Optimizing Small, Low-Risk, Unruptured Intracranial Aneurysm Treatment Using Game Theory.

The incidental diagnosis of unruptured intracranial aneurysms has been increasing in the past several decades. A significant proportion represent small, low-risk, unruptured intracranial aneurysms for which there is equipoise on whether to offer treatment or conservative management. Given this uncertainty, patients may not always be comfortable with their physicians' recommendations. Herein, we use game theory to study the interactions between physicians and patients to determine how conflict and cooperation affect the management of small, low-risk, unruptured intracranial aneurysms. We constructed a game theory model of the interaction between physicians and patients with respect to decision-making for a small, low-risk, unruptured intracranial aneurysm in an asymptomatic patient when there is perceived equipoise between whether to treat or manage conservatively. Assuming that both the physician and patient are rational and eliciting individual patient preferences is not practical, the physician should play the game based on an ex ante probability of meeting a patient with a certain type of preference. This recommendation means that the expectations of the physician regarding the patient's preferences should guide the decision to offer treatment or conservative management as a first option for a small, asymptomatic, low-risk, unruptured intracranial aneurysm for which there is clinical equipoise.

Rescan Time Delays in Ischemic Stroke Imaging: A Retrospective Observation and Analysis of Causes and Clinical Impact.

BACKGROUND AND PURPOSE: Delays to reperfusion negatively impact outcomes of patients with ischemic stroke, yet current guidelines recommend selective sequential imaging for thrombectomy candidates. We aimed to quantify and analyze time delays associated with rescanning in sequential acute stroke imaging. MATERIALS AND METHODS: This was a retrospective cohort study of consecutive patients with acute ischemic stroke who underwent imaging for treatment decision-making from January 1, 2017, to June 30, 2020. Rescan time delay was defined as ≥10-minute difference between initial NCCT and CTA ± CTP. Mean rescan time delays in comprehensive and primary stroke centers were compared. Bivariate and multivariable regression analyses assessed clinical and imaging factors associated with rescanning time delays and early outcomes. RESULTS: A total of 588 patients with acute ischemic were included in statistical analyses. Rescanning occurred in 27.9% (164/588 patients), with a mean time delay of 53.7 (SD, 43.4) minutes. For patients presenting at primary compared with comprehensive stroke centers, rescan time delays were more common (59.6% versus 11.8%, P < .001), with longer delays (65.4 [SD, 45.4] minutes versus 23.6 [SD, 14.0] minutes, P < .001). Independent predictors of rescan time delays included primary stroke center presentation, intravenous thrombolysis administration, black race, admission NIHSS ≥10, baseline independent ambulation, and onset-to-comprehensive stroke center arrival in ≥6 hours. Protocols for early simultaneous comprehensive CT (NCCT + CTA + CTP) were associated with lower odds of time delays (OR = 0.34; 95% CI, 0.21-0.55). Rescanning was associated with lower odds of home discharge (OR = 0.53; 95% CI, 0.30-0.95). CONCLUSIONS: A sequential approach to CT-based imaging may be significantly associated with prolonged acute stroke evaluations. Adoption of early simultaneous comprehensive CT could minimize treatment delays and improve outcomes.