Disagreement on angiography

[nikolaite]

This has been weighing on me this past couple weeks: I’ve been mediating a pretty heated long-standing discussion between some engineers, radiologists, neurologists and endovascular surgeons on inclusion criteria for a mechanical thrombectomy study now that we’ve completed our retrospective portion. The initial area of focus is solely the M1 segment of the R or L MCA.

The Rads are adamant that patients with evidence of high grade stenosis on CTA be admitted as they claim “you can’t tell the difference between ELVO w/robust collaterals and symptomatic high grade atherosclerotic stenosis, on CTA.” The claim is that these patients need to go to the cath lab for angiography to rule out ELVO to keep from missing valuable data, and to keep from missing treatment opportunities for the patient’s sake if it is in fact ELVO. There is also some suggestion of cross enrollment of some qualifying patients into an acute angioplasty/stent study.

The Neuros generally agree with the Rads. The engineers are saying they want the data regardless of whether it’s a narrowing or occlusion.

The EV surgeons are saying that they do not want to include any patients with the appearance of high grade atherosclerotic narrowing. Only those with obvious ELVO on CTA. The recurring undertone I’m getting is that the EVs “feel” they can distinguish between the ELVO and atherosclerosis on a CTA. I am extremely leery of this.

We discussed a sampling of anonymous key objects series, MIPs and axial thins to dispel the contentions and when tested singly none of the EVs agreed completely with the others on the atherosclerotic narrowing images prior to reviewing the angios. This still is not changing their opinions.

One neuro pointed out that post-2019 stroke guidelines would require (to his mind) angiography for the patient body we are discussing. Some of the EVs are caving on this point, but I need all of them on board so that I can write up the protocols to submit to the research head.

Does anyone have any experience in coordinating such a team? And if so, any advice so that we can all “win” without feeling like one of us is compromising ethics?
Thanks in advance.

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[deathmerchant]

This has been weighing on me this past couple weeks: I’ve been mediating a pretty heated long-standing discussion between some engineers, radiologists, neurologists and endovascular surgeons on inclusion criteria for a mechanical thrombectomy study now that we’ve completed our retrospective portion. The initial area of focus is solely the M1 segment of the R or L MCA.

The Rads are adamant that patients with evidence of high grade stenosis on CTA be admitted as they claim “you can’t tell the difference between ELVO w/robust collaterals and symptomatic high grade atherosclerotic stenosis, on CTA.” The claim is that these patients need to go to the cath lab for angiography to rule out ELVO to keep from missing valuable data, and to keep from missing treatment opportunities for the patient’s sake if it is in fact ELVO. There is also some suggestion of cross enrollment of some qualifying patients into an acute angioplasty/stent study.

The Neuros generally agree with the Rads. The engineers are saying they want the data regardless of whether it’s a narrowing or occlusion.

The EV surgeons are saying that they do not want to include any patients with the appearance of high grade atherosclerotic narrowing. Only those with obvious ELVO on CTA. The recurring undertone I’m getting is that the EVs “feel” they can distinguish between the ELVO and atherosclerosis on a CTA. I am extremely leery of this.

We discussed a sampling of anonymous key objects series, MIPs and axial thins to dispel the contentions and when tested singly none of the EVs agreed completely with the others on the atherosclerotic narrowing images prior to reviewing the angios. This still is not changing their opinions.

One neuro pointed out that post-2019 stroke guidelines would require (to his mind) angiography for the patient body we are discussing. Some of the EVs are caving on this point, but I need all of them on board so that I can write up the protocols to submit to the research head.

Does anyone have any experience in coordinating such a team? And if so, any advice so that we can all “win” without feeling like one of us is compromising ethics?
Thanks in advance.

Are you talking about just M1 stenosis? If there is a focal area of narrowing in just one spot, without stenosis elsewhere, that is most likely ELVO/plaque that could potentially benefit from MT and it makes sense to consider angio.
Although, I can't imagine why it would be hard to distinguish focal stenosis from ELVO on CTA in most cases. I mean, isolated focal M1 stenosis causing acute ischemia is not frequent compared to other causes. And CTA is pretty good at diagnosing that- maybe not as good as angio but pretty pretty close. Obviously conventional angio is more high risk and invasive.
And there are studies recommending maximal medical management only for intracranial atherosclerosis.

 

[nikolaite]

Are you talking about just M1 stenosis? If there is a focal area of narrowing in just one spot, without stenosis elsewhere, that is most likely ELVO/plaque that could potentially benefit from MT and it makes sense to consider angio.
Although, I can't imagine why it would be hard to distinguish focal stenosis from ELVO on CTA in most cases. I mean, isolated focal M1 stenosis causing acute ischemia is not frequent compared to other causes. And CTA is pretty good at diagnosing that- maybe not as good as angio but pretty pretty close. Obviously conventional angio is more high risk and invasive.
And there are studies recommending maximal medical management only for intracranial atherosclerosis.

I’m dealing with this from the outside, honestly, as I’m not a physician.

I’m glad we’re doing most of the convo by zoom and such because I think two of our alphas have come close to calling each other out.

The issue is that there are 10 series where there was what appeared on my ADW workstation to be focal occlusion which the rads called “evidence of high grade stenosis”. RAPID angio was run, showing basically symmetrical perfusion between the hemispheres. All recommended conventional angio based solely on those 10 subjects presentation and imaging...NIHSS, etc. The IR guys read the reports, looked at the images and said, “atherosclerotic narrowing, no angio, no MT.” Angio images and reports on these subjects all showed ELVO.

Again, to me, these looked like every other focal occlusion that I’ve seen. And none of the series showed any evidence of atherosclerosis anywhere in the body, neck and brain scans according to the rads.

The engineers want the stenoses objectively graded on the future subjects if that’s what they are. The radiologists and neurologists want the patients to get the best opportunity of a good outcome as well as test the study parameters. The IR guys are coming across as a bit prickly; one even said that he wouldn’t cath a patient unless it was life or death.

I need to find a way of cooling everyone off and opening minds without stepping on toes. I am dreading the upcoming week.

 

[deathmerchant]

I’m dealing with this from the outside, honestly, as I’m not a physician.

I’m glad we’re doing most of the convo by zoom and such because I think two of our alphas have come close to calling each other out.

The issue is that there are 10 series where there was what appeared on my ADW workstation to be focal occlusion which the rads called “evidence of high grade stenosis”. RAPID angio was run, showing basically symmetrical perfusion between the hemispheres. All recommended conventional angio based solely on those 10 subjects presentation and imaging...NIHSS, etc. The IR guys read the reports, looked at the images and said, “atherosclerotic narrowing, no angio, no MT.” Angio images and reports on these subjects all showed ELVO.

Again, to me, these looked like every other focal occlusion that I’ve seen. And none of the series showed any evidence of atherosclerosis anywhere in the body, neck and brain scans according to the rads.

The engineers want the stenoses objectively graded on the future subjects if that’s what they are. The radiologists and neurologists want the patients to get the best opportunity of a good outcome as well as test the study parameters. The IR guys are coming across as a bit prickly; one even said that he wouldn’t cath a patient unless it was life or death.

I need to find a way of cooling everyone off and opening minds without stepping on toes. I am dreading the upcoming week.

In gray areas, the best decision is what causes least harm to the patient. There are lots of IFs here.

What I personally would do - If the clinical presentation is acute stroke with cortical signs (i.e possible ELVO) AND they have perfusion mismatch (and/or in reasonable time window) AND there is either focal stenosis/occlusion AND CTA is inconclusive and/or confirms occlusion- only then I would consider conventional ANGIO and MT respectively. If any of the above conditions are not met, then I wouldn't do it.

 

[nikolaite]

In gray areas, the best decision is what causes least harm to the patient. There are lots of IFs here.

What I personally would do - If the clinical presentation is acute stroke with cortical signs (i.e possible ELVO) AND they have perfusion mismatch (and/or in reasonable time window) AND there is either focal stenosis/occlusion AND CTA is inconclusive and/or confirms occlusion- only then I would consider conventional ANGIO and MT respectively. If any of the above conditions are not met, then I wouldn't do it.

That’s basically what one of the Neuros wrote as his proposal. His team (even his IR colleague) is on board. Our research lead has stepped in and settled the contention by cutting one full team from the proposal roster after checking with the grantor that we can still proceed. Their IR “lead” was unflinchingly opposed to any proposal from offsite neurology. It became a total mess again this morning, but now I’m on to protocols. The other two teams have returned their assent to move forward...woo hoo! Thanks for your input!