title: Inter-observer variability in diagnosing radiological features of aneurysmal subarachnoid hemorrhage; a preliminary single centre study comparing observers from different specialties and levels of training.
abstract: BACKGROUND
  A noncontrast computed tomography (CT) scan remains the initial radiological investigation of choice for a patient with suspected aneurysmal subarachnoid hemorrhage (aSAH). This initial scan may be used to derive key information about the underlying aneurysm which may aid in further management. The interpretation, however, is subject to the skill and experience of the interpreting individual. The authors here evaluate the interpretation of such CT scans by different individuals at different levels of training, and in two different specialties (Radiology and Neurosurgery).
  
  
  METHODS
  Initial nonontrast CT scan of 35 patients with aSAH was evaluated independently by four different observers. The observers selected for the study included two from Radiology and two from Neurosurgery at different levels of training; a resident currently in mid training and a resident who had recently graduated from training of each specialty. Measured variables included interpreter's suspicion of presence of subarachnoid blood, side of the subarachnoid hemorrhage, location of the aneurysm, the aneurysm's proximity to vessel bifurcation, number of aneurysm(s), contour of aneurysm(s), presence of intraventricular hemorrhage (IVH), intracerebral hemorrhage (ICH), infarction, hydrocephalus and midline shift. To determine the inter-observer variability (IOV), weighted kappa values were calculated.
  
  
  RESULTS
  There was moderate agreement on most of the CT scan findings among all observers. Substantial agreement was found amongst all observers for hydrocephalus, IVH, and ICH. Lowest agreement rates were seen in the location of aneurysm being supra or infra tentorial. There were, however, some noteworthy exceptions. There was substantial to almost perfect agreement between the radiology graduate and radiology resident on most CT findings. The lowest agreement was found between the neurosurgery graduate and the radiology graduate.
  
  
  CONCLUSIONS
  Our study suggests that although agreements were seen in the interpretation of some of the radiological features of aSAH, there is still considerable IOV in the interpretation of most features among physicians belonging to different levels of training and different specialties. Whether these might affect management or outcome is unclear.
authors.affiliation: Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Usman T
authors.initials: UT
authors.lastname: Siddiqui
authors.affiliation: Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Anjum F
authors.initials: AF
authors.lastname: Khan
authors.affiliation: Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Muhammad Shahzad
authors.initials: MS
authors.lastname: Shamim
authors.affiliation: Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Rana Shoaib
authors.initials: RS
authors.lastname: Hamid
authors.affiliation: Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Muhammad Mehboob
authors.initials: MM
authors.lastname: Alam
authors.affiliation: Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Emaduddin
keywords: Aneurysm; computed tomography; inter-observer variability; subarachnoid hemorrhage