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Muzammil MA, Javid S, Afridi AK, Siddineni R, Shahabi M, Haseeb M, Fariha FNU, Kumar S, Zaveri S, Nashwan AJ. Artificial intelligence-enhanced electrocardiography for accurate diagnosis and management of cardiovascular diseases. J Electrocardiol 2024; 83:30-40. [PMID: 38301492 DOI: 10.1016/j.jelectrocard.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/28/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
Electrocardiography (ECG), improved by artificial intelligence (AI), has become a potential technique for the precise diagnosis and treatment of cardiovascular disorders. The conventional ECG is a frequently used, inexpensive, and easily accessible test that offers important information about the physiological and anatomical state of the heart. However, the ECG can be interpreted differently by humans depending on the interpreter's level of training and experience, which could make diagnosis more difficult. Using AI, especially deep learning convolutional neural networks (CNNs), to look at single, continuous, and intermittent ECG leads that has led to fully automated AI models that can interpret the ECG like a human, possibly more accurately and consistently. These AI algorithms are effective non-invasive biomarkers for cardiovascular illnesses because they can identify subtle patterns and signals in the ECG that may not be readily apparent to human interpreters. The use of AI in ECG analysis has several benefits, including the quick and precise detection of problems like arrhythmias, silent cardiac illnesses, and left ventricular failure. It has the potential to help doctors with interpretation, diagnosis, risk assessment, and illness management. Aside from that, AI-enhanced ECGs have been demonstrated to boost the identification of heart failure and other cardiovascular disorders, particularly in emergency department settings, allowing for quicker and more precise treatment options. The use of AI in cardiology, however, has several limitations and obstacles, despite its potential. The effective implementation of AI-powered ECG analysis is limited by issues such as systematic bias. Biases based on age, gender, and race result from unbalanced datasets. A model's performance is impacted when diverse demographics are inadequately represented. Potentially disregarded age-related ECG variations may result from skewed age data in training sets. ECG patterns are affected by physiological differences between the sexes; a dataset that is inclined toward one sex may compromise the accuracy of the others. Genetic variations influence ECG readings, so racial diversity in datasets is significant. Furthermore, issues such as inadequate generalization, regulatory barriers, and interpretability concerns contribute to deployment difficulties. The lack of robustness in models when applied to disparate populations frequently hinders their practical applicability. The exhaustive validation required by regulatory requirements causes a delay in deployment. Difficult models that are not interpretable erode the confidence of clinicians. Diverse dataset curation, bias mitigation strategies, continuous validation across populations, and collaborative efforts for regulatory approval are essential for the successful deployment of AI ECG in clinical settings and must be undertaken to address these issues. To guarantee a safe and successful deployment in clinical practice, the use of AI in cardiology must be done with a thorough understanding of the algorithms and their limits. In summary, AI-enhanced electrocardiography has enormous potential to improve the management of cardiovascular illness by delivering precise and timely diagnostic insights, aiding clinicians, and enhancing patient outcomes. Further study and development are required to fully realize AI's promise for improving cardiology practices and patient care as technology continues to advance.
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Affiliation(s)
| | - Saman Javid
- CMH Kharian Medical College, Gujrat, Pakistan
| | | | | | | | | | - F N U Fariha
- Dow University of Health Sciences, Karachi, Pakistan
| | - Satesh Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, Pakistan
| | - Sahil Zaveri
- Department of Medicine, SUNY Downstate Health Sciences University, New York, USA; Cardiovascular Research Program, VA New York Harbor Healthcare System, New York, USA
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Kashou AH, Mulpuru SK, Deshmukh AJ, Ko WY, Attia ZI, Carter RE, Friedman PA, Noseworthy PA. An artificial intelligence-enabled ECG algorithm for comprehensive ECG interpretation: Can it pass the 'Turing test'? CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2022; 2:164-170. [PMID: 35265905 PMCID: PMC8890338 DOI: 10.1016/j.cvdhj.2021.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To develop an artificial intelligence (AI)–enabled electrocardiogram (ECG) algorithm capable of comprehensive, human-like ECG interpretation and compare its diagnostic performance against conventional ECG interpretation methods. Methods We developed a novel AI-enabled ECG (AI-ECG) algorithm capable of complete 12-lead ECG interpretation. It was trained on nearly 2.5 million standard 12-lead ECGs from over 720,000 adult patients obtained at the Mayo Clinic ECG laboratory between 2007 and 2017. We then compared the need for human over-reading edits of the reports generated by the Marquette 12SL automated computer program, AI-ECG algorithm, and final clinical interpretations on 500 randomly selected ECGs from 500 patients. In a blinded fashion, 3 cardiac electrophysiologists adjudicated each interpretation as (1) ideal (ie, no changes needed), (2) acceptable (ie, minor edits needed), or (3) unacceptable (ie, major edits needed). Results Cardiologists determined that on average 202 (13.5%), 123 (8.2%), and 90 (6.0%) of the interpretations required major edits from the computer program, AI-ECG algorithm, and final clinical interpretations, respectively. They considered 958 (63.9%), 1058 (70.5%), and 1118 (74.5%) interpretations as ideal from the computer program, AI-ECG algorithm, and final clinical interpretations, respectively. They considered 340 (22.7%), 319 (21.3%), and 292 (19.5%) interpretations as acceptable from the computer program, AI-ECG algorithm, and final clinical interpretations, respectively. Conclusion An AI-ECG algorithm outperforms an existing standard automated computer program and better approximates expert over-read for comprehensive 12-lead ECG interpretation.
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Affiliation(s)
- Anthony H. Kashou
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Address reprint requests and correspondence: Dr Anthony H. Kashou, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
| | - Siva K. Mulpuru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Wei-Yin Ko
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Zachi I. Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rickey E. Carter
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Sehrawat O, Kashou AH, Noseworthy PA. Artificial Intelligence and Atrial Fibrillation. J Cardiovasc Electrophysiol 2022; 33:1932-1943. [PMID: 35258136 PMCID: PMC9717694 DOI: 10.1111/jce.15440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/03/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
In the context of atrial fibrillation (AF), traditional clinical practices have thus far fallen short in several domains such as identifying patients at risk of incident AF or patients with concomitant undetected paroxysmal AF. Novel approaches leveraging artificial intelligence have the potential to provide new tools to deal with some of these old problems. In this review we focus on the roles of artificial intelligence-enabled ECG pertaining to AF, potential roles of deep learning (DL) models in the context of current knowledge gaps, as well as limitations of these models. One key area where DL models can translate to better patient outcomes is through automated ECG interpretation. Further, we overview some of the challenges facing AF screening and the harms and benefits of screening. In this context, a unique model was developed to detect underlying hidden AF from sinus rhythm and is discussed in detail with its potential uses. Knowledge gaps also remain regarding the best ways to monitor patients with embolic stroke of undetermined source (ESUS) and who would benefit most from oral anticoagulation. The AI-enabled AF model is one potential way to tackle this complex problem as it could be used to identify a subset of high-risk ESUS patients likely to benefit from empirical oral anticoagulation. Role of DL models assessing AF burden from long duration ECG data is also discussed as a way of guiding management. There is a trend towards the use of consumer-grade wristbands and watches to detect AF from photoplethysmography data. However, ECG currently remains the gold standard to detect arrythmias including AF. Lastly, role of adequate external validation of the models and clinical trials to study true performance is discussed. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ojasav Sehrawat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anthony H Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Willcox ME, Compton SJ, Bardy GH. Continuous ECG monitoring versus mobile telemetry: A comparison of arrhythmia diagnostics in human- versus algorithmic-dependent systems. Heart Rhythm O2 2022; 2:543-559. [PMID: 34988499 PMCID: PMC8703156 DOI: 10.1016/j.hroo.2021.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Clinicians rarely scrutinize the full disclosure of a myriad of FDA-approved long-term rhythm monitors, and they rely on manufacturers to detect and report relevant rhythm abnormalities. Objective The objective of this study is to compare the diagnostic accuracy between mobile cardiac telemetry (MCT), which uses an algorithm-based detection strategy, and continuous long-term electrocardiography (LT-ECG) monitoring, which uses a human-based detection strategy. Methods In an outpatient arrhythmia clinic, we enrolled 50 sequential patients ordered to wear a 30-day MCT, to simultaneously wear a continuous LT-ECG monitor. Periods of concomitant wear of both devices were examined using the associated report, which was over-read by 2 electrophysiologists. Results Forty-six of 50 patients wore both monitors simultaneously for an average of 10.3 ± 4.4 days (range: 1.2–14.8 days). During simultaneous recording, patients were more often diagnosed with arrhythmia by LT-ECG compared to MCT (23/46 vs 11/46), P = .018. Similarly, more arrhythmia episodes were detected during simultaneous recording with the LT-ECG compared to MCT (61 vs 19), P < .001. This trend remained consistent across arrhythmia subtypes, including ventricular tachycardia (13 patients by LT-ECG vs 7 by MCT), atrioventricular (AV) block (3 patients by LT-ECG vs 0 by MCT), and AV node reentrant tachycardia (2 patients by LT-ECG vs 0 by MCT). Atrial fibrillation (AF) was documented by both monitors in 2 patients; however, LT-ECG monitoring captured 4 additional AF episodes missed by MCT. Conclusion In a time-controlled, paired analysis of 2 disparate rhythm monitors worn simultaneously, human-dependent LT-ECG arrhythmia detection significantly outperformed algorithm-based MCT arrhythmia detection.
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Affiliation(s)
- Mark E. Willcox
- Alaska Heart and Vascular Institute, Anchorage, Alaska
- Address reprint requests and correspondence: Dr Mark E. Willcox, Alaska Heart & Vascular Institute, Alaska Cardiovascular Research Foundation, 3841 Piper St, Suite T-100, Anchorage AK 99508.
| | | | - Gust H. Bardy
- University of Washington School of Medicine, Seattle, Washington
- Bardy Diagnostics, Seattle, Washington
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Panigutti C, Perotti A, Panisson A, Bajardi P, Pedreschi D. FairLens: Auditing black-box clinical decision support systems. Inf Process Manag 2021. [DOI: 10.1016/j.ipm.2021.102657] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Schwab K, Nguyen D, Ungab G, Feld G, Maisel AS, Than M, Joyce L, Peacock WF. Artificial intelligence MacHIne learning for the detection and treatment of atrial fibrillation guidelines in the emergency department setting (AIM HIGHER): Assessing a machine learning clinical decision support tool to detect and treat non-valvular atrial fibrillation in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12534. [PMID: 34401870 PMCID: PMC8353018 DOI: 10.1002/emp2.12534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 01/04/2021] [Accepted: 07/20/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Advanced machine learning technology provides an opportunity to improve clinical electrocardiogram (ECG) interpretation, allowing non-cardiology clinicians to initiate care for atrial fibrillation (AF). The Lucia Atrial Fibrillation Application (Lucia App) photographs the ECG to determine rhythm detection, calculates CHA2DS2-VASc and HAS-BLED scores, and then provides guideline-recommended anticoagulation. Our purpose was to determine the rate of accurate AF identification and appropriate anticoagulation recommendations in emergency department (ED) patients ultimately diagnosed with AF. METHODS We performed a single-center, observational retrospective chart review in an urban California ED, with an annual census of 70,000 patients. A convenience sample of hospitalized patients with AF as a primary or secondary discharge diagnosis were evaluated for accurate ED AF diagnosis and ED anticoagulation rates. This was done by comparing the Lucia App against a gold standard board-certified cardiologist diagnosis and using the American College of Emergency Physicians AF anticoagulation guidelines. RESULTS Two hundred and ninety seven patients were enrolled from January 2016 until December 2019. The median age was 79 years and 44.1% were female. Compared to the gold standard diagnosis, the Lucia App detected AF in 98.3% of the cases. Physicians recommended guideline-consistent anticoagulation therapy in 78.5% versus 98.3% for the Lucia App. Of the patients with indications for anticoagulation and discharged from the ED, only 25.0% were started at discharge. CONCLUSION Use of a cloud-based ECG identification tool can allow non-cardiologists to achieve similar rates of AF identification as board-certified cardiologists and achieve higher rates of guideline-recommended anticoagulation therapy in the ED.
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Affiliation(s)
- Kim Schwab
- Sharp Chula Vista Medical CenterChula VistaCaliforniaUSA
- Keck Graduate InstituteClaremontCaliforniaUSA
| | - Dacloc Nguyen
- Sharp Chula Vista Medical CenterChula VistaCaliforniaUSA
| | | | - Gregory Feld
- Department of MedicineUC San Diego HealthSan DiegoCaliforniaUSA
| | - Alan S. Maisel
- Coronary Care Unit and Heart Failure ProgramVeterans Affairs San Diego Healthcare SystemSan DiegoCaliforniaUSA
| | - Martin Than
- Department of Emergency MedicineChristchurch HospitalChristchurchNew Zealand
| | - Laura Joyce
- Department of Emergency MedicineChristchurch HospitalChristchurchNew Zealand
| | - W. Frank Peacock
- Henry JN Taub Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
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Kersten DJ, D’Angelo K, Vargas J, Verma G, Malik U, Shavolian S, Zeltser R, Hai O, Makaryus AN. Determining the clinical significance of computer interpreted electrocardiography conclusions. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:375-381. [PMID: 34322307 PMCID: PMC8303043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/10/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Computerized electrocardiogram (EKG) interpretation technology was developed in the mid-20th century, but its use continues to be controversial. This study aims to determine clinical factors which indicate greater odds of clinical significance of an abnormal computerized EKG interpretation. METHODS The inclusion criteria for this retrospective study were patients who underwent outpatient echocardiography for the indication of an abnormal EKG and had an EKG abnormality diagnosed by the computerized EKG system. Qualifying patients had the results of their computerized EKG, echocardiogram, and charted patient characteristics collected. Computerized diagnoses and patient characteristics were assessed to determine if they were associated with increasing or decreasing the odds of an echocardiographic abnormality via logistic regression. Chi-square and t-test analyses were used for categorical and continuous variables, respectively. Odds ratios are presented as odds ratio [95% confidence interval]. A P-value of ≤ 0.05 was considered statistically significant. RESULTS A total of 515 patients were included in this study. The population was 59% women with an average age of 57 ± 16 years, and a mean BMI of 30.1 ± 7.3 kg/m2. Patients with echocardiographic abnormalities tended to have more cardiac risk factors than patients without abnormalities. In our final odds ratio model consisting of both patient characteristics and EKG diagnoses, age, coronary disease (CAD), and diabetes mellitus (DM) increased the odds of an echocardiographic abnormality (1.04 [1.02-1.06], 2.68 [1.41-5.09], and 1.75 [1.01-3.04], respectively). That model noted low QRS voltage decreased the odds of an abnormal echocardiogram (0.31 [0.10-0.91]). CONCLUSION Our findings suggest that in patients with an abnormal computerized EKG reading, the specific factors of older age, CAD, and DM are associated with higher odds of abnormalities on follow-up echocardiography. These results, plus practitioner overreading, can be used to determine more appropriate management when faced with an abnormal computerized EKG diagnosis.
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Affiliation(s)
- Daniel J Kersten
- Department of Cardiology, Nassau University Medical CenterEast Meadow, NY, USA
- New York Institute of Technology College of Osteopathic MedicineOld Westbury, NY, USA
| | - Kyla D’Angelo
- Department of Cardiology, Nassau University Medical CenterEast Meadow, NY, USA
| | - Juana Vargas
- Department of Cardiology, Nassau University Medical CenterEast Meadow, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempstead, NY, USA
| | - Gagan Verma
- New York Institute of Technology College of Osteopathic MedicineOld Westbury, NY, USA
| | - Uzma Malik
- Department of Medicine, Nassau University Medical CenterEast Meadow, NY, USA
| | - Schlomo Shavolian
- Department of Cardiology, Nassau University Medical CenterEast Meadow, NY, USA
| | - Roman Zeltser
- Department of Cardiology, Nassau University Medical CenterEast Meadow, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempstead, NY, USA
| | - Ofek Hai
- Department of Cardiology, Nassau University Medical CenterEast Meadow, NY, USA
| | - Amgad N Makaryus
- Department of Cardiology, Nassau University Medical CenterEast Meadow, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempstead, NY, USA
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Fernholm R, Wachtler C, Malm-Willadsen K, Holzmann MJ, Carlsson AC, Nilsson GH, Pukk Härenstam K. Validation and initial results of surveys exploring perspectives on risks and solutions for diagnostic and medication errors in primary care in Sweden. Scand J Prim Health Care 2020; 38:381-390. [PMID: 33307931 PMCID: PMC7782021 DOI: 10.1080/02813432.2020.1841531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 10/03/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To (1) validate and (2) display initial results of surveys to health care professionals and patients on the importance and mitigation of specified risks for diagnostic and medication errors. DESIGN For validation, psychometric properties were analysed by assessment of construct validity and internal consistency by factor analysis. Non-parametric analyses were used concerning areas of risk, and top ranking of solutions were reported descriptively. SETTING Primary health care in Sweden. PARTICIPANTS Health care professionals (HCPs); including physicians, nurses and practice managers, as well as patients who had experienced diagnostic or medication errors. MAIN OUTCOME MEASURES Psychometric properties of the surveys. Median ratings for risks and top rankings of solutions for professionals and patients. RESULTS There were 939 respondents to the HCP survey. Construct validity resulted in a model with four dimensions: Patient-provider level; Support systems for every day clinical work; Shared information and cooperation between different caregivers; Risks in the environment. Internal consistency was acceptable with Cronbach's α values above 0.7. Confirmatory factor analysis generally showed an acceptable fit. Initial results from the professionals showed the importance of continuity of care, a nationwide on-line medical platform and cooperation in transfer of care. The patient survey could not be validated because of low response rate. CONCLUSION The HCP survey showed some contradicting results regarding model fit and may be tentatively acceptable but validity needs further study. HCP survey answers indicated that relational continuity of care and a nationwide on-line medical platform are highly valued. Current awareness Health care professionals and patients are rather untapped sources of knowledge regarding patient safety in primary health care Main statements Validation is performed on a new survey capturing rating of risks and solutions. The validation of the health care professional survey is tentatively acceptable. Survey answers indicate that health care professionals' and patients' perspectives are complementary.
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Affiliation(s)
- Rita Fernholm
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Caroline Wachtler
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Karolina Malm-Willadsen
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Martin J. Holzmann
- Department of Medicine, Stockholm, Sweden
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Axel C. Carlsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Gunnar H. Nilsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Karin Pukk Härenstam
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Stockholm, Sweden
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Lui YW, Chang PD, Zaharchuk G, Barboriak DP, Flanders AE, Wintermark M, Hess CP, Filippi CG. Artificial Intelligence in Neuroradiology: Current Status and Future Directions. AJNR Am J Neuroradiol 2020; 41:E52-E59. [PMID: 32732276 PMCID: PMC7658873 DOI: 10.3174/ajnr.a6681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fueled by new techniques, computational tools, and broader availability of imaging data, artificial intelligence has the potential to transform the practice of neuroradiology. The recent exponential increase in publications related to artificial intelligence and the central focus on artificial intelligence at recent professional and scientific radiology meetings underscores the importance. There is growing momentum behind leveraging artificial intelligence techniques to improve workflow and diagnosis and treatment and to enhance the value of quantitative imaging techniques. This article explores the reasons why neuroradiologists should care about the investments in new artificial intelligence applications, highlights current activities and the roles neuroradiologists are playing, and renders a few predictions regarding the near future of artificial intelligence in neuroradiology.
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Affiliation(s)
- Y W Lui
- From the Department of Radiology (Y.W.L.), New York University Langone Medical Center, New York, New York
| | - P D Chang
- Department of Radiology (P.D.C.), University of California Irvine Health Medical Center, Orange, California
| | - G Zaharchuk
- Department of Neuroradiology (G.Z., M.W.), Stanford University, Stanford, California
| | - D P Barboriak
- Department of Radiology (D.P.B.), Duke University Medical Center, Durham, North Carolina
| | - A E Flanders
- Department of Radiology (A.E.F.), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - M Wintermark
- Department of Neuroradiology (G.Z., M.W.), Stanford University, Stanford, California
| | - C P Hess
- Department of Radiology and Biomedical Imaging (C.P.H.), University of California, San Francisco, San Francisco, California
| | - C G Filippi
- Department of Radiology (C.G.F.), Northwell Health, New York, New York.
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Affiliation(s)
- Hans Thulesius
- Swedish National Editor, Editorial Board Scandinavian Journal of Primary Health Care, Adjunct and Associate Professor of General Practice, Linnaeus University Kalmar and Lund University, Sweden
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