Bink Andrea, Benner Jan, Reinhardt Julia, De Vere-Tyndall Anthony, Stieltjes Bram, Hainc Nicolin, Stippich Christoph
Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland.
Front Neurol. 2018 Feb 6;9:32. doi: 10.3389/fneur.2018.00032. eCollection 2018.
The aim of this pilot study was to assess the clinical feasibility, diagnostic yield, advantages, and disadvantages of structured reporting for routine MRI-reading in patients with primary diagnosis of intracranial tumors as compared to traditional neuroradiological free text reporting.
A structured MRI reporting template was developed covering pathological, anatomical, and functional aspects in an itemized fashion. Retrospectively, 60 consecutive patients with first diagnosis of an intracranial tumor were selected from the radiology information system/PACS system. Structured reporting was performed by a senior neuroradiologist, blinded to clinical and radiological data. Reporting times were measured per patient. The diagnostic content was compared to free text reporting which was independently performed on the same MRI exams by two other neuroradiologists. The comparisons were categorized per item as: "congruent," "partially congruent," "incongruent," or "not mentioned in free-style report."
Tumor-related items: congruent findings were found for all items (17/17) with congruence rates ranging between 98 and 39% per item. Four items achieved congruence rates ≥90%, 5 items >80%, and 9 items ≥70%. Partially congruent findings were found for all items in up to 50% per item. Incongruent findings were present in 7/17 items in up to 5% per item. Free text reports did not mention 12 of 17 items (range 7-43% per item). Non-tumor-related items, including brain atrophy, microangiopathy, vascular pathologies, and various extracranial pathologies, which were not mentioned in free-text reports between 18 and 85% per item. Mean reporting time for structured reporting was 7:49 min (3:12-17:06 min).
First results showed that expert structured reporting ensured reliable detection of all relevant brain pathologies along with reproducible documentation of all predefined diagnostic items, which was not always the case for free text reporting. A mean reporting time of 8 min per patient seems clinically feasible.
本初步研究旨在评估与传统神经放射学自由文本报告相比，结构化报告在颅内肿瘤初诊患者常规MRI阅片中的临床可行性、诊断率、优点和缺点。
开发了一个结构化MRI报告模板，以逐项方式涵盖病理、解剖和功能方面。回顾性地从放射学信息系统/PACS系统中选取60例首次诊断为颅内肿瘤的连续患者。由一位对临床和放射学数据不知情的资深神经放射学家进行结构化报告。测量每位患者的报告时间。将诊断内容与另外两位神经放射学家在相同MRI检查上独立进行的自由文本报告进行比较。比较按项目分类为：“一致”、“部分一致”、“不一致”或“自由式报告中未提及”。
肿瘤相关项目：所有项目（17/17）均发现一致的结果，每个项目的一致率在98%至39%之间。4个项目的一致率≥90%，5个项目>80%，9个项目≥70%。每个项目高达50%的所有项目发现部分一致的结果。17个项目中有7个项目存在不一致的结果，每个项目高达5%。自由文本报告未提及17个项目中的12个（每个项目范围为7% - 43%）。非肿瘤相关项目，包括脑萎缩、微血管病、血管病变和各种颅外病变，在自由文本报告中每个项目未提及的比例在18%至85%之间。结构化报告的平均报告时间为7:49分钟（3:12 - 17:06分钟）。
初步结果表明，专家结构化报告确保了对所有相关脑部病变的可靠检测以及所有预定义诊断项目的可重复记录，而自由文本报告并非总是如此。每位患者平均8分钟的报告时间在临床上似乎是可行的。
