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Inter-Rater Reliability of the CASCADE Criteria: Challenges in Classifying Arteriopathies
Timothy J Bernard1, Lauren A Beslow2, Marilyn J Manco-Johnson2
1From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.). timothy.bernard@ucdenver.edu.
Insights
The CASCADE criteria show moderate reliability for classifying childhood arterial ischemic stroke subtypes. Further refinement is needed for arteriopathic subtypes to improve consistency in research.
Area of Science:
- Pediatric Neurology
- Stroke Classification
- Medical Diagnostics
Background:
- Limited data exist on the reliability of classifying childhood arterial ischemic stroke (AIS) subtypes.
- The International Pediatric Stroke Study (IPSS) developed the CASCADE criteria for standardized classification and evaluation of pediatric AIS.
- Assessing the reliability of the CASCADE criteria is crucial for consistent research and clinical practice.
Purpose of the Study:
- To determine the reliability of the CASCADE criteria in classifying pediatric arterial ischemic stroke subtypes.
- To evaluate inter-rater agreement among experienced raters using the CASCADE criteria.
Main Methods:
- Eight IPSS raters reviewed 64 pediatric AIS cases, classifying them using the CASCADE criteria.
- Data included neuroimaging, clinical history, risk factors, and acute imaging.
- Inter-rater reliability was measured using the unweighted κ statistic.
Main Results:
- The CASCADE criteria demonstrated moderate overall inter-rater reliability (κ = 0.53).
- High agreement was observed for cardioembolic (κ = 0.84) and bilateral cerebral arteriopathy (κ = 0.90) subtypes.
- Lower agreement was found for aortic/cervical arteriopathy (κ = 0.36), unilateral FCA (κ = 0.49), and small vessel arteriopathy (κ = -0.012).
Conclusions:
- The CASCADE criteria possess moderate reliability for use in multicenter pediatric stroke studies by trained raters.
- Further refinement of arteriopathic subtype definitions is necessary to enhance reliability.
- Improved subtype classification can reduce variability in research on childhood stroke risk factors, recurrence, and outcomes.
Background And Purpose:
There are limited data about the reliability of subtype classification in childhood arterial ischemic stroke, an issue that prompted the IPSS (International Pediatric Stroke Study) to develop the CASCADE criteria (Childhood AIS Standardized Classification and Diagnostic Evaluation). Our purpose was to determine the CASCADE criteria's reliability in a population of children with stroke.
Methods:
Eight raters from the IPSS reviewed neuroimaging and clinical records of 64 cases (16 cases each) randomly selected from a prospectively collected cohort of 113 children with arterial ischemic stroke and classified them using the CASCADE criteria. Clinical data abstracted included history of present illness, risk factors, and acute imaging. Agreement among raters was measured by unweighted κ statistic.
Results:
The CASCADE criteria demonstrated a moderate inter-rater reliability, with an overall κ statistic of 0.53 (95% confidence interval [CI]=0.39-0.67). Cardioembolic and bilateral cerebral arteriopathy subtypes had much higher agreement (κ=0.84; 95% CI=0.70-0.99; and κ=0.90; 95% CI=0.71-1.00, respectively) than cases of aortic/cervical arteriopathy (κ=0.36; 95% CI=0.01-0.71), unilateral focal cerebral arteriopathy of childhood (FCA; κ=0.49; 95% CI=0.23-0.76), and small vessel arteriopathy of childhood (κ=-0.012; 95% CI=-0.04 to 0.01).
Conclusions:
The CASCADE criteria have moderate reliability when used by trained and experienced raters, which suggests that it can be used for classification in multicenter pediatric stroke studies. However, the moderate reliability of the arteriopathic subtypes suggests that further refinement is needed for defining subtypes. Such revisions may reduce the variability in the literature describing risk factors, recurrence, and outcomes associated with childhood arteriopathy.
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