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

Andrea Morotti; Javier M. Romero; Michael J. Jessel; Andrew M. Hernandez; Anastasia Vashkevich; Kristin Schwab; Joseph D. Burns; Qaisar A. Shah; Thomas A. Bergman; M. Fareed K. Suri; Mustapha Ezzeddine; Jawad F. Kirmani; Sachin Agarwal; Angela Hays Shapshak; Steven R. Messe; Chitra Venkatasubramanian; Katherine Palmieri; Christopher Lewandowski; Tiffany R. Chang; Ira Chang; David Z. Rose; Wade Smith; Chung Y. Hsu; Chun Lin Liu; Li Ming Lien; Chen Yu Hsiao; Toru Iwama; Mohammad Rauf Afzal; Christy Cassarly; Steven M. Greenberg; Renee’ Hebert Martin; Adnan I. Qureshi; Jonathan Rosand; John M. Boone; Joshua N. Goldstein; On Behalf of ATACH-II and NETT Investigators

doi:10.1007/s00234-017-1857-4

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

Andrea Morotti, Javier M. Romero, Michael J. Jessel, Andrew M. Hernandez, Anastasia Vashkevich, Kristin Schwab, Joseph D. Burns, Qaisar A. Shah, Thomas A. Bergman, M. Fareed K. Suri, Mustapha Ezzeddine, Jawad F. Kirmani, Sachin Agarwal, Angela Hays Shapshak, Steven R. Messe, Chitra Venkatasubramanian, Katherine Palmieri, Christopher Lewandowski, Tiffany R. Chang, Ira ChangDavid Z. Rose, Wade Smith, Chung Y. Hsu, Chun Lin Liu, Li Ming Lien, Chen Yu Hsiao, Toru Iwama, Mohammad Rauf Afzal, Christy Cassarly, Steven M. Greenberg, Renee’ Hebert Martin, Adnan I. Qureshi, Jonathan Rosand, John M. Boone, Joshua N. Goldstein, On Behalf of ATACH-II and NETT Investigators

Neurology

Research output: Contribution to journal › Article › peer-review

1 Scopus citations

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.

Original language	English (US)
Pages (from-to)	839-844
Number of pages	6
Journal	Neuroradiology
Volume	59
Issue number	9
DOIs	https://doi.org/10.1007/s00234-017-1857-4
State	Published - Sep 1 2017

Bibliographical note

Funding Information:
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.

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

Publisher Copyright:
© 2017, Springer-Verlag Berlin Heidelberg.

Keywords

CT angiography
Intracerebral hemorrhage
Phantom standardization
Spot sign

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Morotti, A., Romero, J. M., Jessel, M. J., Hernandez, A. M., Vashkevich, A., Schwab, K., Burns, J. D., Shah, Q. A., Bergman, T. A., Suri, M. F. K., Ezzeddine, M., Kirmani, J. F., Agarwal, S., Shapshak, A. H., Messe, S. R., Venkatasubramanian, C., Palmieri, K., Lewandowski, C., Chang, T. R., ... On Behalf of ATACH-II and NETT Investigators (2017). Phantom-based standardization of CT angiography images for spot sign detection. Neuroradiology, 59(9), 839-844. https://doi.org/10.1007/s00234-017-1857-4

Morotti, A, Romero, JM, Jessel, MJ, Hernandez, AM, Vashkevich, A, Schwab, K, Burns, JD, Shah, QA, Bergman, TA, Suri, MFK, Ezzeddine, M, Kirmani, JF, Agarwal, S, Shapshak, AH, Messe, SR, Venkatasubramanian, C, Palmieri, K, Lewandowski, C, Chang, TR, Chang, I, Rose, DZ, Smith, W, Hsu, CY, Liu, CL, Lien, LM, Hsiao, CY, Iwama, T, Afzal, MR, Cassarly, C, Greenberg, SM, Martin, RH, Qureshi, AI, Rosand, J, Boone, JM, Goldstein, JN & On Behalf of ATACH-II and NETT Investigators 2017, 'Phantom-based standardization of CT angiography images for spot sign detection', Neuroradiology, vol. 59, no. 9, pp. 839-844. https://doi.org/10.1007/s00234-017-1857-4

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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.",

keywords = "CT angiography, Intracerebral hemorrhage, Phantom standardization, Spot sign",

author = "Andrea Morotti and Romero, {Javier M.} and Jessel, {Michael J.} and Hernandez, {Andrew M.} and Anastasia Vashkevich and Kristin Schwab and Burns, {Joseph D.} and Shah, {Qaisar A.} and Bergman, {Thomas A.} and Suri, {M. Fareed K.} and Mustapha Ezzeddine and Kirmani, {Jawad F.} and Sachin Agarwal and Shapshak, {Angela Hays} and Messe, {Steven R.} and Chitra Venkatasubramanian and Katherine Palmieri and Christopher Lewandowski and Chang, {Tiffany R.} and Ira Chang and Rose, {David Z.} and Wade Smith and Hsu, {Chung Y.} and Liu, {Chun Lin} and Lien, {Li Ming} and Hsiao, {Chen Yu} and Toru Iwama and Afzal, {Mohammad Rauf} and Christy Cassarly and Greenberg, {Steven M.} and Martin, {Renee{\textquoteright} Hebert} and Qureshi, {Adnan I.} and Jonathan Rosand and Boone, {John M.} and Goldstein, {Joshua N.} and {On Behalf of ATACH-II and NETT Investigators}",

note = "Funding Information: 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. Funding Information: This study was funded by the following award from the National Institute of Neurological Disorders and Stroke: R01NS073344. Publisher Copyright: {\textcopyright} 2017, Springer-Verlag Berlin Heidelberg.",

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doi = "10.1007/s00234-017-1857-4",

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T1 - Phantom-based standardization of CT angiography images for spot sign detection

AU - Morotti, Andrea

AU - Romero, Javier M.

AU - Jessel, Michael J.

AU - Hernandez, Andrew M.

AU - Vashkevich, Anastasia

AU - Schwab, Kristin

AU - Burns, Joseph D.

AU - Shah, Qaisar A.

AU - Bergman, Thomas A.

AU - Suri, M. Fareed K.

AU - Ezzeddine, Mustapha

AU - Kirmani, Jawad F.

AU - Agarwal, Sachin

AU - Shapshak, Angela Hays

AU - Messe, Steven R.

AU - Venkatasubramanian, Chitra

AU - Palmieri, Katherine

AU - Lewandowski, Christopher

AU - Chang, Tiffany R.

AU - Chang, Ira

AU - Rose, David Z.

AU - Smith, Wade

AU - Hsu, Chung Y.

AU - Liu, Chun Lin

AU - Lien, Li Ming

AU - Hsiao, Chen Yu

AU - Iwama, Toru

AU - Afzal, Mohammad Rauf

AU - Cassarly, Christy

AU - Greenberg, Steven M.

AU - Martin, Renee’ Hebert

AU - Qureshi, Adnan I.

AU - Rosand, Jonathan

AU - Boone, John M.

AU - Goldstein, Joshua N.

AU - On Behalf of ATACH-II and NETT Investigators

N1 - Funding Information: 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. Funding Information: This study was funded by the following award from the National Institute of Neurological Disorders and Stroke: R01NS073344. Publisher Copyright: © 2017, Springer-Verlag Berlin Heidelberg.

PY - 2017/9/1

Y1 - 2017/9/1

N2 - 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.

AB - 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.

KW - CT angiography

KW - Intracerebral hemorrhage

KW - Phantom standardization

KW - Spot sign

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

Abstract

Bibliographical note

Keywords

UN SDGs

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