title: How good is intercenter agreement in the identification of embolic signals in carotid artery disease?
abstract: OBJECTIVE
  There has been concern regarding the reproducibility of the detection of embolic signals, particularly in patients with carotid artery stenosis in whom the signals are of low intensity. No published studies have examined inter-center agreement in reporting specific embolic signals or the factors responsible for any lack of agreement. We examined reproducibility between two centers in which widely differing proportions of embolic signals have previously been reported in patients with carotid artery stenosis.
  
  
  METHODS
  Recordings from the middle cerebral artery of eight patients with ipsilateral carotid artery stenosis in whom embolic signals had been detected during a previously study were independently examined by three experienced observers in one center and by one experienced observer in another center. We calculated agreement within and between centers by estimating the probability that one observer would identify a specific embolic signal if other observers had identified it (a probability of 1 indicates complete agreement). The influence of different characteristics of the embolic signal on the probability of its detection as an embolic signal was determined.
  
  
  RESULTS
  A high level of agreement in the identification of specific embolic signals was found. This was similar between all observers (.90), between the three observers in one center (.89), and between observers in the two different centers (.94). The probability of detection was independently related to the relative intensity of the embolic signal (P<.0001). It was less (although significantly) independently related to the position of the embolic signal in the cardiac cycle (P=.02), with signals in systole being more reliably detected. There was no independent relationship between the probability of detection and either the duration of the embolic signal or the velocity at the maximum intensity increase. The use of threshold intensity as a criterion for embolic signal detection increased interobserver agreement but reduced the sensitivity in detecting signals.
  
  
  CONCLUSIONS
  The high level of interobserver agreement suggests that the technique is sufficiently reproducible for clinical use.
authors.affiliation: Department of Neurology, King's College School of Medicine and Dentistry, London, UK.
authors.forename: H
authors.initials: H
authors.lastname: Markus
authors.forename: J M
authors.initials: JM
authors.lastname: Bland
authors.forename: G
authors.initials: G
authors.lastname: Rose
authors.forename: M
authors.initials: M
authors.lastname: Sitzer
authors.forename: M
authors.initials: M
authors.lastname: Siebler
mesh_terms: D001783:Blood Flow Velocity; D016893:Carotid Stenosis / Q000000981:diagnostic imaging*; D005583:Fourier Analysis; D006339:Heart Rate; D006801:Humans; D007373:Interinstitutional Relations; D002542:Intracranial Embolism and Thrombosis / Q000000981:diagnostic imaging*; D016015:Logistic Models; D015588:Observer Variation; D011336:Probability; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012815:Signal Processing, Computer-Assisted; D016037:Single-Blind Method; D013599:Systole; D017585:Ultrasonography, Doppler, Transcranial / Q000706:statistics & numerical data