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Updated: Apr 26, 2026
Brain Infarct Segmentation and Registration on MRI or CT for Lesion-symptom Mapping
Published on: September 25, 2019
Color-coded fluid-attenuated inversion recovery images improve inter-rater reliability of fluid-attenuated inversion
Bum Joon Kim1, Yong-Hwan Kim1, Yeon-Jung Kim1
1From the Departments of Neurology (B.J.K., Y.-J.K., S.H.A., S.U.K., J.S.K., D.-W.K.) and Radiology (D.H.L., S.J.K.), and Vision, Image, and Learning Laboratory (Y.-H.K., D.-W.K.), Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
Background And Purpose:
Diffusion-weighted image fluid-attenuated inversion recovery (FLAIR) mismatch has been considered to represent ischemic lesion age. However, the inter-rater agreement of diffusion-weighted image FLAIR mismatch is low. We hypothesized that color-coded images would increase its inter-rater agreement.
Methods:
Patients with ischemic stroke <24 hours of a clear onset were retrospectively studied. FLAIR signal change was rated as negative, subtle, or obvious on conventional and color-coded FLAIR images based on visual inspection. Inter-rater agreement was evaluated using κ and percent agreement. The predictive value of diffusion-weighted image FLAIR mismatch for identification of patients <4.5 hours of symptom onset was evaluated.
Results:
One hundred and thirteen patients were enrolled. The inter-rater agreement of FLAIR signal change improved from 69.9% (k=0.538) with conventional images to 85.8% (k=0.754) with color-coded images (P=0.004). Discrepantly rated patients on conventional, but not on color-coded images, had a higher prevalence of cardioembolic stroke (P=0.02) and cortical infarction (P=0.04). The positive predictive value for patients <4.5 hours of onset was 85.3% and 71.9% with conventional and 95.7% and 82.1% with color-coded images, by each rater.
Conclusions:
Color-coded FLAIR images increased the inter-rater agreement of diffusion-weighted image FLAIR recovery mismatch and may ultimately help identify unknown-onset stroke patients appropriate for thrombolysis.
