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Grayscale-inverted bright-blood late gadolinium enhancement improves reader confidence in ischemic scar detection: a multivendor study

Year: 2026

Type: article

Abstract: OBJECTIVE: Bright-blood late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is standard for myocardial scar detection, yet subendocardial infarcts may be difficult to identify due to limited scar-blood contrast. Grayscale inversion is a simple, vendor-independent post-processing technique that may enhance visual contrast. We assessed whether grayscale inversion improves diagnostic accuracy or reader confidence, and whether its effect varies by reader experience or scanner vendor. METHOD: In this single-center, multivendor study, 120 patients (90 with and 30 without ischemic scar) underwent 2D bright-blood LGE on GE, Philips, and Siemens 1.5 T scanners. Three short-axis slices per patient were evaluated in standard bright-blood and grayscale-inverted visualizations by nine readers (three per EACVI experience level). Readers assessed scar presence, transmurality, and diagnostic confidence (4-point scale). Consensus of two Level-3 experts served as reference. RESULTS: Across 34,560 segment-level assessments, diagnostic accuracy was high (91.5%, 95% CI 91.0-91.9%) and similar for standard vs. inverted images (90.7% vs. 91.9%, p = 0.27), with no differences across experience levels or in low-transmurality lesions. In contrast, reader confidence increased significantly with grayscale-inversion (3.25 ± 0.81 vs. 2.78 ± 0.88, p < 0.0001), with the greatest relative improvement among Level-1 readers (2.63 ± 0.89 → 3.00 ± 0.83, p < 0.001). Interobserver agreement and transmurality reproducibility remained unchanged. Results were consistent across vendors. CONCLUSION: Grayscale-inverted bright-blood LGE significantly increases reader confidence without compromising diagnostic accuracy or interobserver agreement. This simple, vendor-neutral technique may support training and improve interpretive certainty in routine clinical LGE assessment.

Source: European Journal of Radiology

DOI: 10.1016/j.ejrad.2026.112801