Early parenchymal contrast extravasation predicts subsequent hemorrhage progression, clinical deterioration, and need for surgery in patients with traumatic cerebral contusion

Association of Extravascular Leakage on Computed Tomography Angiography with Fibrinogen Levels at Admission in Patients with Traumatic Brain Injury

Extravascular leakage on computed tomography (CT) angiography in patients with traumatic brain injury (TBI) is associated with hematoma expansion, functional prognosis, subsequent surgery, and death. Fresh frozen plasma (FFP) administration is often necessary to treat coagulation disorders associated with TBI. This study aimed to determine the relationship between the presence of extravascular leakage on contrast-enhanced head CT, fibrinogen level at admission, and FFP administration in patients with TBI. The medical records of patients with TBI ≥18 years of age referred to our hospital between January 2010 and December 2020 were examined retrospectively. Patients who underwent contrast-enhanced CT immediately after admission were selected, and the presence or absence of extravascular leakage, fibrinogen level at admission, and percentage of patients who required FFP administration within 24 h of admission were examined; 172 patients were included. Multi-variable linear regression analysis was performed to determine the effects of contrast extravasation on fibrinogen levels at admission and was adjusted for age, sex, systolic blood pressure, time from injury to admission, Marshall CT score, Glasgow Coma Scale score at admission, Injury Severity Score, and need for emergency surgery; the regression coefficient was -19.8. The effect of extravasation on FFP administration within 24 h of admission was analyzed using logistic regression while adjusting for age, systolic blood pressure, Marshall CT score, need for emergency surgery, and fibrinogen level at admission. The odds ratio of contrast extravasation was 7.08 after adjustment. Extravascular leakage is associated with fibrinogen levels at admission and FFP administration within 24 h of admission.

Neutrophil to lymphocyte ratio predicts early growth of traumatic intracerebral haemorrhage

OBJECTIVE

The neutrophil to lymphocyte ratio (NLR) has been proposed to capture the inflammatory status of patients with various conditions involving the brain. This retrospective study aimed to explore the association between the NLR and the early growth of traumatic intracerebral haemorrhage (tICH) in patients with traumatic brain injury (TBI).

METHODS

A multicentre, observational cohort study was conducted. Patients with cerebral contusion undergoing baseline computed tomography for haematoma volume analysis within 6 h after primary injury and follow-up visits within 48 h were included. Routine blood tests were performed upon admission, and early growth of tICH was assessed. Prediction accuracies of the NLR for the early growth of tICH and subsequent surgical intervention in patients were analysed.

RESULTS

There were a total of 1077 patients who met the criteria included in the study cohort. Univariate analysis results showed that multiple risk factors were associated with the early growth of tICH and included in the following multivariate analysis models. The multivariate logistic regression analysis results revealed that the NLR was highly associated with the early growth of tICH (p < 0.001) while considering other risk factors in the same model. The prediction accuracy of the NLR for the early growth of tICH in patients is 82%.

INTERPRETATION

The NLR is easily calculated and might predict the early growth of tICH for patients suffering from TBI.

Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): protocol for a prospective cohort study

INTRODUCTION

Severe traumatic brain injury (TBI) is a catastrophic neurological condition with significant economic burden. Early in-hospital mortality (<48 hours) with severe TBI is estimated at 50%. Several clinical examinations exist to determine brain death; however, most are difficult to elicit in the acute setting in patients with severe TBI. Having a definitive assessment tool would help predict early in-hospital mortality in this population. CT perfusion (CTP) has shown promise diagnosing early in-hospital mortality in patients with severe TBI and other populations. The purpose of this study is to validate admission CTP features of brain death relative to the clinical examination outcome for characterizing early in-hospital mortality in patients with severe TBI.

METHODS AND ANALYSIS

The Early Diagnosis of Mortality using Admission CT Perfusion in Severe Traumatic Brain Injury Patients study, is a prospective cohort study in patients with severe TBI funded by a grant from the Canadian Institute of Health Research. Adults aged 18 or older, with evidence of a severe TBI (Glasgow Coma Scale score ≤8 before initial resuscitation) and, on mechanical ventilation at the time of imaging are eligible. Patients will undergo CTP at the time of first imaging on their hospital admission. Admission CTP compares with the reference standard of an accepted bedside clinical assessment for brainstem function. Deferred consent will be used. The primary outcome is a binary outcome of mortality (dead) or survival (not dead) in the first 48 hours of admission. The planned sample size for achieving a sensitivity of 75% and a specificity of 95% with a CI of ±5% is 200 patients.

ETHICS AND DISSEMINATION

This study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed through forums at the end of the study.

TRIAL REGISTRATION NUMBER

NCT04318665.

Permeability of the Blood-Brain Barrier after Traumatic Brain Injury; Radiological Considerations

Traumatic brain injury (TBI) is a leading cause of death and disability, especially in young persons, and constitutes a major socioeconomic burden worldwide. It is regarded as the leading cause of mortality and morbidity in previously healthy young persons. Most of the mechanisms underpinning the development of secondary brain injury are consequences of disruption of the complex relationship between the cells and proteins constituting the neurovascular unit or a direct result of loss of integrity of the tight junctions (TJ) in the blood-brain barrier (BBB). A number of changes have been described in the BBB after TBI, including loss of TJ proteins, pericyte loss and migration, and altered expressions of water channel proteins at astrocyte end-feet processes. There is a growing research interest in identifying optimal biological and radiological biomarkers of severity of BBB dysfunction and its effects on outcomes after TBI. This review explores the microscopic changes occurring at the neurovascular unit, after TBI, and current radiological adjuncts for its evaluation in pre-clinical and clinical practice.

Contusion Progression Following Traumatic Brain Injury: A Review of Clinical and Radiological Predictors, and Influence on Outcome

Secondary injuries remain an important cause of the morbidity and mortality associated with traumatic brain injury (TBI). Progression of cerebral contusions occurs in up to 75% of patients with TBI, and this contributes to subsequent clinical deterioration and requirement for surgical intervention. Despite this, the role of early clinical and radiological factors in predicting contusion progression remains relatively poorly defined due to studies investigating progression of all types of hemorrhagic injuries as a combined cohort. In this review, we summarize data from recent studies on factors which predict contusion progression, and the effect of contusion progression on clinical outcomes.

Development and external validation of a novel multihematoma fuzzy sign on computed tomography for predicting traumatic intraparenchymal hematoma expansion

Acute traumatic intraparenchymal hematoma (tICH) expansion is a devastating neurological complication that is associated with poor outcome after cerebral contusion. This study aimed to develop and validate a novel noncontrast computed tomography (CT) (NCCT) multihematoma fuzzy sign to predict acute tICH expansion. In this multicenter, prospective cohort study, multihematoma fuzzy signs on baseline CT were found in 212 (43.89%) of total 482 patients. Patients with the multihematoma fuzzy sign had a higher frequency of tICH expansion than those without (90.79% (138) vs. 46.71% (71)). The presence of multihematoma fuzzy sign was associated with increased risk for acute tICH expansion in entire cohort (odds ratio [OR]: 16.15; 95% confidence interval (CI) 8.85-29.47; P < 0.001) and in the cohort after propensity-score matching (OR: 9.37; 95% CI 4.52-19.43; P < 0.001). Receiver operating characteristic analysis indicated a better discriminative ability of the presence of multihematoma fuzzy sign for acute tICH expansion (AUC = 0.79; 95% CI 0.76-0.83), as was also observed in an external validation cohort (AUC = 0.76; 95% CI 0.67-0.84). The novel NCCT marker of multihematoma fuzzy sign could be easily identified on baseline CT and is an easy-to-use predictive tool for tICH expansion in the early stage of cerebral contusion.

The extravasation of contrast as a predictor of cerebral hemorrhagic contusion expansion, poor neurological outcome and mortality after traumatic brain injury: A systematic review and meta-analysis

Background

The active extravasation of contrast on CT angiography (CTA) in primary intracerebral hemorrhages (ICH) is recognized as a predictive factor for ICH expansion, unfavorable outcomes and mortality. However, few studies have been conducted on the setting of traumatic brain injury (TBI).

Purpose

To perform a literature systematic review and meta-analysis of the association of contrast extravasation on cerebral hemorrhagic contusion expansion, neurological outcomes and mortality.

Data sources

The PubMed, Cochrane Library, Medline, Scielo, VHL and IBECS databases up to September 21, 2019, were searched for eligible studies.

Study selection

A total of 505 individual titles and abstracts were identified and screened. A total of 36 were selected for full text analysis, out of which 4 fulfilled all inclusion and exclusion criteria.

Data analysis

All 4 studies yielded point estimates suggestive of higher risk for hematoma expansion with contrast extravasation and the summary RR was 5.75 (95%CI 2.74–10.47, p<0.001). Contrast extravasation was also associated with worse neurological outcomes (RR 3.25, 95%CI 2.24–4.73, p<0.001) and higher mortality (RR 2.77, 95%CI 1.03–7.47, p = 0.04).

Data synthesis

This study is a Systematic Review and Meta-Analysis revealed the extravasation of contrast is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.

Limitations

Only four articles were selected.

Conclusions

The extravasation of contrast in the setting of TBI is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.

Quantification of Iodine Leakage on Dual-Energy CT as a Marker of Blood-Brain Barrier Permeability in Traumatic Hemorrhagic Contusions: Prediction of Surgical Intervention for Intracranial Pressure Management

BACKGROUND AND PURPOSE

Hemorrhagic contusions are associated with iodine leakage. We aimed to identify quantitative iodine-based dual-energy CT variables that correlate with the type of intracranial pressure management.

MATERIALS AND METHODS

Consecutive patients with contusions from May 2016 through January 2017 were retrospectively analyzed. Radiologists, blinded to the outcomes, evaluated CT variables from unenhanced admission and short-term follow-up head dual-energy CT scans obtained after contrast-enhanced whole-body CT. Treatment intensity of intracranial pressure was broadly divided into 2 groups: those managed medically and those managed surgically. Univariable analysis followed by logistic regression was used to develop a prediction model.

RESULTS

The study included 65 patients (50 men; median age, 48 years; Q1 to Q3, 25-65.5 years). Twenty-one patients were managed surgically (14 by CSF drainage, 7 by craniectomy). Iodine-based variables that correlated with surgical management were higher iodine concentration, pseudohematoma volume, iodine quantity in pseudohematoma, and iodine quantity in contusions. The regression model developed after inclusion of clinical variables identified 3 predictor variables: postresuscitation Glasgow Coma Scale (adjusted OR = 0.55; 95% CI, 0.38-0.79; P = .001), age (adjusted OR = 0.9; 95% CI, 0.85-0.97; P = .003), and pseudohematoma volume (adjusted OR = 2.05; 95% CI, 1.1-3.77; P = .02), which yielded an area under the curve of 0.96 in predicting surgical intracranial pressure management. The 2 predictors for craniectomy were age (adjusted OR = 0.89; 95% CI, 0.81-0.99; P = .03) and pseudohematoma volume (adjusted OR = 1.23; 95% CI, 1.03-1.45; P = .02), which yielded an area under the curve of 0.89.

CONCLUSIONS

Quantitative iodine-based parameters derived from follow-up dual-energy CT may predict the intensity of intracranial pressure management in patients with hemorrhagic contusions.

Iodine-based Dual-Energy CT of Traumatic Hemorrhagic Contusions: Relationship to In-Hospital Mortality and Short-term Outcome

BackgroundTraumatic hemorrhagic contusions are associated with iodine leak; however, quantification of leakage and its importance to outcome is unclear.PurposeTo identify iodine-based dual-energy CT variables that correlate with in-hospital mortality and short-term outcomes for contusions at hospital discharge.Materials and MethodsIn this retrospective study, consecutive patients with contusions from May 2016 through January 2017 were analyzed. Two radiologists evaluated CT variables from unenhanced admission head CT and follow-up head dual-energy CT scans obtained after contrast material-enhanced whole-body CT. The outcomes evaluated were in-hospital mortality, Rancho Los Amigos scale (RLAS) score, and disability rating scale (DRS) score. Logistic regression and linear regression were used to develop prediction models for categorical and continuous outcomes, respectively.ResultsThe study included 65 patients (median age, 48 years; interquartile range, 25-65.5 years); 50 were men. Dual-energy CT variables that correlated with mortality, RLAS score, and DRS score were iodine concentration, pseudohematoma volume, iodine quantity in pseudohematoma, and iodine quantity in contusion. The single-energy CT variable that correlated with mortality, RLAS score, and DRS score was hematoma volume at follow-up CT. Multiple logistic regression analysis after inclusion of clinical variables identified two predictors that enabled determination of mortality: postresuscitation Glasgow coma scale (P-GCS) (adjusted odds ratio, 0.42; 95% confidence interval [CI]: 0.2, 0.86; P = 0.01) and iodine quantity in pseudohematoma (adjusted odds ratio, 1.4 per milligram; 95% CI: 1.02 per milligram, 1.9 per milligram; P = 0.03), with a mean area under the receiver operating characteristic curve of 0.96 ± 0.05 (standard error). For RLAS, the predictors were P-GCS (mean coefficient, 0.32 ± 0.06; P < .001) and iodine quantity in contusion (mean coefficient, -0.04 per milligram ± 0.02; P = 0.01). Predictors for DRS were P-GCS (mean coefficient, -1.15 ± 0.27; P < .001), age (mean coefficient, 0.13 per year ± 0.04; P = .002), and iodine quantity in contusion (mean coefficient, 0.19 per milligram ± 0.07; P = .02).ConclusionIodine-based dual-energy CT variables correlate with in-hospital mortality and short-term outcomes for contusions at hospital discharge.© RSNA, 2019Online supplemental material is available for this article.See also the editorial by Talbott and Hess in this issue.

Dual-Energy CT in Hemorrhagic Progression of Cerebral Contusion: Overestimation of Hematoma Volumes on Standard 120-kV Images and Rectification with Virtual High-Energy Monochromatic Images after Contrast-Enhanced Whole-Body Imaging

BACKGROUND AND PURPOSE

In patients with hemorrhagic contusions, hematoma volumes are overestimated on follow-up standard 120-kV images obtained after contrast-enhanced whole-body CT. We aimed to retrospectively determine hemorrhagic progression of contusion rates on 120-kV and 190-keV images derived from dual-energy CT and the magnitude of hematoma volume overestimation.

MATERIALS AND METHODS

We retrospectively analyzed admission and follow-up CT studies in 40 patients with hemorrhagic contusions. After annotating the contusions, we measured volumes from admission and follow-up 120-kV and 190-keV images using semiautomated 3D segmentation. Bland-Altman analysis was used for hematoma volume comparison.

RESULTS

On 120-kV images, hemorrhagic progression of contusions was detected in 24 of the 40 patients, while only 17 patients had hemorrhagic progression of contusions on 190-keV images (P = .008). Hematoma volumes were systematically overestimated on follow-up 120-kV images (9.68 versus 8 mm³; mean difference, 1.68 mm³; standard error, 0.37; P < .001) compared with 190-keV images. There was no significant difference in volumes between admission 120-kV and 190-keV images. Mean and median percentages of overestimation were 29% (95% CI, 18-39) and 22% (quartile 3 - quartile 1 = 36.8), respectively.

CONCLUSIONS

The 120-kV images, which are comparable with single-energy CT images, significantly overestimated the hematoma volumes, hence the rate of hemorrhagic progression of contusions, after contrast-enhanced whole-body CT. Hence, follow-up of hemorrhagic contusions should be performed on dual-energy CT, and 190-keV images should be used for the assessment of hematoma volumes.

Head computed tomographic measurement as a predictor of outcome in patients with subdural hematoma with cerebral edema

BACKGROUND

The ability to predict outcome in patients with cerebral edema is important because it can influence treatment strategy. We evaluated whether differences in head computed tomographic (CT) measurements in Hounsfield units (HU) of white matter and gray matter can be used as a predictor of outcome in patients with subdural hematoma with cerebral edema.

METHODS

We evaluated 34 patients who had subdural hematoma with cerebral edema following acute closed head trauma and had undergone head CT within a few hours of admission. We divided them into the survival (n = 24) group and death (n = 10) group, and measured the HU of white matter and gray matter at injury and non-injury sites.

RESULTS

There were no significant differences in operation time or blood loss during surgery between the two groups. Only the HU of white matter in the injury site of patients in the death group were decreased significantly. A cut-off value of 31.5 for HU of white matter showed 80.0 % sensitivity and 99.9 % specificity for death; the area under the curve was 0.91.

DISCUSSION

Our results are more evidence of the support of neurogenic edema in trauma rather than an important clinical tool at this stage. However, HU values in WM may be one factor in the decision-making process that affects patient outcome. Changing the treatment strategy in patients with a low HU value in the WM at the injury site may bring about an improvement in patient outcome.

CONCLUSION

Measurement in HU of white matter at the injury site might be useful as a predictor of outcome in patients with subdural hematoma with cerebral edema.

Contusion Contrast Extravasation Depicted on Multidetector Computed Tomography Angiography Predicts Growth and Mortality in Traumatic Brain Contusion

Traumatic brain injury (TBI) is the main cause of death in trauma victims and causes high rates of disability and neurological sequelae. Approximately 38-65% of traumatic brain contusions (TBC) demonstrate hemorrhagic expansion on serial computed tomography (CT) scans. Thus far, however, no single variable can accurately predict the hemorrhage expansion of a TBC. Our purpose was to evaluate contrast extravasation (CE) as a predictor of expansion, mortality, and poor outcome in TBC in a Brazilian cohort. After Institutional Review Board approval, we used multidetector CT angiography (MDCTA) to study 121 consecutive patients (106 men, 87.6%) with ages varying from 10 to 85 years. Informed consent was obtained from all subjects. The clinical and imaging findings were correlated with the findings on the initial MDCTA using either the Fisher exact test or Student t test and a multivariate logistic regression model. Of the persons who presented CE in TBC, 21.8% died (in-hospital mortality), whereas in the absence of this sign, the mortality rate was 7.6% (p = 0.014). In addition, expansion of the hemorrhagic component of the TBC was detected in 61.1% of the CE-positive patients, whereas expansion was only observed in 10% of the CE-negative patients (p < 0.001). Poor outcome was observed in 24.2% of the patients in the CE-negative group, but in the presence of CE, 72.7% evolved with poor outcome (p < 0.001). The CE was a strong independent predictor of expansion, poor outcome, and increased risk of in-hospital mortality in our series of patients with TBC.

Risk Factors for Early Hemorrhagic Progression after Traumatic Brain Injury: A Focus on Lipid Profile

The purpose of this study was to identify the risk factors related to the hemorrhagic progression (HP) of brain contusion in patients after traumatic brain injury (TBI). Recently, many studies have reported abnormal lipid levels associated with hemorrhagic stroke. Unlike hemorrhage stroke, however, the lipid profiles in patients with TBI have not been examined. Therefore, we evaluated the risk factors of HP in patients with TBI and focused on lipid profiles. Fifty-six patients with TBI with mild to moderate injuries (Glasgow Coma Scale ≥9) who initially did not need surgical intervention were enrolled in this study. Patients underwent repeated computed tomography (CT) scans at 4 h and 24 h after injury. Magnetic resonance imaging (MRI) was performed 7 days after the initial injury. In each noncontrast CT scan, the hemorrhage volume was quantified using the ABC/2 technique. Clinical features, previous medical history, initial CT, and microbleeding on follow-up MRI were analyzed retrospectively. There were 31 (55%) patients in whom significant HP developed (volume >30%). Current smoking (p=0.034), higher initial systolic blood pressure (p=0.035), and lower triglyceride levels (p=0.039) were significantly associated with HP. Current smoking and a triglyceride (TG) level <150 mg/dL were the only statistically significant predictors of HP in the multivariate analysis (p=0.019, p=0.021, respectively). HP with TBI is common in patients who currently smoke and have lower TG levels (150 mg/dL). These patients should be monitored closely, and surgery may be considered before deterioration occurs.

The accuracy of spot sign in predicting hematoma expansion after intracerebral hemorrhage: a systematic review and meta-analysis

Purpose

The role of spot sign on computed tomography angiography (CTA) for predicting hematoma expansion (HE) after primary intracerebral hemorrhage (ICH) has been the focus of many studies. Our study sought to evaluate the predictive accuracy of spot signs for HE in a meta-analytic approach.

Materials and Methods

The database of Pubmed, Embase, and the Cochrane Library were searched for eligible studies. Researches were included if they reported data on HE in primary ICH patients, assessed by spot sign on first-pass CTA. Studies with additional data of second-pass CTA, post-contrast CT (PCCT) and CT perfusion (CTP) were also included.

Results

18 studies were pooled into the meta-analysis, including 14 studies of first-pass CTA, and 7 studies of combined CT modalities. In evaluating the accuracy of spot sign for predicting HE, studies of first-pass CTA showed that the sensitivity was 53% (95% CI, 49%–57%) with a specificity of 88% (95% CI, 86%–89%). The pooled positive likelihood ratio (PLR) was 4.70 (95% CI, 3.28–6.74) and the negative likelihood ratio (NLR) was 0.44 (95% CI, 0.34–0.58). For studies of combined CT modalities, the sensitivity was 73% (95% CI, 67%–79%) with a specificity of 88% (95% CI, 86%–90%). The aggregated PLR was 6.76 (95% CI, 3.70–12.34) and the overall NLR was 0.17 (95% CI 0.06–0.48).

Conclusions

Spot signs appeared to be a reliable imaging biomarker for HE. The additional detection of delayed spot sign was helpful in improving the predictive accuracy of early spot signs. Awareness of our results may impact the primary ICH care by providing supportive evidence for the use of combined CT modalities in detecting spot signs.

Imaging of cerebral blood flow in patients with severe traumatic brain injury in the neurointensive care

Ischemia is a common and deleterious secondary injury following traumatic brain injury (TBI). A great challenge for the treatment of TBI patients in the neurointensive care unit (NICU) is to detect early signs of ischemia in order to prevent further advancement and deterioration of the brain tissue. Today, several imaging techniques are available to monitor cerebral blood flow (CBF) in the injured brain such as positron emission tomography (PET), single-photon emission computed tomography, xenon computed tomography (Xenon-CT), perfusion-weighted magnetic resonance imaging (MRI), and CT perfusion scan. An ideal imaging technique would enable continuous non-invasive measurement of blood flow and metabolism across the whole brain. Unfortunately, no current imaging method meets all these criteria. These techniques offer snapshots of the CBF. MRI may also provide some information about the metabolic state of the brain. PET provides images with high resolution and quantitative measurements of CBF and metabolism; however, it is a complex and costly method limited to few TBI centers. All of these methods except mobile Xenon-CT require transfer of TBI patients to the radiological department. Mobile Xenon-CT emerges as a feasible technique to monitor CBF in the NICU, with lower risk of adverse effects. Promising results have been demonstrated with Xenon-CT in predicting outcome in TBI patients. This review covers available imaging methods used to monitor CBF in patients with severe TBI.

Clinical application of perfusion computed tomography in neurosurgery

OBJECT

Currently, perfusion CT (PCT) is a valuable imaging technique that has been successfully applied to the clinical management of patients with ischemic stroke and aneurysmal subarachnoid hemorrhage (SAH). However, recent literature and the authors' experience have shown that PCT has many more important clinical applications in a variety of neurosurgical conditions. Therefore, the authors share their experiences of its application in various diseases of the cerebrovascular, neurotraumatology, and neurooncology fields and review the pertinent literature regarding expanding PCT applications for neurosurgical conditions, including pitfalls and future developments.

METHODS

A pertinent literature search was conducted of English-language articles describing original research, case series, and case reports from 1990 to 2011 involving PCT and with relevance and applicability to neurosurgical disorders.

RESULTS

In the cerebrovascular field, PCT is already in use as a diagnostic tool for patients suspected of having an ischemic stroke. Perfusion CT can be used to identify and define the extent of the infarct core and ischemic penumbra core, and thus aid patient selection for acute reperfusion therapy. For patients with aneurysmal SAH, PCT provides assessment of early brain injury, cerebral ischemia, and infarction, in addition to vasospasm. It may also be used to aid case selection for aggressive treatment of patients with poor SAH grade. In terms of oncological applications, PCT can be used as an imaging biomarker to assess angiogenesis and response to antiangiogenetic treatments, differentiate between glioma grades, and distinguish recurrent tumor from radiation necrosis. In the setting of traumatic brain injury, PCT can detect and delineate contusions at an early stage. In patients with mild head injury, PCT results have been shown to correlate with the severity and duration of postconcussion syndrome. In patients with moderate or severe head injury, PCT results have been shown to correlate with patients' functional outcome.

CONCLUSIONS

Perfusion CT provides quantitative and qualitative data that can add diagnostic and prognostic value in a number of neurosurgical disorders, and also help with clinical decision making. With emerging new technical developments in PCT, such as characterization of blood-brain barrier permeability and whole-brain PCT, this technique is expected to provide more and more insight into the pathophysiology of many neurosurgical conditions.

Brain CT perfusion provides additional useful information in severe traumatic brain injury

BACKGROUND

The role of brain CT perfusion (CTP) imaging in severe traumatic brain injury (STBI) is unclear. We hypothesised that in STBI early CTP may provide additional information beyond the non contrast CT (NCCT).

METHODS

Subset analysis of an ongoing prospective observational study on trauma patients with STBI who did not require craniectomy and deteriorated or failed to improve neurologically during the first 48h from trauma. Subsequently to follow-up NCCT, a CTP was obtained. Additional findings were defined as an area of altered perfusion on CTP larger than the abnormal area detected by the simultaneous NCCT. Patients who had additional finding (A-CTP) were compared with patients who did not have additional findings (NA-CTP).

RESULTS

Study population was 30 patients [male: 90%, mean age: 38.6 (SD 16.9), blunt trauma: 100%; prehospital intubation: 6 (20%); lowest GCS before intubation: 5.1 (SD 2.0); mean ISS: 30.5 (SD 8.3); mean head and neck AIS: 4.4 (SD 0.8). Days in ICU: 10.2 (SD 6.3). Intracranial pressure (ICP) monitored in 12 (40%). Mean highest ICP in mmHg: 30.1 (SD14.1). There were five (17%) deaths. Findings of NCCT: primarily diffuse axonal injury (DAI) pattern in seven (23%), primarily haematoma in ten (33%), and primarily intracerebral contusion in nine (30%). CTP was performed 24.9 (SD 13) hours from trauma. There were 18 (60%) patients in the A-CTP group and 12 (40.0%) in NA-CTP. The A-CTP group was older (41.7 (SD16.9) vs 27.7 (SD 12.8): P<0.02) and showed on admission NCCT presence of cerebral contusion and absence of DAI. The degree of hypoperfusion was found to be severe enough to be in the ischaemic range in eight patients (27%). CTP altered clinical management in three patients (10%), who were diagnosed with massive and unsurvivable strokes despite minimal changes on NCCT.

CONCLUSION

When compared to NCCT, CTP provided additional diagnostic information in 60% of patients with STBI. CTP altered clinical management in 10% of patients.

Traumatic intracranial hematomas: prognostic value of contrast extravasation

BACKGROUND AND PURPOSE

Contrast extravasation within spontaneous intracranial hemorrhage is a well-described predictor of hematoma growth, poor clinical outcome, and mortality. The purpose of this study was to assess the prognostic value of contrast extravasation in acute traumatic intracranial hematomas.

MATERIALS AND METHODS

In our institution, CTA (including PCCT) is the primary screening technique for cervical vascular injuries. Sixty consecutive patients with at least 1 acute intracranial hematoma (ICH, subdural hematoma, and/or epidural hematoma) meeting predefined size criteria, with CTA/PCCT performed within 24 hours of admission and follow-up CT within 72 hours of admission, were retrospectively evaluated for CE by 2 observers. The predictive value of CE for a composite outcome (hematoma expansion, need for hematoma evacuation, in-hospital mortality) was evaluated on a per-patient basis. Interobserver agreement for CE and the association between baseline variables and outcome were also examined. Different patterns of extravasation were evaluated on a per-lesion basis, with outcomes including hematoma expansion and evacuation.

RESULTS

CE was present in 30 (50%) patients with almost perfect interobserver agreement (κ=0.87; 95% CI, 0.74-0.99). The per-patient multivariate analysis showed independent association of midline shift (P=.020), Glasgow Coma Scale score≤8 (P=.024), and CE (P=.017), with poor outcome and demonstrated a trend toward poor outcome prediction for age 65 years or older (P=.050). In the per-lesion analysis, only extravasation identified on CTA (active and contained extravasation) was associated with hematoma expansion and evacuation.

CONCLUSIONS

Contrast extravasation within intracranial hematomas predicts poor in-hospital outcome in the setting of acute traumatic intracranial injuries.