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Visual assessment of diffusion weighted imaging infarct volume lacks accuracy and reliability
  1. Naim Khoury1,
  2. Cyril Dargazanli2,
  3. Adrien Guenego3,
  4. Kevin Zuber4,
  5. Asya Ekmen5,
  6. Guillaume Charbonnier6,
  7. Solène Hebert6,
  8. Jean Capron5,
  9. Candice Sabben7,
  10. Erwan Morvan7,
  11. William Boisseau6,
  12. Benjamin Maier6,
  13. Kévin Premat8,
  14. Frédéric Clarençon8,
  15. Stanislas Smajda6,
  16. Hocine Redjem6,
  17. Vanessa Chalumeau9,
  18. Gregoire Boulouis10,
  19. Annaëlle Chetrit11,
  20. Augustin Lecler11,
  21. Patricia Koskas11,
  22. Loic Duron11,
  23. Gabriele Ciccio6,
  24. Célina Ducroux5,
  25. Simon Escalard6,
  26. Jean Philippe Desilles6,
  27. Mylène Hamdani4,
  28. Bertrand Lapergue12,
  29. Mikael Mazighi6,
  30. Malek Ben Maacha4,
  31. Nahida Brikci-Nigassa4,
  32. Raphael Blanc6,
  33. Michel Piotin6,
  34. Robert Fahed6
  1. 1 HSHS Neuroscience Center, HSHS Saint John’s Hospital, Springfield, Illinois, USA
  2. 2 Neuroradiology Department, CHRU Gui de CHauliac, Montpellier, France
  3. 3 Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
  4. 4 Unit of Clinical Research, Fondation Rothschild Hospital, Paris, France
  5. 5 Neurology, Hopital Saint-Antoine, Paris, France
  6. 6 Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
  7. 7 Neurology, Fondation Rothschild Hospital, Paris, France
  8. 8 Department of Interventional Neuroradiology, Hôpital de la Pitié-Salpétrière, Paris, France
  9. 9 Interventional Neuroradiology Department, Hôpital Kremlin-Bicêtre, Le Kremlin-Bicetre, France
  10. 10 Neuroradiology, Sainte-Anne Hospital, Paris, FRANCE
  11. 11 Radiology, Fondation Rothschild Hospital, Paris, France
  12. 12 Foch Hospital, Suresnes, France
  1. Correspondence to Dr Robert Fahed, Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, 75019, France; robert.fahed{at}


Purpose The DAWN trial (Diffusion weighted imaging or CT perfusion Assessment with clinical mismatch in the triage of Wake-up and late presenting strokes undergoing Neurointervention with Trevo) has demonstrated the benefits of thrombectomy in patients with unknown or late onset strokes, using automated software (RAPID) for measurement of infarct volume. Because RAPID is not available in all centers, we aimed to assess the accuracy and repeatability of visual infarct volume estimation by clinicians and the consequences for thrombectomy decisions based on the DAWN criteria.

Materials and methods 18 physicians, who routinely depend on MRI for acute stroke imaging, assessed 32 MR scans selected from a prospective databaseover two independent sessions. Raters were asked to visually estimate the diffusion weighted imaging (DWI) infarct volume for each case. Sensitivity, specificity, and accuracy of the estimated volumes were compared with the available RAPID measurements for various volume cut-off points. Thrombectomy decisions based on DAWN criteria with RAPID measurements and raters’ visual estimates were compared. Inter-rater and intra-rater agreement was measured using kappa statistics.

Results The mean accuracy of raters was <90% for all volume cut-points. Inter-rater agreement was below substantial for each DWI infarct volume cut-off points. Intra-rater agreement was substantial for 55–83% of raters, depending on the selected cut-off points. Applying DAWN criteria with visual estimates instead of RAPID measurements led to 19% erroneous thrombectomy decisions, and showed a lack of reproducibility.

Conclusion The visual assessment of DWI infarct volume lacks accuracy and repeatability, and could lead to a significant number of erroneous decisions when applying the DAWN criteria.

  • stroke
  • thrombectomy

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  • Contributors Study design: NK, CD, AG, and RF. Acquisition, analysis, or interpretation of the data: all authors. Drafting of the manuscript: NK, CD, AG, and RF. Statistical analysis: KZ. Supervision: RF.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The study protocol was approved by the local ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data, analytic methods, and study materials will be made available to any researcher for purposes of reproducing the results or replicating the procedure. Requests to receive these materials should be sent to the corresponding author, who will maintain their availability.