Clinicians' perspectives on incidentally discovered silent brain infarcts - A qualitative study.

Lester Y Leung,David Kent,Paul K J Han,Christine Lundquist,Gene Weinstein,David E Thaler,Damir Janigro

doi:10.1371/journal.pone.0194971

Abstract

BackgroundWhile silent brain infarcts (SBIs) in screened cohorts are associated with risk of symptomatic stroke and dementia, the clinical significance of incidentally discovered SBIs (id-SBIs) is unknown. Detection may offer an opportunity to initiate prevention measures, but uncertainties about id-SBIs may impede clinicians from addressing them and complicate further study of this condition.Methods and resultsThis study used semi-structured interviews of practicing clinicians. Interviews were audio recorded, transcribed, and analyzed using a grounded theory approach. A constant comparative method was used to organize emergent themes and examine new themes. Purposeful sampling was employed to achieve participant diversity. Fifteen clinicians were interviewed. Emergent themes centered on uncertainty about id-SBIs, clinical decision making in response to uncertainty, and evidence needed to resolve uncertainty. All clinicians reported uncertainty about id-SBIs: diagnostic, prognostic, or therapeutic. Differential responses to uncertainties resulted in practice variation within and between specialties. Diagnostic and prognostic uncertainty discouraged disclosure of imaging findings to patients. Vascular neurologists viewed the prognostic significance of id-SBIs as similar to symptomatic stroke. Therapeutic uncertainty was common, but most participants endorsed using stroke secondary prevention strategies. Regarding future research, all internists indicated they would consider changing practices in response to observational studies, whereas half of the neurologists expressed reluctance to modify practices based on non-randomized data. Several expressed concerns about clinical trial feasibility and lack of equipoise.Conclusionsid-SBIs are a focus of uncertainty for clinicians, leading to practice variation. Future studies must address diagnostic and prognostic uncertainty to facilitate implementation of prevention strategies.

Highlights

Silent brain infarcts (SBIs) are common and have important consequences, but optimal management strategies have not been established
While silent brain infarcts (SBIs) in screened cohorts are associated with risk of symptomatic stroke and dementia, the clinical significance of incidentally discovered SBIs is unknown
Conclusions incidentally discovered SBIs (id-SBIs) are a focus of uncertainty for clinicians, leading to practice variation

Summary

Introduction

Silent brain infarcts (SBIs) are common and have important consequences, but optimal management strategies have not been established. SBIs are associated with a two-to-three fold increased risk of symptomatic brain infarction and dementia, independent of vascular risk factors [1,2,3,4]. To guide research on SBIs, the American Heart Association/American Stroke Association (AHA/ASA) refined definitions for silent cerebrovascular diseases and released a scientific statement highlighting potential harms following SBIs, the lack of randomized clinical trial (RCT) data, the probable value of stroke primary prevention strategies following SBIs, and the probable inappropriateness of population screening [6,7]. As the data informing this statement were drawn from studies on SBIs in neuroimaging screened cohorts, it is not clear how clinicians should approach id-SBIs, the only SBIs currently relevant to patient care. While silent brain infarcts (SBIs) in screened cohorts are associated with risk of symptomatic stroke and dementia, the clinical significance of incidentally discovered SBIs (id-SBIs) is unknown. Detection may offer an opportunity to initiate prevention measures, but uncertainties about id-SBIs may impede clinicians from addressing them and complicate further study of this condition

Methods

Results

Discussion

Conclusion