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Dowlatshahi D, Brouwers HB, Demchuk AM, Hill MD, Aviv RI, Ufholz LA, Reaume M, Wintermark M, Hemphill JC, Murai Y, Wang Y, Zhao X, Wang Y, Li N, Sorimachi T, Matsumae M, Steiner T, Rizos T, Greenberg SM, Romero JM, Rosand J, Goldstein JN, Sharma M. Predicting Intracerebral Hemorrhage Growth With the Spot Sign: The Effect of Onset-to-Scan Time. Stroke 2016; 47:695-700. [PMID: 26846857 DOI: 10.1161/strokeaha.115.012012] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/06/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Hematoma expansion after acute intracerebral hemorrhage is common and is associated with early deterioration and poor clinical outcome. The computed tomographic angiography (CTA) spot sign is a promising predictor of expansion; however, frequency and predictive values are variable across studies, possibly because of differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign. METHODS We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to 5 predefined categorized onset-to-CTA times. We calculated spot-sign frequency both as raw and frequency-adjusted rates. RESULTS Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot-sign status, and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up computed tomographies for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within 2 hours of onset to 13% beyond 8 hours (P<0.001). There was a significant decrease in hematoma expansion in spot-positive patients as onset-to-CTA time increased (P=0.004), with positive predictive values decreasing from 53% to 33%. CONCLUSIONS The frequency of the CTA spot sign is inversely related to intracerebral hemorrhage onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk stratification for patients with acute intracerebral hemorrhage and will help refine clinical prediction rules for intracerebral hemorrhage expansion.
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Affiliation(s)
- Dar Dowlatshahi
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.).
| | - H Bart Brouwers
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Andrew M Demchuk
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Michael D Hill
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Richard I Aviv
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Lee-Anne Ufholz
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Michael Reaume
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Max Wintermark
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - J Claude Hemphill
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Yasuo Murai
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Yongjun Wang
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Xingquan Zhao
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Yilong Wang
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Na Li
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Takatoshi Sorimachi
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Mitsunori Matsumae
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Thorsten Steiner
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Timolaos Rizos
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Steven M Greenberg
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Javier M Romero
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Jonathan Rosand
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Joshua N Goldstein
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Mukul Sharma
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
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17
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Huynh TJ, Flaherty ML, Gladstone DJ, Broderick JP, Demchuk AM, Dowlatshahi D, Meretoja A, Davis SM, Mitchell PJ, Tomlinson GA, Chenkin J, Chia TL, Symons SP, Aviv RI. Multicenter Accuracy and Interobserver Agreement of Spot Sign Identification in Acute Intracerebral Hemorrhage. Stroke 2014; 45:107-12. [DOI: 10.1161/strokeaha.113.002502] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Rapid, accurate, and reliable identification of the computed tomography angiography spot sign is required to identify patients with intracerebral hemorrhage for trials of acute hemostatic therapy. We sought to assess the accuracy and interobserver agreement for spot sign identification.
Methods—
A total of 131 neurology, emergency medicine, and neuroradiology staff and fellows underwent imaging certification for spot sign identification before enrolling patients in 3 trials targeting spot-positive intracerebral hemorrhage for hemostatic intervention (STOP-IT, SPOTLIGHT, STOP-AUST). Ten intracerebral hemorrhage cases (spot-positive/negative ratio, 1:1) were presented for evaluation of spot sign presence, number, and mimics. True spot positivity was determined by consensus of 2 experienced neuroradiologists. Diagnostic performance, agreement, and differences by training level were analyzed.
Results—
Mean accuracy, sensitivity, and specificity for spot sign identification were 87%, 78%, and 96%, respectively. Overall sensitivity was lower than specificity (
P
<0.001) because of true spot signs incorrectly perceived as spot mimics. Interobserver agreement for spot sign presence was moderate (
k
=0.60). When true spots were correctly identified, 81% correctly identified the presence of single or multiple spots. Median time needed to evaluate the presence of a spot sign was 1.9 minutes (interquartile range, 1.2–3.1 minutes). Diagnostic performance, interobserver agreement, and time needed for spot sign evaluation were similar among staff physicians and fellows.
Conclusions—
Accuracy for spot identification is high with opportunity for improvement in spot interpretation sensitivity and interobserver agreement particularly through greater reliance on computed tomography angiography source data and awareness of limitations of multiplanar images. Further prospective study is needed.
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Affiliation(s)
- Thien J. Huynh
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Matthew L. Flaherty
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - David J. Gladstone
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Joseph P. Broderick
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Andrew M. Demchuk
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Dar Dowlatshahi
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Atte Meretoja
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Stephen M. Davis
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Peter J. Mitchell
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - George A. Tomlinson
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Jordan Chenkin
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Tze L. Chia
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Sean P. Symons
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
| | - Richard I. Aviv
- From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology,
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