Welcome to the Delphi Panel Questionnaire Fourth Round · Welcome to the Delphi Panel Questionnaire...

Welcome to the

Delphi Panel Questionnaire

Fourth Round

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About the questionnaire ABOUT THE QUESTIONNAIRE

THE CONSENSUAL DEFINITION OF LANDMARKS HAS BEEN COMPLETED.

A significant agreement has been achieved for all landmarks, and for two segmentation modalities. You can have a

look at panelists’ answers and at the statistics for the completed items.

In this round you will find two different sections:

I section:TWO SEGMENTATION MODALITIES TO BE COMPLETED

II section: ANSWERS TO COMMENTS

You can change your mind and your answers until you have clicked the “submit” button. Filled questionnaires can

be received and processed only after you have clicked the “submit” button.

If you need to read the original questions posed in the previous rounds, you can still access the previous Delphi

rounds with the credentials that you have received for accessing and voting for the first and second round

respectively. Edits of the previous questionnaires, anyway, are no longer valid.

Thank you for your precious cooperation.

START QUESTIONNAIRE

Welcome

user


Instructions for separating the A/F from the fornix ABOUT THE QUESTIONNAIRE

SECTION I : Segmentationmodalities to be completed

Instructions for separating the A/F from the

fornix

P1 = Fisher’s exact test (2x9)

P2 = exact p at Binomial Test (<5 vs >5) (2x2)

The definition proposed previously obtained significant agreement. Nonetheless, the necessary changes (red in the

new definition) based on panelists’ comments were not minor. Among these is the issue that indeed the alveus can

still be detected, caudal to the appearance of the fornix. Based on previous decisions of panelists on the inclusion

of A/F, this portion should still be included in the segmentation. The issue thus relates how to separate the WM of

the A/F from the WM of the fornix in the caudal slice where the fornix appears.

Please let us know your level of agreement for the modified definition, and any relevant comment.

Please consider that an agreement to include alveus and fimbria in the segmentation was achieved already.

Therefore, the A/F inclusion is no longer questioned, and the issue relates only to the instructions on how to

exclude the fornix.

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Welcome

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Separation of A/F from the fornix - QUESTION 1

“Include the white matter as A/F whenever it appears attached to the hippocampal gray matter. At the level of the

fornices, include the white matter directly attached to the GM, running parallel to the parahippocampal white matter located

at the ventral border of the hippocampus (a, b, c).

Exclude the above white matter as fornix: this part diverges from the plane parallel to the parahippocampal white

matter, taking a different angle (d, e), and is clearly detached from hippocampal gray matter. Note that slices caudal to

the appearance of the fornices in their full length can still show hippocampal white matter (alveus) on their dorso-

lateral aspects, adjacent to the lateral ventricle. This should be included in the segmentation.”

1) To what extent do you agree with the above definition

(1=minimum agreement, 9=maximum agreement)?

1 2 3 4 5 6 7 8 9

Choice justification and comments:

Vote

ABOUT THE QUESTIONNAIRE

SECTION I : Segmentationmodalities to be completed

Instructions for separating the A/F from the

fornix

Separation of A/F from the fornix (QUESTION

1)

Welcome


Separation of A/F from the fornix - QUESTION 1

Thanks for voting, we have recorderedyour answer.

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1)

Orientation along the hippocampus axis


(QUESTION 2)

SECTION II : Answers tocomments

Hippocampus subdivision

Segmentation tool

Further comments

Summary

Welcome


Orientation along hippocampus axis ABOUT THE QUESTIONNAIRE


1)



(QUESTION 2)



Segmentation tool

Further comments

Summary

P1 = Fisher’s exact test (2x3)

P2 = exact p at Binomial Test (2x2): a (left hippo, 31%) vs b+c (left and right; mean left and right, 69%)

Panelists’ choices are equally distributed among the three options. Nonetheless, 69% of panelists voted for an

orientation that keeps into account the inclination of both hippocampi.

Panelists agree that segmentation on slices orthogonal to the axis of the currently segmented hippocampus

provides optimal visualization of boundaries. Nonetheless, 38% of panelists believe that orienting each subject only

once, along the mean angle between the left and right hippocampi, may be an optimal solution, minimizing both

biases and load of work for preprocessing. Moreover, some say that they do not believe that there is such a large

difference between the inclination of the right and left hippocampi, to justify a different inclination for each of them.

This last position seems to be shared also by the 31% of panelists who believe that one may orient images along

the axis of the only left hippocampus.

One panelist notes that only one orientation may be convenient, but should keep into account the inclination of

both left and right hippocampus, as this would minimize biases, particularly if one is interested in comparing right

versus left volumes.

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Welcome


Orientation along hippocampus axisQUESTION 2

Please note that orientation along the long axis of the hippocampus relates to the post-processing procedure of

orienting image stacks. Original MRIs are not supposed to be acquired along the hippocampal axis.

Based on the above answers and comments, an optimal solution may be orienting images along the mean angle of

the long axes of the right and left hippocampus, in each subject. This would minimize both the preprocessing load

of work and the error between right and left orientations compared to their own axes.

2) To what extent do you agree with this solution(1=minimum agreement, 9=maximum agreement)?

1 2 3 4 5 6 7 8 9

Choice justification and comments:

Vote



1)



(QUESTION 2)



Segmentation tool

Further comments

Summary

Welcome


Orientation along hippocampus axisQUESTION 2

Thanks for voting, we have recorderedyour answer.

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1)



(QUESTION 2)



Segmentation tool

Further comments

Summary

Welcome


Answers to Comments/Questions

Comment 1)

“The panel is coming up with an overly inclusive hippocampus (e.g., includes white matter and tail). I believe we

should also build in standard "subdivisions" that would allow harmonization of subdivisions (especially related to

the caudal extent of the measure) that may be more useful that the whole. This could be as simple as to specify that

the caudal 2cm will be considered the "caudal" hippocampus.”

Answer 1)

For the study of the hippocampus itself, these are undoubtedly useful suggestions. Expansions of the project may

benefit from these considerations.

For the goals of this project, requiring a standard protocol to extract hippocampal volume, which could help

research and diagnosis of Alzheimer’s disease, only a uniform way to extract hippocampal volume is required, and

further specifications may go beyond the aim.

The decision on how to propose hippocampal subdivisions might follow different criteria, each of which can be

useful, depending on the specific aim. We believe that this kind of work deserves careful attention in a specific

project, but goes beyond the scope of this financed research.

Anyway, we are pleased to receive comments from panelists about this point in the box below.

COMMENT :

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1)



(QUESTION 2)



Segmentation tool

Further comments

Summary

Welcome


Answers to Comments/Questions (II)

Comment 2)

“Further variability is created through the different software programs used for segmentation by the different

laboratories - this should probably be taken into account as well.”

Answer 2)

Indeed variability can be introduced by the segmentation software. In the validation phase of this project only one

software (MultiTracer) will be used by all laboratories. The identification of the best software is not an aim of this

project, but we agree that the problem should be solved, sooner or later, for a standard procedure.

We are not proposing MultiTracer as the standard tool for the Harmonized Protocol: we only used this tool to get to a

Harmonized Protocol.

We chose MultiTracer because it is free, and it allows 3D navigation, subvoxel segmentation and volume

computation, and segmentation of different labels at a time.

So far, we do not know of another free software allowing all of these functions and possibly more.

Further functions that may be desirable are:

• the possibility of editing in 3D, rather than only navigate in 3D but edit only on one plane.

• the possibility to carry out preprocessing steps (orientation, besides tracing functions)

• the possibility to increase the zoom magnification

• better editing functions (e.g. possibility of “undo” rather than necessity to re-edit)

We ask panelists to tell us which free software would be a better alternative, allowing for these additional

improvements, in the box below.

COMMENT :




1)



(QUESTION 2)



Segmentation tool

Further comments

Summary

Welcome


Answers to Comments/Questions (III)

Comment 3)

“Thank you for all your hard work on this project and for making these surveys very easy to use.”

Answer 3)

We thank all participants for their precious feedback, that allows us to try improve communication, and to proceed

the work at the best of our possibilities.

Below, the final box for comments on any issue.

COMMENT :




1)



(QUESTION 2)



Segmentation tool

Further comments

Summary

Welcome

user


SECTION I : Segmentation modalities

Separationf of A/F

from fornix

1) To what extent do you agree with the above definition (1=minimum agreement, 9=maximum

agreement)?

Answer: 7

Orientation along

hippo axis

2) To what extent do you agree with this solution (1=minimum agreement, 9=maximum

agreement)?

Answer: 7

SECTION II : Answers to comments

You can modify your comments about:


Segmentation tool

Any further issue

If you click SUBMIT, you will not be able to change your answers anymore. Please click only if you are sure.

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