Reliability of CT Angiography in Cerebral Vasospasm: A Systematic Review of the Literature and an Inter- and Intraobserver Study

Abstract

Background and purpose: Computed tomography angiography offers a non-invasive alternative to DSA for the assessment of cerebral vasospasm following subarachnoid hemorrhage but there is limited evidence regarding its reliability. Our aim was to perform a systematic review (Part I) and to assess (Part II) the inter- and intraobserver reliability of CTA in the diagnosis of cerebral vasospasm.

Materials and methods: In Part I, articles reporting the reliability of CTA up to May 2018 were systematically searched and evaluated. In Part II, 11 raters independently graded 17 arterial segments in each of 50 patients with SAH for the presence of vasospasm using a 4-category scale. Raters were additionally asked to judge the presence of any moderate/severe vasospasm (≥ 50% narrowing) and whether findings would justify augmentation of medical treatment or conventional angiography ± balloon angioplasty. Four raters took part in the intraobserver reliability study.

Results: In Part I, the systematic review revealed few studies with heterogeneous vasospasm definitions. In Part II, we found interrater reliability to be moderate at best (κ ≤ 0.6), even when results were stratified according to specialty and experience. Intrarater reliability was substantial (κ > 0.6) in 3/4 readers. In the per arterial segment analysis, substantial agreement was reached only for the middle cerebral arteries, and only when senior raters' judgments were dichotomized (presence or absence of ≥50% narrowing). Agreement on the medical or angiographic management of vasospasm based on CTA alone was less than substantial (κ ≤ 0.6).

Conclusions: The diagnosis of vasospasm using CTA alone was not sufficiently repeatable among observers to support its general use to guide decisions in the clinical management of patients with SAH.

Fig 1.

Interreader reliability coefficients (95% confidence intervals) including all subgroups (senior, junior, interventional, and diagnostic neuroradiologists) for the 3 main questions: detection of moderate-severe vasospasm in any arterial segment (≥ 50% narrowing), recommendations of medical treatment augmentation, and DSA ± angioplasty based on imaging findings. The horizontal dashed line indicates the threshold for substantial agreement (κ > 0.6). INR indicates interventional neuroradiology; DNR, diagnostic neuroradiology.

Fig 2.

Intrareader reliability coefficients for the 3 main questions (95% confidence intervals) among 4 observers: detection of moderate-severe vasospasm in any arterial segment (≥ 50% narrowing), recommendations for medical treatment augmentation, and DSA ± angioplasty based on imaging findings. The horizontal dashed line indicates the threshold for substantial agreement (κ > 0.6).