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Hofmann BB, Fischer I, Neyazi M, Karadag C, Donaldson DM, Abusabha Y, Muhammad S, Beseoglu K, Cornelius JF, Hänggi D. Revisiting the WFNS Score: Native Computed Tomography Imaging Improves Identification of Patients With "False Poor Grade" Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2024; 94:515-523. [PMID: 37823661 DOI: 10.1227/neu.0000000000002715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/13/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In patients suffering from aneurysmal subarachnoid hemorrhage (aSAH), the optimal time to determine the World Federation of Neurosurgical Societies (WFNS) score remains controversial because of possible confounding factors. Goals of this study were (1) to analyze the most sensitive timepoint to determine the WFNS score in patients with aSAH and (2) to evaluate the impact of initial native computed tomography (CT) imaging on reducing the mismatch of "false poor grade" patients. METHODS We retrospectively analyzed daily WFNS scores from admission until day 7 in 535 aSAH patients and evaluated their predictive value for the modified Rankin Scale at discharge and 6 months postbleeding. Patients with an initial WFNS score of IV-V who showed improvement to a WFNS score of I-II within the first 7 days (even short-term) were defined as "false poor grade" patients. We tried to identify the "false poor grade" patients using parameters of the initial native CT imaging. RESULTS Later determination of the WFNS score (day 1 vs 7; pseudo-R 2 = 0.13 vs 0.21) increasingly improved its predictive value for neurological outcome at discharge ( P < .001). We identified 39 "false poor grade" patients who had significantly better outcomes than "real poor grade" patients (N = 220) (modified Rankin Scale-discharge: 0-2, 56% vs 1%, P < .001; 3-5: 41% vs 56%, P = .12; 6: 3% vs 43%, P < .001). "False poor grade" patients differed significantly in initial CT parameters. A predictive model called "initial CT WFNS" ( ICT WFNS) was developed, incorporating SEBES, Hijdra score, and LeRoux score (sensitivity = 0.95, specificity = 0.84, accuracy = 0.859, F1 = 0.673). ICT WFNS scores of ≤4.6 classified patients as "false poor grade." CONCLUSION The initial WFNS score may misclassify a subgroup of patients with aSAH as poor grade, which can be avoided by later determination of the WFNS score, at days 3-4 losing its usefulness. Alternatively, the initial WFNS score can be improved in its predictive value, especially in poor-grade patients, using criteria from the initial native CT imaging, such as the Hijdra, LeRoux, and Subarachnoid Hemorrhage Early Brain Edema score, combined in the ICT WFNS score with even higher predictive power.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki , Finland
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Daniel Hänggi
- Department of Neurosurgery, International Neuroscience Institute, Hannover , Germany
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Abdulazim A, Heilig M, Rinkel G, Etminan N. Diagnosis of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage and Triggers for Intervention. Neurocrit Care 2023; 39:311-319. [PMID: 37537496 PMCID: PMC10542310 DOI: 10.1007/s12028-023-01812-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is a major determinant for poor neurological outcome after aneurysmal subarachnoid hemorrhage (aSAH). Detection and treatment of DCI is a key component in the neurocritical care of patients with aSAH after initial aneurysm repair. METHODS Narrative review of the literature. RESULTS Over the past 2 decades, there has been a paradigm shift away from macrovascular (angiographic) vasospasm as a main diagnostic and therapeutic target. Instead, the pathophysiology of DCI is hypothesized to derive from several proischemic pathomechanisms. Clinical examination remains the most reliable means for monitoring and treatment of DCI, but its value is limited in comatose patients. In such patients, monitoring of DCI is usually based on numerous neurophysiological and/or radiological diagnostic modalities. Catheter angiography remains the gold standard for the detection of macrovascular spasm. Computed tomography (CT) angiography is increasingly used instead of catheter angiography because it is less invasive and may be combined with CT perfusion imaging. CT perfusion permits semiquantitative cerebral blood flow measurements, including the evaluation of the microcirculation. It may be used for prediction, early detection, and diagnosis of DCI, with yet-to-prove benefit on clinical outcome when used as a screening modality. Transcranial Doppler may be considered as an additional noninvasive screening tool for flow velocities in the middle cerebral artery, with limited accuracy in other cerebral arteries. Continuous electroencephalography enables detection of early signs of ischemia at a reversible stage prior to clinical manifestation. However, its widespread use is still limited because of the required infrastructure and expertise in data interpretation. Near-infrared spectroscopy, a noninvasive and continuous modality for evaluation of cerebral blood flow dynamics, has shown conflicting results and needs further validation. Monitoring techniques beyond neurological examinations may help in the detection of DCI, especially in comatose patients. However, these techniques are limited because of their invasive nature and/or restriction of measurements to focal brain areas. CONCLUSION The current literature review underscores the need for incorporating existing modalities and developing new methods to evaluate brain perfusion, brain metabolism, and overall brain function more accurately and more globally.
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Affiliation(s)
- Amr Abdulazim
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Marina Heilig
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Gabriel Rinkel
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Hofmann BB, Donaldson DM, Fischer I, Karadag C, Neyazi M, Piedade GS, Abusabha Y, Muhammad S, Rubbert C, Hänggi D, Beseoglu K. Blood Pressure Affects the Early CT Perfusion Imaging in Patients with aSAH Reflecting Early Disturbed Autoregulation. Neurocrit Care 2023; 39:125-134. [PMID: 36802010 PMCID: PMC10499698 DOI: 10.1007/s12028-023-01683-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/26/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early computed tomography perfusion (CTP) is frequently used to predict delayed cerebral ischemia following aneurysmatic subarachnoid hemorrhage (aSAH). However, the influence of blood pressure on CTP is currently controversial (HIMALAIA trial), which differs from our clinical observations. Therefore, we aimed to investigate the influence of blood pressure on early CTP imaging in patients with aSAH. METHODS We retrospectively analyzed the mean transit time (MTT) of early CTP imaging within 24 h after bleeding prior to aneurysm occlusion with respect to blood pressure shortly before or after the examination in 134 patients. We correlated the cerebral blood flow with the cerebral perfusion pressure in the case of patients with intracranial pressure measurement. We performed a subgroup analysis of good-grade (World Federation of Neurosurgical Societies [WFNS] I-III), poor-grade (WFNS IV-V), and solely WFNS grade V aSAH patients. RESULTS Mean arterial pressure (MAP) significantly correlated inversely with the mean MTT in early CTP imaging (R = - 0.18, 95% confidence interval [CI] - 0.34 to - 0.01, p = 0.042). Lower mean blood pressure was significantly associated with a higher mean MTT. Subgroup analysis revealed an increasing inverse correlation when comparing WFNS I-III (R = - 0.08, 95% CI - 0.31 to 0.16, p = 0.53) patients with WFNS IV-V (R = - 0.2, 95% CI - 0.42 to 0.05, p = 0.12) patients, without reaching statistical significance. However, if only patients with WFNS V are considered, a significant and even stronger correlation between MAP and MTT (R = - 0.4, 95% CI - 0.65 to 0.07, p = 0.02) is observed. In patients with intracranial pressure monitoring, a stronger dependency of cerebral blood flow on cerebral perfusion pressure is observed for poor-grade patients compared with good-grade patients. CONCLUSIONS The inverse correlation between MAP and MTT in early CTP imaging, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. Our results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Guilherme S Piedade
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Hofmann BB, Fischer I, Donaldson DM, Abusabha Y, Karadag C, Muhammad S, Beseoglu K, Hänggi D, Turowski B, Rubbert C, Cornelius JF, Kamp MA. Evaluation of MTT Heterogeneity of Perfusion CT Imaging in the Early Brain Injury Phase: An Insight into aSAH Pathopysiology. Brain Sci 2023; 13:brainsci13050824. [PMID: 37239296 DOI: 10.3390/brainsci13050824] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The concept of early brain injury (EBI) is based on the assumption of a global reduction in brain perfusion following aneurysmal subarachnoid hemorrhage (aSAH). However, the heterogeneity of computed tomography perfusion (CTP) imaging in EBI has not yet been investigated. In contrast, increased mean transit time (MTT) heterogeneity, a possible marker of microvascular perfusion heterogeneity, in the delayed cerebral ischemia (DCI) phase has recently been associated with a poor neurological outcome after aSAH. Therefore, in this study, we investigated whether the heterogeneity of early CTP imaging in the EBI phase is an independent predictor of the neurological outcome after aSAH. We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation (cvMTT) in early CTP scans (within 24 h after ictus) of 124 aSAH patients. Both linear and logistic regression were used to model the mRS outcome, which were treated as numerical and dichotomized values, respectively. Linear regression was used to investigate the linear dependency between the variables. No significant difference in cvMTT between the patients with and those without EVD could be observed (p = 0.69). We found no correlation between cvMTT in early CTP imaging and initial modified Fisher (p = 0.07) and WFNS grades (p = 0.23). The cvMTT in early perfusion imaging did not correlate significantly with the 6-month mRS for the entire study population (p = 0.15) or for any of the subgroups (without EVD: p = 0.21; with EVD: p = 0.3). In conclusion, microvascular perfusion heterogeneity, assessed by the heterogeneity of MTT in early CTP imaging, does not appear to be an independent predictor of the neurological outcome 6 months after aSAH.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
- Department of Neurosurgery, International Neuroscience Institute, 30625 Hannover, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Marcel A Kamp
- Centre for Palliative and Neuro-Palliative Care, Brandenburg Medical School Theodor Fontane, Campus Rüdersdorf, 15562 Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany
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Wen L, Zhou L, Wu Q, Tang X, Ge J, Zhou X, Zhang X. Early Microcirculatory Hemodynamic Changes Are Correlated With Functional Outcomes at Discharge in Patients With Aneurysmal SAH. Front Neurol 2022; 12:793411. [PMID: 35126294 PMCID: PMC8811302 DOI: 10.3389/fneur.2021.793411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose The technique of color-coding blood flow analysis was used to explore the correlation between the microcirculatory hemodynamic changes on digital subtraction angiography (DSA) images in patients with aneurysmal subarachnoid hemorrhage (SAH) at the early stage and functional outcomes at discharge. Methods Data of 119 patients who underwent DSA examination due to SAH were retrospectively analyzed. The following hemodynamic parameters of the four region of interests (ROIs) [an ophthalmic segment of the internal carotid artery (ICA), frontal and parietal lobe, and superior sagittal sinus] were analyzed: the time-to-peak (TTP), the area under the curve (AUC), the full width at half maximum (FWHM), mean transit time (MTT), and circulation time. Multifactor regression analysis was performed to explore the correlation between the hemodynamic parameters and functional outcomes in patients at discharge. Results Of 119 patients with SAH, good and poor outcomes were found in 83 (69.7%) and 36 (30.3%) patients, respectively. The hemodynamic parameters including the FWHM, relative TTP (rTTP), and circulation time were significantly correlated with the Hunt–Hess grade (p < 0.005, p = 0.03, and p < 0.005) and the World Federation of Neurological Societies Scale grade (p < 0.005, p = 0.02, and p = 0.01). The FWHM was significantly prolonged with the increase of modified Fisher grade (p = 0.02). The multifactor analysis showed that the FWHM [odds ratio (OR) 17.56, 95% CI: 1.13–272.03, p = 0.04] was an independent risk factor predicting the functional outcomes in patients at discharge. Conclusion The technique of color-coding blood flow analysis could be suitable for the qualified evaluation of disease conditions at an early stage of SAH as well as the prediction of outcomes.
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Affiliation(s)
- Lili Wen
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Longjiang Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaoyu Tang
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jiajia Ge
- Advanced Therapies, Siemens Healthineers Ltd., Shanghai, China
| | - Xiaoming Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
- *Correspondence: Xin Zhang
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Labak CM, Shammassian BH, Zhou X, Alkhachroum A. Multimodality Monitoring for Delayed Cerebral Ischemia in Subarachnoid Hemorrhage: A Mini Review. Front Neurol 2022; 13:869107. [PMID: 35493831 PMCID: PMC9043346 DOI: 10.3389/fneur.2022.869107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/14/2022] [Indexed: 12/13/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage is a disease with high mortality and morbidity due in large part to delayed effects of the hemorrhage, including vasospasm, and delayed cerebral ischemia. These two are now recognized as overlapping yet distinct entities, and supportive therapies for delayed cerebral ischemia are predicated on identifying DCI as quickly as possible. The purpose of this overview is to highlight diagnostic tools that are being used in the identification of DCI in the neurocritical care settings.
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Affiliation(s)
- Collin M. Labak
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Department of Neurosurgery, University Hospitals Cleveland Medicine Center, Cleveland, OH, United States
| | - Berje Haroutuon Shammassian
- Department of Neurology, Division of Neurocritical Care, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
| | - Xiaofei Zhou
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Department of Neurosurgery, University Hospitals Cleveland Medicine Center, Cleveland, OH, United States
| | - Ayham Alkhachroum
- Department of Neurology, Division of Neurocritical Care, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
- *Correspondence: Ayham Alkhachroum
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Hofmann BB, Fischer I, Engel A, Jannusch K, Donaldson DM, Karadag C, van Lieshout JH, Beseoglu K, Muhammad S, Turowski B, Hänggi D, Kamp MA, Rubbert C. MTT Heterogeneity in Perfusion CT Imaging as a Predictor of Outcome after Aneurysmal SAH. AJNR Am J Neuroradiol 2021; 42:1387-1395. [PMID: 34083263 DOI: 10.3174/ajnr.a7169] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/09/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Impairment of tissue oxygenation caused by inhomogeneous microscopic blood flow distribution, the so-called capillary transit time heterogeneity, is thought to contribute to delayed cerebral ischemia after aneurysmal SAH but has so far not been systematically evaluated in patients. We hypothesized that heterogeneity of the MTT, derived from CTP parameters, would give insight into the clinical course of patients with aneurysmal SAH and may identify patients at risk of poor outcome. MATERIALS AND METHODS We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation in CTP scans from 132 patients. A multivariable logistic regression model was used to model the dichotomized mRS outcome. Linear regression was used to eliminate variables with high linear dependence. T tests were used to compare the means of 2 groups. Furthermore, the time of the maximum coefficient of variation for MTT after bleeding was evaluated for correlation with the mRS after 6 months. RESULTS On average, each patient underwent 5.3 CTP scans during his or her stay. Patients with high coefficient of variation for MTT presented more often with higher modified Fisher (P = .011) and World Federation of Neurosurgical Societies grades (P = .014). A high coefficient of variation for MTT at days 3-21 after aneurysmal SAH correlated significantly with a worse mRS score after 6 months (P = .016). We found no correlation between the time of the maximum coefficient of variation for MTT after bleeding and the patients' outcomes after 6 months (P = .203). CONCLUSIONS Heterogeneity of MTT in CTP after aneurysmal SAH correlates with the patients' outcomes. Because the findings are in line with the pathophysiologic concept of the capillary transit time heterogeneity, future studies should seek to verify the coefficient of variation for MTT as a potential imaging biomarker for outcome.
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Affiliation(s)
- B B Hofmann
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - I Fischer
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - A Engel
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - K Jannusch
- Department of Diagnostic and Interventional Radiology (K.J., B.T., C.R.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - D M Donaldson
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - C Karadag
- Medical Faculty (C.K.), University Düsseldorf, Düsseldorf, Germany
| | - J H van Lieshout
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - K Beseoglu
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - S Muhammad
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - B Turowski
- Department of Diagnostic and Interventional Radiology (K.J., B.T., C.R.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - D Hänggi
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - M A Kamp
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - C Rubbert
- Department of Diagnostic and Interventional Radiology (K.J., B.T., C.R.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
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Neulen A, Kunzelmann S, Kosterhon M, Pantel T, Stein M, Berres M, Ringel F, Brockmann MA, Brockmann C, Kantelhardt SR. Automated Grading of Cerebral Vasospasm to Standardize Computed Tomography Angiography Examinations After Subarachnoid Hemorrhage. Front Neurol 2020; 11:13. [PMID: 32082241 PMCID: PMC7002561 DOI: 10.3389/fneur.2020.00013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/07/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Computed tomography angiography (CTA) is frequently used with computed tomography perfusion imaging (CTP) to evaluate whether endovascular vasospasm treatment is indicated for subarachnoid hemorrhage patients with delayed cerebral ischemia. However, objective parameters for CTA evaluation are lacking. In this study, we used an automated, investigator-independent, digital method to detect vasospasm, and we evaluated whether the method could predict the need for subsequent endovascular vasospasm treatment. Methods: We retrospectively reviewed the charts and analyzed imaging data for 40 consecutive patients with subarachnoid hemorrhages. The cerebrovascular trees were digitally reconstructed from CTA data, and vessel volume and the length of the arteries of the circle of Willis and their peripheral branches were determined. Receiver operating characteristic curve analysis based on a comparison with digital subtraction angiographies was used to determine volumetric thresholds that indicated severe vasospasm for each vessel segment. Results: The automated threshold-based volumetric evaluation of CTA data was able to detect severe vasospasm with high sensitivity and negative predictive value for predicting cerebral hypoperfusion on CTP, although the specificity and positive predictive value were low. Combining the automated detection of vasospasm on CTA and cerebral hypoperfusion on CTP was superior to CTP or CTA alone in predicting endovascular vasospasm treatment within 24 h after the examination. Conclusions: This digital volumetric analysis of the cerebrovascular tree allowed the objective, investigator-independent detection and quantification of vasospasms. This method could be used to standardize diagnostics and the selection of subarachnoid hemorrhage patients with delayed cerebral ischemia for endovascular diagnostics and possible interventions.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Svenja Kunzelmann
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Maximilian Stein
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Manfred Berres
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, Remagen, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
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Neulen A, Pantel T, Kosterhon M, Kirschner S, Brockmann MA, Kantelhardt SR, Giese A, Thal SC. A segmentation-based volumetric approach to localize and quantify cerebral vasospasm based on tomographic imaging data. PLoS One 2017; 12:e0172010. [PMID: 28199398 PMCID: PMC5310853 DOI: 10.1371/journal.pone.0172010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 01/30/2017] [Indexed: 12/19/2022] Open
Abstract
Introduction Quantification of cerebral vasospasm after subarachnoid hemorrhage (SAH) is crucial in animal studies as well as clinical routine. We have developed a method for computer-based volumetric assessment of intracranial blood vessels from cross-sectional imaging data. Here we demonstrate the quantification of vasospasm from micro computed tomography (micro-CT) data in a rodent SAH model and the transferability of the volumetric approach to clinical data. Methods We obtained rodent data by performing an ex vivo micro-CT of murine brains after sham surgery or SAH by endovascular filament perforation on day 3 post hemorrhage. Clinical CT angiography (CTA) was performed for diagnostic reasons unrelated to this study. We digitally reconstructed and segmented intracranial vascular trees, followed by calculating volumes of defined vessel segments by standardized protocols using Amira® software. Results SAH animals demonstrated significantly smaller vessel diameters compared with sham (MCA: 134.4±26.9μm vs.165.0±18.7μm, p<0.05). We could highlight this difference by analyzing vessel volumes of a defined MCA-ICA segment (SAH: 0.044±0.017μl vs. sham: 0.07±0.006μl, p<0.001). Analysis of clinical CTA data allowed us to detect and volumetrically quantify vasospasm in a series of 5 SAH patients. Vessel diameters from digital reconstructions correlated well with those measured microscopically (rodent data, correlation coefficient 0.8, p<0.001), or angiographically (clinical data, 0.9, p<0.001). Conclusions Our methodological approach provides accurate anatomical reconstructions of intracranial vessels from cross-sectional imaging data. It allows volumetric assessment of entire vessel segments, hereby highlighting vasospasm-induced changes objectively in a murine SAH model. This method could also be a helpful tool for analysis of clinical CTA.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
- * E-mail: (AN); (SCT)
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
| | - Stefanie Kirschner
- Department of Neuroradiology, University Medical Center of Mainz, Mainz, Germany
| | - Marc A. Brockmann
- Department of Neuroradiology, University Medical Center of Mainz, Mainz, Germany
| | - Sven R. Kantelhardt
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
| | - Serge C. Thal
- Department of Anesthesiology, University Medical Center of Mainz, Mainz, Germany
- * E-mail: (AN); (SCT)
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