Standardised Visual assessment

Visual rating of White Matter Changes

Lena Bronge MRI-Dept Aleris rntgen, Sabbatsberg

White matter lesions (WML) / Age Related White Matter Changes (ARWMC)

Degeneration of the brain white matter Unknown cause Age related Hypertension, cerebrovasc risk factors Probably due to chronic ischemia Relation to cognitive decline Relation to dementia?

White matter changes

A spectrum of degeneration/destruction

of tissue elements Myelin pallor Demyelination Increased distance between myelin fibres Loss of axons Gliosis Cavitation/Necrosis

MRI

Periventricular Deep white matter lesions (bands)

Periventricular lesions (caps)

CT

 Many have studied relations between

WMC and different clinical parameters Disparate results, Poor agreement

Methods for assessing WMC

Visual rating according to different scales

(MRI or CT) Semiautomatic computer based analysis -segmentation- (MRI), manual settings Automatic computer analysis -segmentation- (MRI)

Visual rating scales

A great number of scales exist

Fazekas - 87 Wahlund - 91 van Swieten - 92 Scheltens - 93 ARWMC scale (European task force) 01 Etc, etc

White matter changes 0 No 1 Yes

Simplest possible scale

White matter changes 0 No 1 Minor changes 2 Extensive changes

Or 0-3, 0-7, 0-9

Fazekas scale for MRI

Periventricular Lesions 0 No lesions 1 Caps or thin line 2 Smooth halo 3 Extension into the white matter White matter lesions 0 No lesions 1 Punctate foci 2 Beginning confluence of foci 3 Large confluent areas

ARWMC scale for both CT and MRI

Applied for several different regions
Frontal, Parieto-occipital, Temporal, Infratentorial, Basal ganglia

White Matter Lesions (PVL and WML)

0 No lesions

1 2 3
0 1 2 3

Focal lesions Beginning confluence of lesions Diffuse involvement of entire region

No lesions One focal lesion More than one focal lesion Confluent lesions

Basal Ganglia Lesions

Scheltens scale
Periventricular hyperintensities1
Caps Bands Frontal Occipital Lat. Ventricles

0-6
0-2 0-2 0-2

Deep white matter hyperintensities2

Frontal Parietal Occipital Temporal

0-24
0-6 0-6 0-6 0-6

Basal Ganglia hyperintensities2

Caudate Nucleus Putamen Globus pallidus Thalamus Internal capsule

0-30
0-6 0-6 0-6 0-6 0-6

Infratentorial hyperintensities
1 2

0-24

0 = absent; 1 = <= 5 mm; 2 = 6-10 mm 0 = No abnormalities; 1 = < 3 mm, n <= 5; 2 = < 3 mm, n > 5; 3 = 4-10 mm, n <= 5; 4 = 4-10 mm, n > 5; 5 = > 10 mm, n >= 1; 6 = confluent.

Rating scales
Give numbers but not measures Give data that are not quantitative but
qualitative Give ordinal data, at best Non-parametric statistics

Scheltens scale

Is claimed to be semiquantitative
Considering both number and volume of lesions The total score ranges from 0-84 Modified variant (separating sin/dx) 0-108

It is an obvious disadvantage that there are a number of different scales measuring the same thing

Are the results even

comparable?

Poor agreement between different scales

Mntyl et al (Stroke 1997)
-Compared 13 different scales in the same patient group (400 post-stroke patients) -Poor agreement overall -different relation between WMC and e.g. Hypertension
Part of the inconsistensies in previous studies are due to the different properties of the scales

Scale properties
Ceiling effect / Floor effect (truncation) Different and sometimes vague definitions of
the scores Varying number of points (dichotomic, 0-3, 0-6) Different types and location of lesions Sum of scores from different areas or lesion types sometimes measuring the same thing twice Validation (how well does the scale match a gold
standard i.e. the true phenomenon?)

What are the advantages with rating scales?

When and why do we use them?

What are the advantages with rating scales? When and why do we use them?

In the absence of other techniques Measuring a phenomenon that is not

easily quantified by automatic methods (e.g. segmentation contrast, threshold effects, manual settings) Often quicker than automatic methods Sometimes more appropriate (results are more reproducible)

What are the advantages with rating scales? When and why do we use them?

Measurements from nonstandardised images (multicenter) In case of poor image quality Possible even with different imaging modalities (i.e. CT and MRI) Not only area / volume but other characteristics like appearance, number or location

What type of scale is best?

The simplest one or the one with the most detailed rating?

What type of scale is best? The simplest one or the one with the most detailed rating?

Depends on the purpose, what kind of

information is required? Ratings on a simple scale are often easier to reproduce, but not always

Fazekas scale has had low reproducibility

in several studies Scheltens scale had even somewhat higher reproducibility

Setting:

What type of scale is best? The simplest one or the one with the most detailed rating?

Many different raters simple scale Varying image quality simple scale Very large material consider simple scale Few raters and standardised images; You could use a more complex scale. Practice first and harmonise your ratings Experienced rater? more complex scale

Reliability of ratings
Many, but not all, scales have previously

published reliability measures Recommendable to also do your own reliability testing Inter- and/or intra-observer agreement Inter-: more than one rater Intra-: the same rater more than once (but some time apart) Kappa ratio;

Kappa ratio
weighted if ordinal scale

Reliability of ratings

From 1 to +1 0 = no agreement <0.40; poor agreement 0.40-0.60; fair agreement 0.60-0.80; good agreement >0.80; excellent agreement

Reliability of ratings

Rating scales never give perfect

agreement Reliability is no proof of validity

Different kinds of data

With ratings you can get Dichotomous data (Yes or No) Nominal data (categories) Ordered nominal data (categories with an
order) Ordinal data (values with order but no fixed intervals)

Different kinds of data

With ratings you can NEVER get Interval scale data (the same interval
between each point)

Ratio scale data (interval scale that

include an absolute zero: the ratio has a meaning)

Ordinal data
There is no real measure
just an arbitrary value based on identification and comparison

The steps or intervals on the scale are

defined by a text

Ordinal data
A step from one score to the next mean
different things depending on where on the scale you are and who is the rater

The scale is often truncated

Ordinal data
Sums of scores are often used
But; a great number of different
combinations of scores can give the same sum score The same sum of score in two persons does not mean the same thing The sum score often includes rating the same thing twice

Ordinal data
You cannot calculate means or
standard deviations on ordinal data

Use medians, quartiles and

ranges

To summarize
Choose an appropriate rating scale Consider what type of data you need, what
questions do you want to answer? How does your material look? Who will do the rating? When? Previous studies that you want to compare?

Choose appropriate statistical tests Do your own reliability testing