Is This Contrast? Is This Blood? An Agreement Study on Post-thrombectomy Computed Tomography Scans

Background: Hemorrhagic transformation after acute ischemic stroke is a dreaded and severe complication of thrombolysis and thrombectomy. However, its detection on post-thrombectomy conventional non-contrast computed tomography (CT) scan can be complicated by the frequent (and sometimes concomitant) presence of contrast, resulting in changes in management. Aims: Our objective was to assess the inter- and intra-rater reliability for the detection of blood and/or contrast on day-1 post-thrombectomy CT scans. Methods: A total of 18 raters across 3 different specialties independently examined 30 post-thrombectomy CT scans selected from the Aspiration vs. STEnt-Retriever (ASTER) trial. They were asked to judge the presence of blood and contrast. Thirty days later, the same 18 raters again independently judged the 30 scans, in randomized order. Agreement was measured with Fleiss' and Cohen's K statistics. Results: Overall agreement on blood and/ or contrast presence was only fair, k = 0.291 (95% CI = 0.273-0.309). There were 0 scans with consensus among the 18 readers on the presence of blood and/or contrast. However, intra-rater global agreement across all 18 physicians was relatively high, with a median kappa value of 0.675. This intra-rater consistency was seen across all specialties, regardless of level of training. Conclusion: Physician judgment for the presence of blood and/or contrast on day-1 post-thrombectomy non-contrast CT scan shows limited inter-observer reliability. Advanced imaging modalities may then be warranted for challenging clinical cases.