Comparison of Radiological diagnosis made by Radiologist with Clinical … Fahmida Arab Mallah et al.

Original Article
Fahmida Arab Mallah*
Comparison of Radiological diagnosis Muhammad Khalid**
Syed Aamir Shah**
made by Radiologist with Clinical Basis Umer Farooq Riana**
Khaleeq uz Zaman***
Diagnosing of Brain tumors with Respect
Registrar*
to Final Histopathologic Diagnosis Resident**
Professor and Head of Dept***
Objective: To study the opinion of radiologists compared to that of a
neurosurgeon with respect to final histopathology and to find the reason for any Department of Neurosurgery
discrepancy. Pakistan Institute of Medical
Sciences, SZABMU, Islamabad
Place and Duration: This descriptive study was carried out in the Neurosurgery
department, PIMS Islamabad
Introduction: Brain tumors are a diverse group of neoplasm, diagnosed by
numerous imaging modalities; however CT scan and MRI are most important and
commonly used. Accuracy varies from 69-90%, which is mostly due to availability
of equipment’s and skills of radiologist. We have compared the radiological
diagnosis with clinical basis diagnosis keeping histopathology as gold standard. .
Material and Methods: in this descriptive study we enrolled a total of 100 cases
of different types of brain tumors in a period of one year and eight months. All
patients suspected of brain tumor on radiology and planned for surgery of both
sex and those who were willing for surgery were included and those who were
above 70 years, unfit for anesthesia and those having recurrent tumors were
excluded.
Results: Total 100 cases were enrolled with mean age of 33.8±12.7 years
ranging from 13-65 years,with male and female ratio 1.5:1.As per study out of
100 cases 27 were high grade Glioma,18 low grade Glioma,meningioma16,Cp
angle acoustic neuroma 6,metastases 5 and pituitary 5 cases.
Overall accuracy of preoperative diagnosis of brain tumors by neurosurgeon was
about 82% of histopathology and that of radiologist about 51% on CT scan and
MRI. Address for Correspondence  
Conclusion: As per study findings neurosurgeons are more likely to pick the Dr. Muahmmmad Khalid
Postgraduate Trainee
type of brain tumors with great accuracy as compared to radiologist. The Department of Neurosurgery
accuracy of diagnosis by radiologist can be enhanced if clinical details and other Pakistan Institute of Medical
medical record of patient along with CT scan and MRI provided. Sciences, SZABMU, Islamabad
Key words: Brain tumors, clinical basis diagnosis, Radiology basis diagnosis, Email: drkhalid86@yahoo.com
Histopathology basis diagnosis.
varies from 69% to 90%, which is mostly due to
Introduction availability of equipment’s as well as the skills of the
Brain tumors are a diverse group of neoplasm arising radiologists.17-19 The radiologist can accurately diagnose
from different cells within central nervous system brain tumors with the help of neuroimaging (CT, MRI)
(CNS).1-10 Numerous imaging modalities have been in but there is still diagnostic diversity among radiologist
practice for diagnosis of brain tumors. However and neurosurgeons opinion.20-26 In current study we
magnetic resonance imaging (MRI) and computed have compared the radiologists' opinion on the basis of
tomography (CT) scan are the most important in CT and MRI scans keeping histopathology as gold
diagnosing tumors of central nervous system.11-16 The standard, also any factor that affects the difference of
accuracy of these tests in diagnosing brain tumors

Ann. Pak. Inst. Med. Sci. 2015; 11(4): 180-184 180

Comparison of Radiological diagnosis made by Radiologist with Clinical … Fahmida Arab Mallah et al.

opinion among them and thought to suggest the ways
and means to reduce the any discrepancy.
Materials and Methods
This descriptive study was carried out in the
Neurosurgery department, PIMS Islamabad, total of 100
cases of different types of brain tumors in a period of
one year and eight months were enrolled. All patients
below the age of seventy who had sign and symptoms
and diagnosed to have brain tumors on the basis of CT
and MRI scan by both neurosurgeon and radiologist and
planned for surgery of both gender and those who were
willing for surgery were included. Those who were
above 70 years age and unfit for anesthesia; and those
having recurrent tumors were excluded. According to
location of tumor excision was planned and tumor
specimen was sent for histopathology.
The reports of the radiologist were compared with that of
a neurosurgeons diagnosis prior to surgery and were
clearly documented in the proforma whether the
diagnosis was made by consultant neurosurgeon and
compared with consultant radiologist. Later on
histopathology reports were also recorded.
Results
In our study a total of 100 cases of brain tumors were
enrolled .The mean age of study patients was 33.8±12.7
years ranging from 13to 65 years. The male to female
neuroma, 6 had metastases, 5 had pituitary adenoma
and 5 had craniopharyngioma. Similarly 3 had
Oligodendroglioma, 2 had ependymoma, and 1each had
choroid plexus papilloma and Germinoma.(Table II)
The correct opinion of the radiologist and
neurosurgeons according to CT/MRI was judged against
final histopathology findings. This difference was
statically significant. Neurosurgeons were more
accurate in diagnoses of type of brain tumors compared
to radiologists. Neurosurgeons correctly diagnosed high
grade Glioma in (88.8%) cases as compared to(55.0%)
by radiologist and this difference was statically
significant (P-value=0.701). Similarly neurosurgeon
diagnosed low grade Glioma in (72.2%) compared to
(33.3%) by radiologist and this difference was also
significant(p-value =0.238).Meningioma was diagnosed
in(81.2%) cases by neurosurgeon and in(33.3%) cases
by radiologist the difference was statistically proven.
further detail (Table II).
Table II. Comparison of pre op; correct diagnosis by
neurosurgeon and radiologist with final histopathological
diagnosis (n=100)
Total no. by Correct Correct p-
histopatholog diagnosis by diagnosis by value***
y Neurosurge Radiologist*
on* *
High grade 27 24 (88.8%) 15 (55.5%) 0.701
Glioma

ratio was 1.5:1.(Table I) and Figure A. low grade 18 13(72.3%) 6 (33.3%) 0.238
Glioma
Table 1: Demographic characteristic of study patients Meningioma 16 13 (81.2) 11 (68.7%) 0.210
(n=100)
Number of Percentage CP Acoustic 12 8 (66.6%) 8 (66.6%) 0.238
patients Neuroma
Age (years) METs 6 4(66.6) 2 (33.3%) 0.687
Mean + SD 33.8+12.7
Range (min-max) 13-65 Pituitary 5 5 (100%) 4 (80%) 1.0
Age categories Mac
(years) 20 20.0% Craniophary 5 5 (100%) 4 (80%) .11.0
11 to 20 28 28.0%
21 to 30 22 22.0% ngioma
31 to 40 21 21.0% Abscess 3 3 (100%) 0 (0.0%) 0.10
41 to 50 9 9.0%
51or above CP angle 2 2 (100%) 0 (0.0%) 0.33
Gender Dermoid
Male 60 60.0% Medulloblast 2 2 (100%) 1 (50.0%) 1.0
Female 40 40.0%
oma
Ratio (Male : 1.5:1
Female) AVM 2 2 (100%) 0 (0.0%) 0.33
As per objective the opinion of radiologist and Choroid 1 1 (100%) 0 (0.0%) 1.0
neurosurgeon were calculated. Plexus
Out of total 100 study patients according to final Papilloma
histopathological findings, 27 (had HGG ,18 had Low Germinoma 1 1 (100%) 0 (0.0%) 1.0
GG ,16 had meningioma,12 had CP angle acoustic
*Percentage out of Total Histopathology

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Comparison of Radiological diagnosis made by Radiologist with Clinical … Fahmida Arab Mallah et al.

**Percentage out of Total Histopathology Neuroradiology imaging is the major diagnostic modality
***p-value is calculated on the basis of comparison in the evaluation of brain tumors. These studies are
between neurosurgeon's and radiologist’s diagnosis critical for pre-operative planning and they often provide
information about the etiology of a mass lesion.5-10
In the current study the factors affecting the diagnosis of
Computed tomography (CT) and magnetic resonance
brain tumors were assessed. It was observed that
imaging (MRI) is usually the only test needed to suggest
history affected 77 (77.0%) cases; clinical examination
a brain tumor. Both imaging modalities have been found
in 71(71%) cases in the current study and examination
highly sensitive and specific in diagnosing brain
was third frequent cause affecting the diagnosis (Table
lesions.11-14.
III).
The current study was planned to study the factors
In our study the quality of the diagnosis was also
causing difference of opinion in diagnosing brain tumors
evaluated in terms of the doctors reporting the
by radiologist and neurosurgeon with respect to final
diagnosis,82 out of 100 cases the correct reporting was
histopathology. This is the first study of its type aiming at
done by consultant neurosurgeon. Similarly the
comparing the ability and quality of radiologist and
diagnosis made by radiologist was assessed; consultant
neurosurgeons in detecting the type of brain tumors
radiologist correctly diagnosed 51cases out of 100cases
correctly. The final diagnosis was made on the basis of
(56%).
histopathology report.15,16
The key findings of our study as per objective were that
Table III. Factors affecting diagnosis in the study
(n=100) neurosurgeons are better in picking brain tumors than
radiologists. Neurosurgeons were more correctly
Number of Percentage diagnose the type and location of brain tumors
patients
compared to radiologists.17,18.
History 77 77.0% Neurosurgeons correctly diagnosed HGG and low GG
in 88.8% and 72.2% respect of cases as compared to
Clinical 71 71.0% 55.0% and 33.3% by radiologist. Meningioma 81.2% of
cases correctly diagnosed by neurosurgeon as
Examination
compared to 68.7 %by radiologist. Further see(Table 3).
Investigations 68 68.0% The above picture shows poor quality of diagnosis by
radiologist as compared to neurosurgeon, even if we
The overall correct diagnosis of brain tumors by the look at the individual type of tumor diagnosis was more
radiologists and neurosurgeons were compared. We accurate than radiologist( Figure B).comparatively ,the
found out that the neurosurgeons correctly diagnosed previous evidence also shows that Neuroradiologist are
brain tumors in 82 patients while radiologists could more accurate in diagnosing brain tumors as compared
diagnose correctly in 51 cases.(Table IV) The difference to radiologist.19-23
was statically significant .Thus showing neurosurgeons In our study the factors which affected the diagnosis
are more accurate in diagnosing brain tumors as were patient’s history (77.0%),clinical examination was
compared to radiologist. also a cause which affected (71%) cases, while
laboratory investigations were found to be the third
Table IV. Distribution of correct and incorrect frequent cause affecting the diagnosis of a patient
diagnosis by neurosurgeon and Radiologist having brain tumor. History is very important not only in
Diagnosis made Correct Incorrect Total diagnosis, type of tumor but it also helps in the
by cases management and prognosis.
Neurosurgeon 82 cases 18 cases 100
Other probable factors could be the demographic
Radiologist 51cases 49 cases 100
features of the patients.
Discussion In the pediatric age group Medulloblastoma,
Ependymoma and PNET are more common, if gender
The diagnosis of an adult presenting with sign and
distribution is observed, Meningiomaisvery common in
symptoms suggestive of brain tumor includes both
females as compared to male patients. The duration is
neoplastic and non-neoplastic conditions.1-4
also very important if history is prolong then clinical

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Comparison of Radiological diagnosis made by Radiologist with Clinical …
impression could be for benign tumors like meningioma
and low grade Glioma and if history is of short duration
then clinical impression goes to malignant or aggressive
tumor and inflammatory conditions like GBM and
abscess.
In our setting mostly the clinical and pathological details
of the patients are not in access of the radiologists so
that they can correlate the CT/MRI report with these
findings, on the other hand the neurosurgeons directly
deal with these patients in their department and have
easy access to patient record.
In the OPD based cases as well as in EAC the patient
does not bring the medical and clinical history on
majority of occasions to the radiologist as well as
neurosurgeon.
If the sensitivity and specificity of diagnosing brain
tumors has to be increased, it is of utmost important that
CT/MRI reporting is correlated with clinical and
pathological data. Through radiologists successfully pick
brain tumors from most of the cases (69 %to 99%),
however by modernizing the equipment and self-skills of
the radiologists the sensitivity and specify can be
increased.2
In a study done by Haque MZ and colleagues on the
role of CT in the evaluation of pediatric brain tumors, the
authors reported a very high accuracy of CT imaging.
They revealed that CT was successful in diagnosing
38% astrocytoma compared to 40.5% on histopathology
26.2% Medulloblastoma compared to 24% on
histopathology and 145 Craniopharyngioma compared
to 17%.17
Another local study by Khan K and colleagues on the
accuracy of CT imaging in the diagnosis of brain tumors
in children reported a different. They revealed that CT
scan imaging over picked each type of intracranial tumor
as 68 cases were diagnosed as Glioma on CT scan
compared to 63 on histopathology, 23 cases of
Medulloblastoma verses 19 on histopathology. Author
revealed that CT scan is more accurate indicator of
brain tumors; however it is not always 100% accurate
MRI may also provide information that indicated the
specific tumor type.
Malignant Gliomas are typically hypo intense on T1
weighted images and enhance heterogeneously
following contrast infusion. Enhancing tumor can be
distinguished from the surrounding hypo intense signal
of edema on T1 weighted sequences.
Regardless of the histology grade, astrocytoma
generally showed increased T2 and FLAIR signal
Ann. Pak. Inst. Med. Sci. 2015; 11(4): 180-184
Fahmida Arab Mallah et al.
intensity, however some Astrocytoma do not manifest
contrast enhancement.7,24
The clinical signs and symptoms, laboratory findings
and radiological findings if integrated are believed to
achieve more definite diagnosis of brain tumors in terms
of type and its specific locality25, 26
In this study, it is concluded that clinical correlation with
radiology is very important while diagnosis and
management of the brain tumors patients.
Conclusion
The authors concluded that the diagnosis made by
neurosurgeon on the basis of clinical assessment are
more likely to pick the accurate type and site of brain
tumors with more accuracy as compared to diagnosis
made by radiologists without considering the history and
examination. The accuracy of radiologists can be
enhanced if clinico pathological details and other
medical record of the patients are accompanied with
CT/MRI films so that the radiologist is not completely
blind about clinical picture. It is to be kept in mind that
history is very important not only in diagnosing the type
of the tumor but also helps in the appropriate
management and suggests the long term outcome of
these patients.
The authors suggested Multicenter studies on this issue
so that the quality and accuracy in the diagnosis of brain
tumors and mangement is improved.
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