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Phantom-based standardization of CT angiography images for spot sign detection

  • Diagnostic Neuroradiology
  • Published:
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Abstract

Purpose

The CT angiography (CTA) spot sign is a strong predictor of hematoma expansion in intracerebral hemorrhage (ICH). However, CTA parameters vary widely across centers and may negatively impact spot sign accuracy in predicting ICH expansion. We developed a CT iodine calibration phantom that was scanned at different institutions in a large multicenter ICH clinical trial to determine the effect of image standardization on spot sign detection and performance.

Methods

A custom phantom containing known concentrations of iodine was designed and scanned using the stroke CT protocol at each institution. Custom software was developed to read the CT volume datasets and calculate the Hounsfield unit as a function of iodine concentration for each phantom scan. CTA images obtained within 8 h from symptom onset were analyzed by two trained readers comparing the calibrated vs. uncalibrated density cutoffs for spot sign identification. ICH expansion was defined as hematoma volume growth >33%.

Results

A total of 90 subjects qualified for the study, of whom 17/83 (20.5%) experienced ICH expansion. The number of spot sign positive scans was higher in the calibrated analysis (67.8 vs 38.9% p < 0.001). All spot signs identified in the non-calibrated analysis remained positive after calibration. Calibrated CTA images had higher sensitivity for ICH expansion (76 vs 52%) but inferior specificity (35 vs 63%) compared with uncalibrated images.

Conclusion

Normalization of CTA images using phantom data is a feasible strategy to obtain consistent image quantification for spot sign analysis across different sites and may improve sensitivity for identification of ICH expansion.

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Author information

Authors and Affiliations

  1. Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA

    Andrea Morotti, Javier M. Romero, Jonathan Rosand & Joshua N. Goldstein

  2. J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA

    Andrea Morotti, Javier M. Romero, Michael J. Jessel, Anastasia Vashkevich, Kristin Schwab, Steven M. Greenberg, Jonathan Rosand & Joshua N. Goldstein

  3. Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Javier M. Romero

  4. Department of Radiology, University of California Davis, Sacramento, CA, USA

    Andrew M. Hernandez & John M. Boone

  5. Department of Neurology, Lahey Hospital and Medical Center, Burlington, MA, USA

    Joseph D. Burns

  6. Abington Memorial Hospital, Abington, PA, USA

    Qaisar A. Shah

  7. Hennepin County Medical Center, Minneapolis, MN, USA

    Thomas A. Bergman

  8. St. Cloud Hospital, St. Cloud, MN, USA

    M. Fareed K. Suri

  9. University of Minnesota, Minneapolis, MN, USA

    Mustapha Ezzeddine

  10. Stroke & Neurovascular Center, JFK Medical Center, Edison, NJ, USA

    Jawad F. Kirmani

  11. Columbia University Medical Center, New York, NY, USA

    Sachin Agarwal

  12. University of Alabama at Birmingham, Birmingham, AL, USA

    Angela Hays Shapshak

  13. University of Pennsylvania, Philadelphia, PA, USA

    Steven R Messe

  14. Stanford University, Stanford, CA, USA

    Chitra Venkatasubramanian

  15. The University of Kansas Health System, Kansas City, KS, USA

    Katherine Palmieri

  16. Henry Ford Hospital, Detroit, MI, USA

    Christopher Lewandowski

  17. University of Texas Medical School, Houston, TX, USA

    Tiffany R. Chang

  18. Colorado Neurological Institute, Swedish Medical Center, Englewood, CO, USA

    Ira Chang

  19. Tampa General Hospital, University of South Florida College of Medicine, Tampa, FL, USA

    David Z. Rose

  20. UCSF Medical Center, San Francisco, CA, USA

    Wade Smith

  21. China Medical University Hospital, Taichung, Taiwan

    Chung Y. Hsu & Chun-Lin Liu

  22. Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan

    Li-Ming Lien & Chen-Yu Hsiao

  23. Gifu University Hospital, Gifu, Japan

    Toru Iwama

  24. Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN, USA

    Mohammad Rauf Afzal & Adnan I. Qureshi

  25. Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA

    Christy Cassarly & Renee’ Hebert Martin

  26. Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Joshua N. Goldstein

Authors
  1. Andrea Morotti
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  2. Javier M. Romero
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  3. Michael J. Jessel
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  4. Andrew M. Hernandez
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  5. Anastasia Vashkevich
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  6. Kristin Schwab
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  7. Joseph D. Burns
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  8. Qaisar A. Shah
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  9. Thomas A. Bergman
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  10. M. Fareed K. Suri
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  11. Mustapha Ezzeddine
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  12. Jawad F. Kirmani
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  13. Sachin Agarwal
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  14. Angela Hays Shapshak
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  15. Steven R Messe
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  16. Chitra Venkatasubramanian
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  17. Katherine Palmieri
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  18. Christopher Lewandowski
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  19. Tiffany R. Chang
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  20. Ira Chang
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  21. David Z. Rose
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  22. Wade Smith
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  23. Chung Y. Hsu
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  24. Chun-Lin Liu
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  25. Li-Ming Lien
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  26. Chen-Yu Hsiao
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  27. Toru Iwama
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  28. Mohammad Rauf Afzal
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  29. Christy Cassarly
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  30. Steven M. Greenberg
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  31. Renee’ Hebert Martin
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  32. Adnan I. Qureshi
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  33. Jonathan Rosand
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  34. John M. Boone
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  35. Joshua N. Goldstein
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Consortia

On Behalf of ATACH-II and NETT Investigators

Corresponding author

Correspondence to Andrea Morotti.

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Funding

This study was funded by the following award from the National Institute of Neurological Disorders and Stroke: R01NS073344.

Conflict of interest

JR receives research funding from the NIH. JG receives research funding from the NIH, Boehringer Ingelheim, Pfizer and Portola, and consults for Bristol Myers Squibb. TAB receives funding from the NIH, the Minnesota State and Spinal Cord Injury and Traumatic Brain Injury Grant and Vertex Pharmaceuticals. CL receives research funding from the NIH.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Morotti, A., Romero, J.M., Jessel, M.J. et al. Phantom-based standardization of CT angiography images for spot sign detection. Neuroradiology 59, 839–844 (2017). https://doi.org/10.1007/s00234-017-1857-4

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  • DOI: https://doi.org/10.1007/s00234-017-1857-4

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