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(Stroke. 1999;30:1528-1533.)
© 1999 American Heart Association, Inc.
Original Contributions |
Agreement and Variability in the Interpretation of Early CT Changes in Stroke Patients Qualifying for Intravenous rtPA Therapy
From the Department of Neurology (J.C.G., D.C.), University of Texas–Houston Medical School, Houston, Tex; Department of Biostatistics and Research Epidemiology (M.L., B.C.T.), Department of Radiology (S.P., J.C., S.T.), Department of Neurology (S.R.L., P.M., D.T.), and Department of Emergency Medicine (C.A.L.), Henry Ford Health Science Center, Detroit, Mich; Department of Neurology (T.G.B., J.P.B.) and Department of Emergency Medicine (R.K.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Neurology (E.C.H.) and Department of Emergency Medicine (S.H.), University of Virginia, Charlottesville, Va; Department of Neurosciences (P.D.L.), University of California–San Diego; Department of Neurology (M.F.), Emory University, Atlanta, Ga; Department of Neurology (R.L.) and Department of Emergency Medicine (T.K.), Long Island Jewish Medical Center, New Hyde Park, NY; and Division of Stroke and Trauma (J.R.M.), National Institute of Neurological Disorders and Stroke, Bethesda, Md..
Correspondence to James Grotta, MD, Stroke Program, Department Neurology, University of Texas Medical School, 6431 Fannin, Houston, TX 77030. E-mail jgrotta{at}neuro.med.uth.tmc.edu
Background and Purpose—Ischemic changes identified on CT scans performed in the first few hours after stroke onset, which are thought to possibly represent early cytotoxic edema and development of irreversible injury, may have important implications for subsequent treatment. However, insecurity and conflicting data exist over the ability of clinicians to correctly recognize and interpret these changes. We performed a detailed review of selected baseline CT scans from the NINDS rt-PA Stroke Trial to test agreement among experienced stroke specialists and other physicians on the presence of early CT ischemic changes.
Methods—Seventy baseline CT scans from the NINDS Stroke
Trial were read and classified for the presence or absence of various
early findings of ischemia by 16 individuals, including NINDS
trial investigators, other neurologists, other emergency medicine
physicians, and radiology or stroke fellows. CT scans included normal
scans and scans from patients who later developed
symptomatic intracranial hemorrhage, as well as
scans on which the NINDS rt-PA Stroke Trial neuroradiologist identified
clear-cut early CT changes. For each CT finding, 
-statistics were
used to assess the proportion of agreement beyond chance.
Results—-Values (95% confidence interval [CI]) ranged
from 0.20 (-0.20, 0.61) (fair agreement) to 0.41 (0.37, 0.45)
(moderate agreement) among the 16 viewers, and the -value was only
0.39 (0.29, 0.49) (fair) in answer to the question "do early CT
changes involve more than one third of the MCA [middle cerebral
artery] territory?" There was substantial variability within each
specialty group and between groups. -Values were only fair to
moderate even among physicians experienced in selecting and treating
acute stroke patients with rtPA. Observed agreement ranged from 68% to
85%. Physicians agreed on the finding of early CT changes involving
>33% of the MCA territory 77% of the time, although the -value of
0.39 suggested only moderate agreement beyond chance.
Conclusions—There is considerable lack of agreement, even among experienced clinicians, in recognizing and quantifying early CT changes. Improved methods of recognizing and quantifying early ischemic brain damage are needed.
Key Words: cerebral infarction • statistics • stroke • tissue plasminogen activator • tomography, emission-computed
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