Letter to the Editor. Barrow Ruptured Aneurysm Trial 10-year results

View More View Less
  • 1 University of Alberta Hospital, Edmonton, AB, Canada
  • 2 Centre Hospitalier de l’Université de Montréal–CHUM, Montreal, QC, Canada
Free access

If the inline PDF is not rendering correctly, you can download the PDF file here.

TO THE EDITOR: We would like to thank Spetzler et al.1 for their continued contributions to the management of ruptured aneurysms with the publication of the BRAT 10-year results (Spetzler RF, McDougall CG, Zabramski JM, et al. Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg. 2020;132[3]:771–776). The authors of the accompanying editorials2–4 should also be thanked for critically discussing the pitfalls of the available evidence. We also wanted to comment on the statement that “it remains to be seen whether ISAT-2 can be successfully completed.”4

BRAT and ISAT are based on 15- to 30-year-old interventions. The relevance of past evidence to contemporary practice remains a concern. Sometimes labeled the “moving target problem,” this argument against trials, if true, would leave us without access to outcome-based medical care. How else can we determine whether our surgical practice is doing good or doing harm? The alternative, to rely on “a nuanced view of individualized care based on numerous factors,” as suggested by some,3 is actually an unregulated free-for-all that allows unreliable, unrepeatable “individualized” decisions to deceptively pass for “optimal care,”5 while we sink into unverifiable, potentially harmful surgical practices. As Spetzler et al. remind us, “Randomized trials remain the gold standard to establish best practice.”6

The difficulty is that we must repair the boat while it is at sea. How are we to practice while waiting for reliable evidence from ongoing trials? The answer would have been obvious, had we not been trained to conceive of research as an activity distinct from patient care, and to somehow think that good medical practice could systematically be defined even before anyone really knew what to do.7

We have come to understand that trials can play a more immediate goal than providing long-term answers regarding what best practice will eventually turn out to be. Trials can deliver best practice immediately, especially when care is to be provided in the presence of uncertainty (as it remains for many ruptured aneurysms). Trials must be designed in the best medical interest of the participating patient.8 The focus is not on “will we successfully complete the trial?”4 but rather on how to optimize practice under uncertainty now, when confronted with the question: “How should I manage this patient?” The secondary goal of obtaining reliable data remains important, but it’s just like mountains are climbed not by consideration of the far-off peaks but rather by steadily placing one foot in front of the other.

In the meantime, we must continue to ethically and seamlessly integrate randomized trials into our day-to-day neurosurgical care, as they did at the Barrow during the BRAT, for progress is possible.9 With trial participation, in the presence of uncertainty about “best management,” not only will patients be offered a 50% chance of getting the treatment that will turn out to be best (whichever it is), but also the next generation of trainees and vascular surgeons will be given an opportunity to learn and refine clipping techniques. This may be the best way to ensure that the legacies of surgical giants do not disappear.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Spetzler RF, McDougall CG, Zabramski JM, Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg. 2020;132(3):771776.

    • Search Google Scholar
    • Export Citation
  • 2

    Riina HA, Barker FG II. Editorial. The relevance of the BRAT and the management of ruptured brain aneurysms. J Neurosurg. 2020;132(3):760761.

    • Search Google Scholar
    • Export Citation
  • 3

    Cockroft KM. Editorial. Clip versus coil: the debate continues? J Neurosurg. 2020;132(3):762764.

  • 4

    Amenta PS, Nerva JD, Dumont AS. Contemporary treatment of ruptured intracranial aneurysms: perspectives from the Barrow Ruptured Aneurysm Trial. J Neurosurg. 2020;132(3):765767.

    • Search Google Scholar
    • Export Citation
  • 5

    Darsaut TE, Fahed R, Macdonald RL, Surgical or endovascular management of ruptured intracranial aneurysms: an agreement study. J Neurosurg. 2018;131(1):2531.

    • Search Google Scholar
    • Export Citation
  • 6

    Spetzler RF, Albuquerque FC, Zabramski JM, Nakaji P. Response to editorials. Saccular aneurysms in the Barrow Ruptured Aneurysm Trial: 10 years later. J Neurosurg. 2020;132(3):768770.

    • Search Google Scholar
    • Export Citation
  • 7

    Raymond J, Darsaut TE, Roy D. Care and research concepts should be revised to practice outcome-based medical care. J Clin Epidemiol. 2019;116:155160.

    • Search Google Scholar
    • Export Citation
  • 8

    Raymond J, Darsaut TE, Altman DG. Pragmatic trials can be designed as optimal medical care: principles and methods of care trials. J Clin Epidemiol. 2014;67(10):11501156.

    • Search Google Scholar
    • Export Citation
  • 9

    Darsaut TE, Roy D, Weill A, A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: interim results from ISAT2. Neurochirurgie. 2019;65(6):370376.

    • Search Google Scholar
    • Export Citation
View More View Less
  • Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
Keywords:

Response

We appreciate the eloquence of Drs. Darsaut and Raymond. We are in complete agreement. We fully appreciate the problem and look forward to their finding a solution so that clinical research to define best practices becomes the standard of care.

Acknowledgments

We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

Disclosures

Dr. Spetzler is a consultant for Carl Zeiss Meditec AG and receives royalties from Stryker Corp. and Kogent Surgical. Funding for this study was provided by the Barrow Neurological Foundation and the Hanley Aneurysm Fund.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Contributor Notes

Correspondence Jean Raymond: jean.raymond@umontreal.ca.

INCLUDE WHEN CITING Published online June 26, 2020; DOI: 10.3171/2020.4.JNS201372.

Disclosures The authors report no conflict of interest.

  • 1

    Spetzler RF, McDougall CG, Zabramski JM, Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg. 2020;132(3):771776.

    • Search Google Scholar
    • Export Citation
  • 2

    Riina HA, Barker FG II. Editorial. The relevance of the BRAT and the management of ruptured brain aneurysms. J Neurosurg. 2020;132(3):760761.

    • Search Google Scholar
    • Export Citation
  • 3

    Cockroft KM. Editorial. Clip versus coil: the debate continues? J Neurosurg. 2020;132(3):762764.

  • 4

    Amenta PS, Nerva JD, Dumont AS. Contemporary treatment of ruptured intracranial aneurysms: perspectives from the Barrow Ruptured Aneurysm Trial. J Neurosurg. 2020;132(3):765767.

    • Search Google Scholar
    • Export Citation
  • 5

    Darsaut TE, Fahed R, Macdonald RL, Surgical or endovascular management of ruptured intracranial aneurysms: an agreement study. J Neurosurg. 2018;131(1):2531.

    • Search Google Scholar
    • Export Citation
  • 6

    Spetzler RF, Albuquerque FC, Zabramski JM, Nakaji P. Response to editorials. Saccular aneurysms in the Barrow Ruptured Aneurysm Trial: 10 years later. J Neurosurg. 2020;132(3):768770.

    • Search Google Scholar
    • Export Citation
  • 7

    Raymond J, Darsaut TE, Roy D. Care and research concepts should be revised to practice outcome-based medical care. J Clin Epidemiol. 2019;116:155160.

    • Search Google Scholar
    • Export Citation
  • 8

    Raymond J, Darsaut TE, Altman DG. Pragmatic trials can be designed as optimal medical care: principles and methods of care trials. J Clin Epidemiol. 2014;67(10):11501156.

    • Search Google Scholar
    • Export Citation
  • 9

    Darsaut TE, Roy D, Weill A, A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: interim results from ISAT2. Neurochirurgie. 2019;65(6):370376.

    • Search Google Scholar
    • Export Citation

Metrics