title: Uncertainty and agreement regarding the role of flow diversion in the management of difficult aneurysms.
abstract: OBJECTIVE
  The role of flow diversion in the management of aneurysms remains unknown. We sought to evaluate the community agreement regarding indications for flow diversion.
  
  
  METHODS
  A portfolio of 35 difficult aneurysm cases was sent to 40 clinicians with varying backgrounds and experience. Responders were asked whether they considered flow diversion a treatment option, whether other options were possible, whether recruitment in a randomized trial would be considered, and to select their final choice. Agreement was studied by using κ statistics.
  
  
  RESULTS
  Decisions for flow diversion were more frequent (n = 300, 39%) than decisions to coil (n = 163, 21.2%), to observe (n = 121, 15.7%), to occlude the parent vessel (n = 102, 13.2%), or to clip (n = 66, 8.6%). Sidewall aneurysm morphology was associated with flow diversion as the final choice (P = .001). Interjudge agreement was fair at best (κ <0.3) for all cases and all judges, despite high certainty levels (range, 7.2-8.9 ± 2.0 on a 0-10 scale). Agreement was no better within specialties or with more experience. All patients were judged to have other treatment options. Judges were willing to offer trial participation in 417 of 741 (56.3%) scenarios, more frequently when the aneurysm was sidewall (P = .001) or in the anterior circulation (P = .028).
  
  
  CONCLUSIONS
  Individuals did not agree regarding the indications for flow diversion. There is sufficient uncertainty to justify trials designed to protect patients from the potential risks of premature adoption of an innovation.
authors.affiliation: From the Division of Neurosurgery (T.E.D., C.M.M.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada.
authors.forename: T E
authors.initials: TE
authors.lastname: Darsaut
authors.affiliation: Department of Radiology (J.-C.G., D.R., A.W., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada.
authors.forename: J-C
authors.initials: JC
authors.lastname: Gentric
authors.affiliation: From the Division of Neurosurgery (T.E.D., C.M.M.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada.
authors.forename: C M
authors.initials: CM
authors.lastname: McDougall
authors.affiliation: Laboratory of Interventional Neuroradiology (G.G., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada.
authors.forename: G
authors.initials: G
authors.lastname: Gevry
authors.affiliation: Department of Radiology (J.-C.G., D.R., A.W., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada.
authors.forename: D
authors.initials: D
authors.lastname: Roy
authors.affiliation: Department of Radiology (J.-C.G., D.R., A.W., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Weill
authors.affiliation: Department of Radiology (J.-C.G., D.R., A.W., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada Laboratory of Interventional Neuroradiology (G.G., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada. jean.raymond@umontreal.ca.
authors.forename: J
authors.initials: J
authors.lastname: Raymond
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods*; D000783:Aneurysm / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods*; D010818:Practice Patterns, Physicians'; D011859:Radiography; D035501:Uncertainty; D014656:Vascular Surgical Procedures / Q000379:methods*