Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy
Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy
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DOI：
10.1161/01.str.30.8.1528
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发表时间：
1999-08-01
期刊：
影响因子：
8.3
通讯作者：
Tanne, D
中科院分区：
文献类型：
--
作者：
Grotta, JC;Chin, D;Tanne, D
背景和目的：脑卒中发作后最初几小时内CT扫描发现的缺血性改变，被认为可能代表早期细胞毒性水肿和不可逆损伤的发展，可能对后续治疗有重要意义。然而，临床医生正确识别和解释这些改变的能力存在不安全性和相互矛盾的数据。我们对NINDS rt-PA卒中试验中选定的基线CT扫描进行了详细的回顾，以测试经验丰富的卒中专家和其他医生对早期CT缺血性变化的存在的一致性。方法-由16名个体阅读来自NINDS卒中试验的70份基线CT扫描，并对缺血的各种早期发现的存在或不存在进行分类，这些个体包括NINDS试验研究者、其他神经学家、其他急诊医生和放射科或中风研究员。CT扫描包括正常扫描和后来出现症状性颅内出血的患者的扫描，以及NINDS rt-PA卒中试验神经放射学家确定明确的早期CT变化的扫描。对于每一个CT结果，kappa统计量用于评估超出偶然的一致率。（95%置信区间[CI]）范围为0.20（-0.20，0.61）（公平协议）至0.42（0.37，GAS）（中等一致），卡帕值仅为0.39（0.29，0.49）（一般）在回答“早期CT改变是否涉及超过三分之一的MCA [大脑中动脉]区域？“每个专业组内和组间都有很大的差异。即使在选择和治疗急性卒中患者的rtPA经验丰富的医生中，kappa值也仅为中等至中等，观察到的一致性范围为68%至85%。医生同意的发现早期CT变化涉及>33%的MCA领土的77%的时间，虽然卡帕值为0.39建议只有中度：协议超越chance. Conclusions，有相当大的缺乏协议，即使是有经验的临床医生，在认识和量化早期CT变化。需要改进识别和量化早期缺血性脑损伤的方法。
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, kappa-statistics were used to assess the proportion of agreement beyond chance.Results-kappa-Values (95% confidence interval [CI]) ranged from 0.20 (-0.20, 0.61) (fair agreement) to 0.42 (0.37, GAS) (moderate agreement) among the 16 viewers, and the kappa-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. kappa-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 kappa-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.