I applaud Amber et al for their piece in the August issue of Academic Radiology in which they explore the impact of diagnosing small intracranial aneurysms . The topic is truly deserving of attention as these lesions are not uncommonly encountered by neuroradiologists and general radiologists alike. Further, the reporting of these lesions often leads to a cascade of events that may or may not be based on scientific evidence and that may result in unnecessary and potentially harmful repercussions. In their conclusion, Amber et al state that “a change in the nomenclature of small aneurysms is a possible solution to mitigate patient anxiety from a diagnosis of intracranial aneurysm.” I would like to provide a counterargument with the assertion that such proposed changes in nomenclature would provide little actual benefit for patients.
As radiologists, the language that we use matters, all the more given that many (if not the vast majority) of our interactions with our audience are not face to face but rather through the words we choose to include in our reports. It therefore behooves us to make critical and conscious decisions regarding the lexicon, tone, and style of our reports to accurately and effectively convey the ideas that we actually intend to convey to our audience. The challenges of this task are growing in the current era of open patient access to their reports. This revolution in the way health care information is handled confounds the concept of who our audience actually is—referring clinicians, patients, plaintiff’s attorneys, or all of the above. As such, we are now responsible for communicating results of radiological studies to individuals with widely divergent background knowledge, variable understanding of the impact of the diagnoses rendered, and potentially divergent incentives.
Does reporting a 5-mm anterior communicating artery aneurysm as a vascular outpouching of indeterminate relevance (VOIR), as Amber et al suggest, actually mitigate the emotional impact to a patient reading this in her radiology report? Perhaps to some degree, yes. We know that words viewed as emotionally positive or negative are processed differently by the brain . Therefore, it seems reasonable that different words, even if they represent the same concept, may be processed differently. Further, the emotional impact of potentially provocative words in a radiology report is influenced by the preexisting neurophysiological and emotional state of the reader. As an example, intranasal administration of oxytocin has been shown to modulate the processing of emotional stimuli and produce a shift toward a positive interpretation bias . Radiologists are typically not privy to information on our patients’ complete past medical, psychiatry, and family history, nor do they know the specific circumstances under which their patients’ imaging examination has been performed. Reading the word “aneurysm” is likely to have more impact on a patient whose father died as a result of a ruptured intracranial aneurysm at age 35 than on someone without such a history. Whether the patient is currently symptomatic is also likely to influence their perception of what they read in their radiology report.
Taking a step back, does choosing to use the term VOIR actually serve to insulate patients? Most patients, in fact most radiologists, reading this word in a report will not know what it means. How will patients respond once they go online and discover that VOIR actually means small aneurysm? Such a revelation has the potential to exacerbate the emotional impact of this finding and may give patients the impression that radiologists are minimizing, or even worse, hiding findings of their examinations. Choices regarding terminology must be weighed against the alternative course of simply not reporting small intracranial aneurysms that are unlikely to be of any clinical significance. Instead, inclusion of a statement regarding the actual risk of rupture (near zero for aneurysms <7 mm in the anterior circulation) can provide context to a finding and thus legitimately mitigate its negative impact while maintaining full disclosure in a way that can be understood by patients and referring clinicians alike. Personally, I will continue to report an aneurysm as an aneurysm until I am convinced that usage of an alternative term truly adds value to my report and positively influences the outcome of my patients.
References
1. Amber I., Mohan S., Nucifora P.: Intracranial aneurysms: a game of millimeters. Acad Radiol 2015; 22: pp. 1020-1023.
2. Kuchinke L., Jacobs A.M., Grubich C., et. al.: Incidental effects of emotional valence in single word processing: an fMRI study. Neuroimage 2005; 28: pp. 1022-1032.
3. Fossati P., Hevenor S.J., Graham S.J., et. al.: In search of the emotional self: an fMRI study using positive and negative emotional words. Am J Psychiatry 2003; 160: pp. 1938-1945.
4. Di Simplicio M., Massey-Chase R., Cowen P., et. al.: Oxytocin enhances processing of positive versus negative emotional information in healthy male volunteers. J Psychopharmacol 2009; 23: pp. 241-248.
5. Brown R.D., Broderick J.P.: Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. Lancet Neural 2014; 13: pp. 393-404.