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Delphi Panel Questionnaire
Fourth Round
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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
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Instructions for separating the A/F from the fornix
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SECTION I : Segmentation
modalities 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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ABOUT THE QUESTIONNAIRE
Separation of A/F from the fornix - QUESTION 1
SECTION I : Segmentation
modalities to be completed
Instructions for separating the A/F from the
fornix
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).
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 dorsolateral aspects, adjacent to the lateral ventricle. This should be included in the segmentation.”
Exclude the above white matter as fornix:
1) To what extent do you agree with the above definition
(1=minimum agreement, 9=maximum agreement)?
1
2
3
4
5
6
Choice justification and comments:
Vote
7
8
9
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Separation of A/F from the fornix - QUESTION 1
Separation of A/F from the fornix (QUESTION
1)
Orientation along the hippocampus axis
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Orientation along the hippocampus axis
(QUESTION 2)
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SECTION II : Answers to
comments
Hippocampus subdivision
Segmentation tool
Further comments
Summary
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Orientation along hippocampus axis
ABOUT THE QUESTIONNAIRE
Separation of A/F from the fornix (QUESTION
1)
Orientation along the hippocampus axis
Orientation along the hippocampus axis
(QUESTION 2)
SECTION II : Answers to
comments
Hippocampus subdivision
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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Orientation along hippocampus axis
QUESTION 2
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Separation of A/F from the fornix (QUESTION
1)
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
Orientation along the hippocampus axis
Orientation along the hippocampus axis
(QUESTION 2)
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)?
SECTION II : Answers to
comments
Hippocampus subdivision
Segmentation tool
1
2
3
4
5
6
Choice justification and comments:
Vote
7
8
9
Further comments
Summary
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Orientation along hippocampus axis
QUESTION 2
ABOUT THE QUESTIONNAIRE
Separation of A/F from the fornix (QUESTION
1)
Orientation along the hippocampus axis
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Orientation along the hippocampus axis
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SECTION II : Answers to
comments
Hippocampus subdivision
Segmentation tool
Further comments
Summary
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Answers to Comments/Questions
ABOUT THE QUESTIONNAIRE
Separation of A/F from the fornix (QUESTION
1)
Orientation along the hippocampus axis
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
Orientation along the hippocampus axis
(QUESTION 2)
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)
SECTION II : Answers to
comments
For the study of the hippocampus itself, these are undoubtedly useful suggestions. Expansions of the project may
Hippocampus subdivision
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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Segmentation tool
Further comments
Summary
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Answers to Comments/Questions (II)
ABOUT THE QUESTIONNAIRE
Separation of A/F from the fornix (QUESTION
1)
Orientation along the hippocampus axis
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.”
Orientation along the hippocampus axis
(QUESTION 2)
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
SECTION II : Answers to
comments
project, but we agree that the problem should be solved, sooner or later, for a standard procedure.
Hippocampus subdivision
We are not proposing MultiTracer as the standard tool for the Harmonized Protocol: we only used this tool to get to a
Harmonized Protocol.
Segmentation tool
We chose MultiTracer because it is free, and it allows 3D navigation, subvoxel segmentation and volume
Further comments
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 :
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Summary
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Answers to Comments/Questions (III)
ABOUT THE QUESTIONNAIRE
Separation of A/F from the fornix (QUESTION
1)
Orientation along the hippocampus axis
Comment 3)
“Thank you for all your hard work on this project and for making these surveys very easy to use.”
Orientation along the hippocampus axis
(QUESTION 2)
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.
SECTION II : Answers to
comments
Hippocampus subdivision
Segmentation tool
COMMENT :
Further comments
Summary
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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
Answer:
7
Orientation along
hippo axis
2) To what extent do you agree with this solution (1=minimum agreement, 9=maximum
Answer:
7
agreement)?
agreement)?
SECTION II : Answers to comments
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Hippocampus subdivision
Segmentation tool
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