Volumetric analysis of subarachnoid hemorrhage: assessment of the reliability of two computerized methods and their comparison with other radiographic scales

Clinical article

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There were two main purposes to this study: first, to assess the feasibility and reliability of 2 quantitative methods to assess bleeding volume in patients who suffered spontaneous subarachnoid hemorrhage (SAH), and second, to compare these methods to other qualitative and semiquantitative scales in terms of reliability and accuracy in predicting delayed cerebral ischemia (DCI) and outcome.


A prospective series of 150 patients consecutively admitted to the Hospital 12 de Octubre over a 4-year period were included in the study. All of these patients had a diagnosis of SAH, and diagnostic CT was able to be performed in the first 24 hours after the onset of the symptoms. All CT scans were evaluated by 2 independent observers in a blinded fashion, using 2 different quantitative methods to estimate the aneurysmal bleeding volume: region of interest (ROI) volume and the Cavalieri method. The images were also graded using the Fisher scale, modified Fisher scale, Claasen scale, and the semiquantitative Hijdra scale. Weighted κ coefficients were calculated for assessing the interobserver reliability of qualitative scales and the Hijdra scores. For assessing the intermethod and interrater reliability of volumetric measurements, intraclass correlation coefficients (ICCs) were used as well as the methodology proposed by Bland and Altman. Finally, weighted κ coefficients were calculated for the different quartiles of the volumetric measurements to make comparison with qualitative scales easier. Patients surviving more than 48 hours were included in the analysis of DCI predisposing factors and analyzed using the chi-square or the Mann-Whitney U-tests. Logistic regression analysis was used for predicting DCI and outcome in the different quartiles of bleeding volume to obtain adjusted ORs. The diagnostic accuracy of each scale was obtained by calculating the area under the receiver operating characteristic curve (AUC).


Qualitative scores showed a moderate interobserver reproducibility (weighted κ indexes were always < 0.65), whereas the semiquantitative and quantitative scores had a very strong interobserver reproducibility. Reliability was very high for all quantitative measures as expressed by the ICCs for intermethod and interobserver agreement. Poor outcome and DCI occurred in 49% and 31% of patients, respectively. Larger bleeding volumes were related to a poorer outcome and a higher risk of developing DCI, and the proportion of patients suffering DCI or a poor outcome increased with each quartile, maintaining this relationship after adjusting for the main clinical factors related to outcome. Quantitative analysis of total bleeding volume achieved the highest AUC, and had a greater discriminative ability than the qualitative scales for predicting the development of DCI and outcome.


The use of quantitative measures may reduce interobserver variability in comparison with categorical scales. These measures are feasible using dedicated software and show a better prognostic capability in relation to outcome and DCI than conventional categorical scales.

Abbreviations used in this paper:AUC = area under the curve; DCI = delayed cerebral ischemia; ICC = intraclass correlation coefficient; ROI = region of interest; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurological Surgeons.

Article Information

Address correspondence to: Alfonso Lagares, M.D, Ph.D., Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid, Avda de Cordoba s/n, Madrid, Spain 28041. email: algadoc@yahoo.com.

Please include this information when citing this paper: published online September 21, 2012; DOI: 10.3171/2012.8.JNS12100.

© AANS, except where prohibited by US copyright law.



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    Analysis of the intermethod agreement (Cavalieri-ROI) both for cisternal bleeding volume (A–C) and total bleeding volume (D–F). cc = milliliters; CV = Cavalieri; Cv = cisternal bleeding volume; TV = total bleeding volume.

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    Analysis of interobserver agreement for cisternal bleeding volume for the ROI method (A–C), Cavalieri method (D–F), and semiquantitative cisternal Hijdra score (G–I). CH = cisternal Hijdra score.

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    Analysis of interobserver agreement for total bleeding volume for the ROI method (A–C), Cavalieri method (D–F), and semiquantitative total Hijdra score (G–I). TH = total Hijdra score.

  • View in gallery

    Receiver operating characteristic curves for the different qualitative, semiquantitative, and quantitative measures used for determining poor outcome (left) or the development of DCI (right).



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