HSHS Neuroscience Center, HSHS Saint John's Hospital, Springfield, Illinois, USA.
Neuroradiology Department, CHRU Gui de CHauliac, Montpellier, France.
J Neurointerv Surg. 2019 Sep;11(9):947-954. doi: 10.1136/neurintsurg-2018-014613. Epub 2019 Feb 2.
The DAWN trial (Diffusion weighted imaging or CT perfusion Assessment with clinical mismatch in the triage of Wake-up and late presenting strokes undergoing Neurointervention with Trevo) has demonstrated the benefits of thrombectomy in patients with unknown or late onset strokes, using automated software (RAPID) for measurement of infarct volume. Because RAPID is not available in all centers, we aimed to assess the accuracy and repeatability of visual infarct volume estimation by clinicians and the consequences for thrombectomy decisions based on the DAWN criteria.
18 physicians, who routinely depend on MRI for acute stroke imaging, assessed 32 MR scans selected from a prospective databaseover two independent sessions. Raters were asked to visually estimate the diffusion weighted imaging (DWI) infarct volume for each case. Sensitivity, specificity, and accuracy of the estimated volumes were compared with the available RAPID measurements for various volume cut-off points. Thrombectomy decisions based on DAWN criteria with RAPID measurements and raters' visual estimates were compared. Inter-rater and intra-rater agreement was measured using kappa statistics.
The mean accuracy of raters was <90% for all volume cut-points. Inter-rater agreement was below substantial for each DWI infarct volume cut-off points. Intra-rater agreement was substantial for 55-83% of raters, depending on the selected cut-off points. Applying DAWN criteria with visual estimates instead of RAPID measurements led to 19% erroneous thrombectomy decisions, and showed a lack of reproducibility.
The visual assessment of DWI infarct volume lacks accuracy and repeatability, and could lead to a significant number of erroneous decisions when applying the DAWN criteria.
DAWN 试验（在通过神经介入治疗醒来和发病较晚的中风患者中，使用 CT 灌注评估与临床失匹配的弥散加权成像）已经证明了在使用自动软件（RAPID）测量梗塞体积的情况下，对未知或发病较晚的中风患者进行血栓切除术的益处。由于 RAPID 并非在所有中心都可用，因此我们旨在评估临床医生对视觉梗塞体积估计的准确性和可重复性，以及基于 DAWN 标准对血栓切除术决策的影响。
18 名经常依靠 MRI 进行急性中风成像的医生，在两个独立的时段内评估了从一个前瞻性数据库中选择的 32 个 MRI 扫描。评估者被要求对每个病例的弥散加权成像（DWI）梗塞体积进行视觉估计。对于各种体积截止点，比较了估计体积的敏感性、特异性和准确性，以及与可用 RAPID 测量值的比较。比较了基于 DAWN 标准的 RAPID 测量值和评估者视觉估计的血栓切除术决策。使用 Kappa 统计数据测量了组内和组间的一致性。
对于所有体积截止点，评估者的平均准确性均<90%。对于每个 DWI 梗塞体积截止点，组间一致性均低于显著水平。对于 55-83%的评估者，取决于所选的截止点，组内一致性是显著的。使用视觉估计而不是 RAPID 测量值来应用 DAWN 标准会导致 19%的错误血栓切除术决策，并且显示出缺乏可重复性。
DWI 梗塞体积的视觉评估缺乏准确性和可重复性，在应用 DAWN 标准时可能会导致大量错误的决策。
