Related Experiment Video
Updated: Aug 28, 2025
Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study
W Boisseau1, T E Darsaut2, R Fahed3
1From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology.
Background And Purpose:
MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms.
Materials And Methods:
A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later.
Results:
Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time.
Conclusions:
Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.
Insights
Clinical uncertainty is high for middle cerebral artery (MCA) aneurysms. Experts disagree on surgical versus endovascular treatment, highlighting the need for a randomized trial to determine optimal MCA aneurysm management.
Area of Science:
- Neurosurgery
- Interventional Neuroradiology
- Clinical Decision-Making
Background:
- Middle cerebral artery (MCA) aneurysms are frequently treated surgically, despite advancements in endovascular techniques.
- Clinical uncertainty exists regarding the optimal management strategy for MCA aneurysms.
Purpose of the Study:
- To measure clinical uncertainty in the management of MCA aneurysms.
- To assess the reliability of treatment decisions made by neurosurgical and endovascular specialists.
Main Methods:
- A portfolio of 60 MCA aneurysms was presented to 47 specialists (22 neurosurgeons, 25 interventional neuroradiologists).
- Raters indicated treatment options, trial eligibility, and management recommendations.
- Interrater and intrarater reliability were assessed using kappa statistics.
Main Results:
- Neurosurgeons favored surgical clipping (64%), while interventional neuroradiologists preferred endovascular treatment (76.6%).
- Overall interrater agreement was "slight" (κ = 0.094), with no improvement based on experience or specialty.
- 31% of raters showed intrarater disagreement on over 20% of cases upon re-evaluation.
Conclusions:
- Significant disagreement exists among clinicians regarding the optimal management of MCA aneurysms.
- Both surgical and endovascular options were consistently deemed viable.
- A randomized clinical trial comparing endovascular and surgical management for MCA aneurysms is warranted.
Related Concept Videos
01:26Aneurysm III: Interprofessional Care
01:22Aneurysm IV: Nursing Management