵, J Ognard⁶, J Burel⁷, A Ter Schiphorst⁸, M Boulanger⁹, A Nehme⁹, J Boucherit¹⁰, G Marnat¹¹, D Volders¹, Q Holay¹², G Forestier¹³, M Bretzner¹⁴, D Roy², S Vingadassalom¹⁵, M Elhorany^{16

17}, L Nico¹⁸, G Jacquin¹⁹, M Abdalkader²⁰, A Guedon²¹, P Seners^{22

23}, K Janot²⁴, V Dumas²⁵, R Olatunji⁴, S Gazzola^{1

1}, G Milot^{2

2}, J Zehr^{3

3}, T E Darsaut^{4

4}, D Iancu², J Raymond²⁶

Affiliations

¹ From the Department of Interventional Neuroradiology (W.B., S.S.), Fondation Rothschild Hospital, Paris, France.
² Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada.
³ Department of Neurology (C.D., R.F.), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada.
⁴ Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., R.O.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
⁵ Interventional Neuroradiology Department (G.C.), Besançon University Hospital, Besançon, France.
⁶ Interventional Neuroradiology Department (J.O.), Hôpital de la Cavale Blanche, Brest, Bretagne, France.
⁷ Department of Radiology (J. Burel), Rouen University Hospital, Rouen, France.
⁸ Neurology Department (A.T.S.), CHRU Gui de Chauliac, Montpellier, France.
⁹ Department of Neurology (M. Boulanger, A.N.), Caen University Hospital, Caen, France.
¹⁰ Department of Radiology (J. Boucherit), Rennes University Hospital, Rennes, France.
¹¹ Department of Neuroradiology (G. Marnat), University Hospital of Bordeaux, Bordeaux, France.
¹² Radiology Department (Q.H.), Hôpital d'Instruction des armées Saint-Anne, Toulon, France.
¹³ Neuroradiology Department (G.F.), University Hospital of Limoges, Limoges, France.
¹⁴ Neuroradiology Department (M. Bretzner), CHU Lille, University Lille, Inserm, U1172 Lille Neuroscience & Cognition, F-59000, Lille, France.
¹⁵ Interventional Neuroradiology Department (S.V.), CHRU Marseille, La Timone, France.
¹⁶ Department of Neuroradiology (M.E.), Groupe Hospitalier de Pitié Salpêtrière, Paris, France.
¹⁷ Department of Neurology (M.E.), Tanta University, Tanta, Egypt.
¹⁸ Department of Radiology (L.N.), University Hospital of Padova, Padova, Italy.
¹⁹ Neurovascular Health Program (G.J.), Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
²⁰ Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.
²¹ Department of Neuroradiology (A.G.), Lariboisière Hospital, Paris, France.
²² Neurology Department (P.S.), Hôpital Fondation A. de Rothschild, Fondation Rothschild Hospital, Paris, France.
²³ Institut de Psychiatrie et Neurosciences de Paris (P.S.), UMR_S1266, INSERM, Université de Paris, Paris, France.
²⁴ Interventional Neuroradiology (K.J.), University Hospital of Tours, Tours, France.
²⁵ Radiology Department (V.D.), University Hospital of Poitiers, Poitiers, France.
²⁶ Department of Radiology (W.B., A.B., D.R, D.I., J.R.), Centre Hospitalier de l'Université de Montréal Montréal, Canada jean.raymond@umontreal.ca.

PMID: 38388684
PMCID: PMC11288561 (available on 2025-04-01)
DOI: 10.3174/ajnr.A8149

Abstract

Background and purpose: The best management of patients with persistent distal occlusion after mechanical thrombectomy with or without IV thrombolysis remains unknown. We sought to evaluate the variability and agreement in decision-making for persistent distal occlusions.

Materials and methods: A portfolio of 60 cases was sent to clinicians with varying backgrounds and experience. Responders were asked whether they considered conservative management or rescue therapy (stent retriever, aspiration, or intra-arterial thrombolytics) a treatment option as well as their willingness to enroll patients in a randomized trial. Agreement was assessed using κ statistics.

Results: The electronic survey was answered by 31 physicians (8 vascular neurologists and 23 interventional neuroradiologists). Decisions for rescue therapies were more frequent (n = 1116/1860, 60%) than for conservative management (n = 744/1860, 40%; P < .001). Interrater agreement regarding the final management decision was "slight" (κ = 0.12; 95% CI, 0.09-0.14) and did not improve when subgroups of clinicians were studied according to background, experience, and specialty or when cases were grouped according to the level of occlusion. On delayed re-questioning, 23 of 29 respondents (79.3%) disagreed with themselves on at least 20% of cases. Respondents were willing to offer trial participation in 1295 of 1860 (69.6%) cases.

Conclusions: Individuals did not agree regarding the best management of patients with persistent distal occlusion after mechanical thrombectomy and IV thrombolysis. There is sufficient uncertainty to justify a dedicated randomized trial.