title: CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke.
abstract: OBJECTIVE
  Diffusion-weighted MRI (DWI) has become a commonly used imaging modality in stroke centers. The value of this method as a routine procedure is still being discussed. In previous studies, CT was always performed before DWI. Therefore, infarct progression could be a reason for the better result in DWI.
  
  
  METHODS
  All hyperacute (<6 hours) stroke patients admitted to our emergency department with a National Institutes of Health Stroke Scale (NIHSS) score >3 were prospectively randomized for the order in which CT and MRI were performed. Five stroke experts and 4 residents blinded to clinical data judged stroke signs and lesion size on the images. To determine the interrater variability, we calculated kappa values for both rating groups.
  
  
  RESULTS
  A total of 50 patients with ischemic stroke and 4 patients with transient symptoms of acute stroke (median NIHSS score, 11; range, 3 to 27) were analyzed. Of the 50 patients, 55% were examined with DWI first. The mean delay from symptom onset until CT was 180 minutes; that from symptom onset until DWI was 189 minutes. The mean delay between DWI and CT was 30 minutes. The sensitivity of infarct detection by the experts was significantly better when based on DWI (CT/DWI, 61/91%). Accuracy was 91% when based on DWI (CT, 61%). Interrater variability of lesion detection was also significantly better for DWI (CT/DWI, kappa=0.51/0.84). The assessment of lesion extent was less homogeneous on CT (CT/DWI, kappa=0.38/0.62). The differences between the 2 modalities were stronger in the residents' ratings (CT/DWI: sensitivity, 46/81%; kappa=0.38/0.76).
  
  
  CONCLUSIONS
  CT and DWI performed with the same delay after onset of ischemic stroke resulted in significant differences in diagnostic accuracy. DWI gives good interrater homogeneity and has a substantially better sensitivity and accuracy than CT even if the raters have limited experience.
authors.affiliation: Department of Neuroradiology, University of Heidelberg Medical School, Heidelberg, Germany. Jochen_Fiebach@med.uni-heidelberg.de
authors.forename: J B
authors.initials: JB
authors.lastname: Fiebach
authors.forename: P D
authors.initials: PD
authors.lastname: Schellinger
authors.forename: O
authors.initials: O
authors.lastname: Jansen
authors.forename: M
authors.initials: M
authors.lastname: Meyer
authors.forename: P
authors.initials: P
authors.lastname: Wilde
authors.forename: J
authors.initials: J
authors.lastname: Bender
authors.forename: P
authors.initials: P
authors.lastname: Schramm
authors.forename: E
authors.initials: E
authors.lastname: Jüttler
authors.forename: J
authors.initials: J
authors.lastname: Oehler
authors.forename: M
authors.initials: M
authors.lastname: Hartmann
authors.forename: S
authors.initials: S
authors.lastname: Hähnel
authors.forename: M
authors.initials: M
authors.lastname: Knauth
authors.forename: W
authors.initials: W
authors.lastname: Hacke
authors.forename: K
authors.initials: K
authors.lastname: Sartor
mesh_terms: D000208:Acute Disease; D000368:Aged; D002545:Brain Ischemia / Q000150:complications / Q000175:diagnosis*; D004058:Diffusion; D018450:Disease Progression; D006801:Humans; D008279:Magnetic Resonance Imaging; D015588:Observer Variation; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications / Q000175:diagnosis*; D013997:Time Factors; D014057:Tomography, X-Ray Computed