title: Substantial observer variability in the differentiation between primary intracerebral hemorrhage and hemorrhagic transformation of infarction on CT brain imaging.
abstract: OBJECTIVE
  CT remains the most commonly used imaging technique in acute stroke but is often delayed after minor stroke. Interobserver reliability in distinguishing hemorrhagic transformation of infarction from intracerebral hemorrhage may depend on delays to CT but has not been reported previously despite the clinical importance of this distinction.
  
  
  METHODS
  Initial CT scans with intraparenchymal hematoma from the first 1000 patients with stroke in the Oxford Vascular Study were independently categorized as intracerebral hemorrhage or hemorrhagic transformation of infarction by 5 neuroradiologists, both blinded and unblinded to clinical history. Thirty scans were reviewed twice. Agreement was quantified by the kappa statistic.
  
  
  RESULTS
  Seventy-eight scans showed intraparenchymal hematoma. Blinded pairwise interrater agreements for a diagnosis of intracerebral hemorrhage ranged from kappa=0.15 to 0.48 with poor overall agreement (kappa=0.35; 95% CI, 0.15 to 0.54) even after unblinding (kappa=0.41; 0.21 to 0.60). Blinded intrarater agreements ranged from kappa=0.21 to 0.92. Lack of consensus after unblinding was greatest in patients scanned >or=24 hours after stroke onset (67% versus 25%, P=0.001) and in minor stroke (National Institutes of Health Stroke Scale <or=5: 56% versus 29%, P=0.04) with disagreement in 75% of patients scanned >or=24 hours after minor stroke and in 48% of all 30-day stroke survivors in whom reliable diagnosis would be expected to influence long-term management.
  
  
  CONCLUSIONS
  Reliability of diagnosis of intraparenchymal hematoma on CT brain scan in minor stroke is poor, particularly if scanning is delayed. Immediate brain imaging is justified in patients with minor stroke.
authors.affiliation: Stroke Prevention Research Unit, Department of Clinical Neurology, John Radcliffe Hospital, Oxford, UK.
authors.forename: Caroline E
authors.initials: CE
authors.lastname: Lovelock
authors.forename: Philip
authors.initials: P
authors.lastname: Anslow
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Molyneux
authors.forename: James V
authors.initials: JV
authors.lastname: Byrne
authors.forename: Wilhelm
authors.initials: W
authors.lastname: Kuker
authors.forename: Pieter M
authors.initials: PM
authors.lastname: Pretorius
authors.forename: Andrew
authors.initials: A
authors.lastname: Coull
authors.forename: Peter M
authors.initials: PM
authors.lastname: Rothwell
mesh_terms: D000368:Aged; D001921:Brain / Q000098:blood supply / Q000000981:diagnostic imaging* / Q000473:pathology; D002536:Cerebral Arteries / Q000000981:diagnostic imaging* / Q000473:pathology / Q000503:physiopathology; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging* / Q000209:etiology / Q000473:pathology; D002544:Cerebral Infarction / Q000150:complications / Q000000981:diagnostic imaging* / Q000473:pathology; D015331:Cohort Studies; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000517:prevention & control; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods / Q000592:standards; D008297:Male; D015588:Observer Variation; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000592:standards* / Q000706:statistics & numerical data*