Treatment score aids decision-making in unruptured intracranial aneurysm management

Aug 20 2015

By Lucy Piper, Senior medwireNews Reporter

Researchers have developed an unruptured intracranial aneurysm treatment score (UIATS) model that arms clinicians with consensus from a group of specialists on how to manage individuals with the condition.

The model was designed using the Delphi method by 39 international multidisciplinary specialists and accounts for 12 main categories, with 29 stratifications, in UIA management.

“By applying this scoring model, clinicians can appreciate what highly informed individuals in the cerebrovascular field would advise in a particular patient based on current data and uncertainties”, says the team of researchers, led by Nima Etminan (Heinrich-Heine-University, Dusseldorf, Germany.

The 39 panel members, including neurosurgeons, interventional neuroradiologists, neurologists and a clinical epidemiologist, identified relevant factors involved in clinical decision-making in the management of UIAs.

These factors are grouped into patient factors, such as age, risk factor incidence, clinical symptoms related to UIA, life expectancy and the presence of comorbid disease; aneurysm features, such as size, morphology and location; and the risk of treatment in light of age, aneurysm size and aneurysm complexity.

The features are scored in two management columns, one that favours UIA repair and one that favours UIA conservative management. The recommended management depends on the difference in these scores.

For example, a point difference of 3 or more would favour one type of treatment over the other, while a 2-point difference or below would not be definitive and either management approach could be supported in conjunction with other factors not considered in the model.

The researchers found that agreement on the recommendations for each individual patient was high among the members of the design panel, with an average Likert score of 4.3 out of a possible 5 (indicating strong agreement), and a score of 4.5 for an external panel of 30 similarly multidisciplinary experts who were not involved in developing the model.

The average Likert score per reviewer was 4.2 for both panels and the overall inter-rater agreement was 0.026, where 0 indicates excellent agreement. The researchers also note that agreement scores were similar between interventional and noninterventional reviewers and so independent of the specialist’s professional background.

They explain that their model differs from the recently developed PHASES score, in that is not a predictive model for UIA rupture. But the authors believe that the the UIATS addresses some of the uncertainties that are not accounted for in the PHASES score due to varying levels of evidence, and as such reduces the high level of variation among clinicians in how to manage individual patients with UIA.

“[O]ur proposed scoring model constitutes an organized and objective means of capturing the best consensus possible on UIA management as a complement to existing UIA rupture risk prediction models”, they conclude in Neurology.

Indeed, editorialists Philippe Bijlenga (Geneva University Medical Center, Switzerland) and Christian Stapf (Université Paris Diderot, France) congratulate the team on their “Herculean effort in developing a pragmatic decision guidance model based on a systematic comparison of expert views.”

But they note that, in its current form, the model does not estimate the risk of the treatment management decision and therefore validation is needed and prospective outcome data included.

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