Is cerebrovascular neurosurgery sacrified on the altar of RCTs?

摘要

Microneurosurgery is decreasingly considered a treatment option for people with surgically curable cerebrovascular diseases, partly due to the misconceptions and misinterpretations of some randomised controlled trials (RCTs). RCTs are regarded as the gold standard to assess the efficacy of a novel pharmacological intervention. RCTs of drugs do not usually need to focus on the variability in the delivery of care, and ineligible patients are never treated with the study drug outside the RCT on the basis of a clinical decision. However, in the most important RCTs of neurosurgically curable cerebrovascular diseases, a substantial number of patients were not randomised but treated in study centres (table). This raises the question of the genuine uncertainty-clinical equipoise-needed to be clarified with an RCT for a small proportion of all patients.