Interdisciplinary Decision Making in Hemorrhagic Stroke Based on CT Imaging-Differences Between Neurologists and Neurosurgeons Regarding Estimation of Patients' Symptoms, Glasgow Coma Scale, and National Institutes of Health Stroke Scale

Abstract

Background and Purpose: Acute intracerebral hemorrhage (ICH) requires rapid decision making toward neurosurgery or conservative neurological stroke unit treatment. In a previous study, we found overestimation of clinical symptoms when clinicians rely mainly on cerebral computed tomography (cCT) analysis. The current study investigates differences between neurologists and neurosurgeons estimating specific scores and clinical symptoms. Methods: Overall, 14 neurologists and 15 neurosurgeons provided clinical estimates and National Institutes of Health Stroke Scale (NIHSS) as well as Glasgow Coma Scale (GCS) based on cCT images and basic information of 50 patients with hypertensive and lobar ICH. Subgroup analyses were performed for the different professions (neurologists vs. neurosurgeons) and bleeding subtypes (typical location vs. atypical). The differences between the actual GCS and NIHSS scores and the cCT-imaging-based estimated scores were depicted as Bland-Altman plots and negative and positive predictive value (NPV and PPV) for prediction of clinical relevant items. ΔNIHSS points (ΔGCS points) were calculated as the difference between actual and rated NIHSS (GCS) including 95% confidence interval (CI). Results: Mean ΔGCS points for neurosurgeons was 1.16 (95% CI: -2.67-4.98); for neurologists, 0.99 (95% CI: -2.58-4.55), p = 0.308; mean ΔNIHSS points for neurosurgeons was -2.95 (95% CI: -12.71-6.82); for neurologists, -0.33 (95% CI: -9.60-8.94), p < 0.001. NPV and PPV for stroke symptoms were low, with large differences between different symptoms, bleeding subtypes, and professions. Both professions had more problems in proper rating of specific clinic-neurological symptoms than rating scores. Conclusion: Our results stress the need for joint decision making based on detailed neurological examination and neuroimaging findings also in telemedicine.

Keywords: Glasgow coma scale; cerebral amyloid angiopathy; computed tomography; intracerebral hemorrhage; national institutes of health stroke scale; outcome; quality of life; telestroke.

Figure 1

(A–C) The Bland–Altman plots show the difference between the actual and the estimated GCS score (mean for all raters) on patient basis: The mean estimated GCS score is too low by 1.07 GCS points (A). (B,C) Subgroup analyses for estimated GCS score in neurosurgeons as well as neurologists, showing mean estimated scores too low by 1.16 and 0.99 GCS points, respectively. (D–F) The Bland–Altman plots show the difference between the actual and the estimated NIHSS score (mean for all raters) on patient basis: The median estimated NIHSS score is too high by 1.24 NIHSS points (D). (E,F) Subgroup analyses. Neurologists overestimate NIHSS scores by 0.33 points, neurosurgeons by 2.95 points.