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      <h1 class="highwire-cite-title" id="page-title">Reliability of CTA Alone and in Combination with CTP in the Detection of Cerebral Vasospasm: Methodologic Issues on Reliability to Avoid Misinterpretation</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">Siamak Sabour</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">June 2024,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">45 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(6) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E14; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A8241 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-108041--6956297949" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">Siamak Sabour </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Safety Promotion and Injury Prevention Research CenterShahid Beheshti University of Medical SciencesTehran, I.R. Iran</div><div class='author-affiliation'><span class='nlm-sup'>b</span>Department of Clinical EpidemiologySchool of Public Health and SafetyShahid Beheshti University of Medical SciencesTehran, I.R. Iran</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=Siamak%2BSabour%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Sabour%20S&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3ASiamak%2BSabour%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-1928-992X" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for Siamak Sabour</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">I was interested in the article by Heitkamp et al<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> published in the March 2024 issue of the <em>American Journal of Neuroradiology</em>. The authors investigated the reliability of CTA alone and in combination with CTP in the detection of cerebral vasospasm and the decision to initiate endovascular treatment. Three neuroradiologists were asked to grade 15 intracranial artery segments in 71 cases using a tripartite scale (no, mild &lt;50%, or severe &gt;50% vasospasm). They reported that the interrater reliability for per-segment analysis of vessels was highly variable (κ = 0.16–0.61). When one focused on senior raters, the addition of CTP images resulted in higher interrater reliability for severe vasospasm (κ = 0.28 versus κ = 0.46) and subsequently higher concordance (κ = 0.23 versus κ = 0.73) for the decision to start endovascular treatment.</p><p id="p-2">Although the article provides insight into the decision about using CTA in combination with CTP to increase the reliability of endovascular treatment, its conclusion is limited in 2 important methodologic and statistical ways. First, the value of κ depends on the prevalence in each category. It is possible to have the prevalence of concordance cells equal to 90% and discordance cells equal to 10% and, however, obtain different κ values (0.44 as moderate versus 0.81 as very good, respectively).<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a><a id="xref-ref-3-1" class="xref-down-link" href="#ref-3"><span>⇓</span></a>-<a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></sup> Second, the Fleiss κ is a statistical measure for assessing the reliability of agreement among a fixed number of raters when assigning categoric ratings to a number of items. This use contrasts with other applications of κ such as the simple Cohen κ, which works only when assessing the agreement between not more than 2 raters or the intrarater reliability.</p><p id="p-3">The authors concluded that CTA alone offers only low interrater reliability in the graduation of cerebral vasospasm. However, using CTA in combination with CTP might help, especially senior neuroradiologists, to increase the interrater reliability to identify severe vasospasm following aneurysmal SAH and to increase the reliability regarding endovascular treatment decisions. Considering the above-mentioned methodologic and statistical issues, such conclusions can easily be a misleading message.<sup><a id="xref-ref-2-2" class="xref-bibr" href="#ref-2">2</a><a id="xref-ref-3-2" class="xref-down-link" href="#ref-3"><span>⇓</span></a>-<a id="xref-ref-4-2" class="xref-bibr" href="#ref-4">4</a></sup> Briefly, the prevalence-adjusted and bias-adjusted Fleiss κ should be applied to correctly assess the reliability of CTA alone and in combination with CTP in the detection of cerebral vasospasm and the decision to initiate endovascular treatment.</p><div class="section fn-group" id="fn-group-1"><h2>Footnotes</h2><ul><li class="fn-financial-disclosure" id="fn-1"><p id="p-4"><a href="https://www.ajnr.org/sites/default/files/additional-assets/Disclosures/June%202024/0102.pdf">Disclosure forms</a> provided by the authors are available with the full text and PDF of this article at <a href="http://www.ajnr.org">www.ajnr.org</a>.</p></li></ul></div><div class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-45.6.E14.1" data-doi="10.3174/ajnr.A8110"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Heitkamp</span>  <span class="cit-name-given-names">C</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Geest</span>  <span class="cit-name-given-names">V</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Tokareva</span>  <span class="cit-name-given-names">B</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">CTA supplemented by CTP increases interrater reliability and endovascular treatment use in patients with aneurysmal SAH</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2024</span>;<span class="cit-vol">45</span>:<span class="cit-fpage">284</span>–<span class="cit-lpage">90</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.3174/ajnr.A8110</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>38238090</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiI0NS8zLzI4NCI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci80NS82L0UxNC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a><div class="cit ref-cit ref-journal" id="cit-45.6.E14.2" data-doi="10.2214/AJR.14.12649"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Sabour</span>  <span class="cit-name-given-names">S</span></span></li></ol><cite>. <span class="cit-article-title">Methodologic concerns in reliability of noncalcified coronary artery plaque burden quantification</span>. <abbr class="cit-jnl-abbrev">AJR Am J Roentgenol</abbr> <span class="cit-pub-date">2014</span>;<span class="cit-vol">203</span>:<span class="cit-fpage">W343</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.2214/AJR.14.12649</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>25148196</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.2214/AJR.14.12649&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=25148196&amp;link_type=MED&amp;atom=%2Fajnr%2F45%2F6%2FE14.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a><div class="cit ref-cit ref-journal" id="cit-45.6.E14.3" data-doi="10.1007/s10654-007-9123-4"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Sabour</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Rutten</span>  <span class="cit-name-given-names">A</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">van der Schouw</span>  <span class="cit-name-given-names">YT</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Inter-scan reproducibility of coronary calcium measurement using multi detector-row computed tomography (MDCT)</span>. <abbr class="cit-jnl-abbrev">Eur J Epidemiol</abbr> <span class="cit-pub-date">2007</span>;<span class="cit-vol">22</span>:<span class="cit-fpage">235</span>–<span class="cit-lpage">43</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1007/s10654-007-9123-4</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>17427036</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1007/s10654-007-9123-4&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=17427036&amp;link_type=MED&amp;atom=%2Fajnr%2F45%2F6%2FE14.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">4.</span><a class="rev-xref-ref" href="#xref-ref-4-1" title="View reference 4. in text" id="ref-4">↵</a><div class="cit ref-cit ref-journal" id="cit-45.6.E14.4" data-doi="10.1093/bja/aeu423"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Sabour</span>  <span class="cit-name-given-names">S</span></span></li></ol><cite>. <span class="cit-article-title">Reliability of the ASA physical status scale in clinical practice: methodological issues</span>. <abbr class="cit-jnl-abbrev">Br J Anaesth</abbr> <span class="cit-pub-date">2015</span>;<span class="cit-vol">114</span>:<span class="cit-fpage">162</span>–<span class="cit-lpage">63</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1093/bja/aeu423</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>25500399</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1093/bja/aeu423&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=25500399&amp;link_type=MED&amp;atom=%2Fajnr%2F45%2F6%2FE14.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li></ol></div><ul 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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 45</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 6 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Jun 2024 </div></div>
      
      
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