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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?
of tissue elements Myelin pallor Demyelination Increased distance between myelin fibres Loss of axons Gliosis Cavitation/Necrosis
MRI
CT
1 2 3
0 1 2 3
Scheltens scale
Periventricular hyperintensities1
Caps Bands Frontal Occipital Lat. Ventricles
0-6
0-2 0-2 0-2
0-24
0-6 0-6 0-6 0-6
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
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?
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?
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
Ordinal data
There is no real measure
just an arbitrary value based on identification and comparison
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
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
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?