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Huang K, Yao W, Zha M, Qin S, Li Y, Xu Y, Liu R, Ye R, Han Y, Zhu W, Teng Z, Du J, Liu X. Angiography-based hemodynamic features predict recurrent ischemic events after angioplasty and stenting of intracranial vertebrobasilar atherosclerotic stenosis. Eur Radiol 2024; 34:2352-2363. [PMID: 37723287 PMCID: PMC10957605 DOI: 10.1007/s00330-023-10209-x] [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: 02/24/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVES To assess the predictive value of hemodynamic features for stroke relapse in patients with intracranial vertebrobasilar atherosclerotic stenosis treated with percutaneous transluminal angioplasty and stenting (PTAS) using quantitative digital subtraction angiography (q-DSA). METHODS In this retrospective longitudinal study, patients with intracranial vertebrobasilar atherosclerotic stenosis and who underwent PTAS treatment between January 2012 and May 2020 were enrolled. The q-DSA assessment was performed before and after PTAS. ROIs 1-4 were placed along the vertebral artery, proximal and distal basilar artery, and posterior cerebral artery; ROIs 5-8 were in 5 mm and 10 mm proximal and distal to the lesion, respectively. Relative time to peak (rTTP) was defined as the difference in TTP between ROIs. Cox regression analyses were performed to determine risk factors for recurrent stroke. RESULTS A total of 137 patients (mean age, 62 years ± 10 [standard deviation], 83.2% males) were included, and 26 (19.0%) patients had stroke relapse during follow-up (median time of 42.6 months [interquartile range, 19.7-60.7]). Preprocedural rTTP4-1 (adjusted hazard ratio (HR) = 2.270; 95% CI 1.371-3.758; p = 0.001) and preprocedural rTTP8-5 (adjusted HR = 0.240; 95% CI 0.088-0.658; p = 0.006) were independently associated with the recurrent stroke. These hemodynamic parameters provided an incremental prognostic value for stroke relapse (AUC, 0.817 [0.704-0.931]; the net reclassification index, 0.431 [0.057-0.625]; and the integrated discrimination index, 0.140 [0.035-0.292]). CONCLUSIONS In patients with intracranial vertebrobasilar atherosclerosis treated with PTAS, preprocedural prolonged TTP of the target vessel and shortened trans-stenotic TTP difference were associated with stroke relapse. Q-DSA-defined hemodynamic parameters provided incremental predictive value over conventional parameters for stroke recurrence. CLINICAL RELEVANCE STATEMENT Quantitative DSA analysis enables intuitive observation and semi-quantitative evaluation of peri-therapeutic cerebral blood flow. More importantly, quantitative DSA-defined hemodynamic parameters have the potential for risk stratification of patients with intracranial atherosclerotic stenosis. KEY POINTS Semi-quantitative angiography-based parameters can reflect pre- and postprocedural subtle changes in blood flow in patients with intracranial atherosclerotic stenosis. Although angioplasty procedures can significantly improve blood flow status, patients with more restricted baseline blood flow still show a higher risk of stroke recurrence. Angiography-based hemodynamic features possess prognostic value and can serve as clinical markers to assess stroke risk of patients with intracranial atherosclerotic stenosis.
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Affiliation(s)
- Kangmo Huang
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weihe Yao
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Mingming Zha
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Shanmei Qin
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yingle Li
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Yan Xu
- Neusoft Medical Systems Co., Ltd., Shenyang, China
| | - Rui Liu
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ruidong Ye
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yunfei Han
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wusheng Zhu
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhongzhao Teng
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Juan Du
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Xinfeng Liu
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China.
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Vasospasm-Related Death after Aneurysmal Subarachnoid Hemorrhage: A Retrospective Case–Control Study. J Clin Med 2022; 11:jcm11164642. [PMID: 36012881 PMCID: PMC9410410 DOI: 10.3390/jcm11164642] [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: 06/20/2022] [Revised: 07/20/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Vasospasm after the rupture of an intracranial aneurysm is a frequent phenomenon and is the main cause of morbidity and mortality in patients who have survived intracranial hemorrhage and aneurysm treatment. We analyzed the diagnosis and management of patients with aneurysmal subarachnoid hemorrhage who eventually died from ischemic brain damage due to vasospasm. Methods: Between January 2007 and December 2021 (15 years), a total of 1064 patients were diagnosed with an aneurysmal intracranial hemorrhage in a single comprehensive neurovascular center. Vasospasm was diagnosed in 408 patients (38.4%). A total of 187 patients (17.6%) died within 90 days of the aneurysm rupture. In 64 of these 187 patients (33.7%), vasospasm was considered to be the cause of death. In a retrospective analysis, demographic and clinical data for patients without, with non-fatal, and with fatal vasospasm were compared. The patients with fatal vasospasm were categorized into the following subgroups: “no diagnosis and treatment” (Group a), “delayed diagnosis” (Group b), “cardiovascular complications” (Group c), and “vasospasm-treatment complications” (Group d). Results: Among the patients with fatal vasospasm, 31 (48.4%) were assigned to group a, 26 (40.6%) to group b, seven (10.9%) to group c, and none (0%) to group d. Conclusion: The early recognition of severe posthemorrhagic vasospasm is a prerequisite for any treatment and requires routine diagnostic imaging in all unconscious patients. Aggressive endovascular vasospasm treatment may fail to prevent death but is infrequently the cause of a fatal outcome.
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Mielke D, Döring K, Behme D, Psychogios MN, Rohde V, Malinova V. The Impact of Endovascular Rescue Therapy on the Clinical and Radiological Outcome After Aneurysmal Subarachnoid Hemorrhage: A Safe and Effective Treatment Option for Hemodynamically Relevant Vasospasm? Front Neurol 2022; 13:838456. [PMID: 35614929 PMCID: PMC9124775 DOI: 10.3389/fneur.2022.838456] [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: 12/17/2021] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Cerebral vasospasm (CVS) represents one of the multiple contributors to delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH). Especially the management of CVS, refractory to medical treatment, is a challenging task during the acute phase after aSAH. Endovascular rescue therapies (ERT), such as medical and mechanical dilation, are possible treatment options on an individual basis. However, data about the influence on the patients' functional outcomes are limited. This study aims to assess the impact of ERT on the long-term functional outcome in aSAH-patients with refractory CVS. Methods We performed a retrospective analysis of aSAH patients treated between 2012 and 2018. CVS was considered refractory, if it persisted despite oral/intravenous nimodipine application and induced hypertension. The decision to perform ETR was made on an individual basis, according to the detection of “tissue at risk” on computed tomography perfusion (CTP) scans and CVS on computed tomography angiography (CTA) or digital subtraction angiography (DSA). The functional outcome was assessed according to the modified Rankin scale (mRS) 3 months after the ictus, whereas an mRS ≤ 2 was considered as a good outcome. Results A total of 268 patients were included. Out of these, 205 patients (76.5%) were treated without ERT (group 1) and 63 patients (23.5%) with ERT (group 2). In 20 patients (31.8%) balloon dilatation was performed, in 23 patients (36.5%) intra-arterial nimodipine injection alone, and in 20 patients (31.8%) both procedures were combined. Considering only the patient group with DCI, the patients who were treated with ERT had a significantly better outcome compared to the patients without ERT (Mann–Whitney test, p = 0.02). Conclusion Endovascular rescue therapies resulted in a significantly better functional outcome in patients with DCI compared to the patient group treated without ETR. CTP and CTA-based identification of “tissue at risk” might be a reliable tool for patient selection for performing ERT.
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Affiliation(s)
- Dorothee Mielke
- Department of Neurosurgery, Georg-August-University Göttingen, Göttingen, Germany
- *Correspondence: Dorothee Mielke
| | - Katja Döring
- Department of Neurosurgery, Georg-August-University Göttingen, Göttingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, Georg-August-University Göttingen, Göttingen, Germany
- Department of Neuroradiology, Otto von Guericke University, Magdeburg, Germany
| | - Marios Nikos Psychogios
- Department of Neuroradiology, Georg-August-University Göttingen, Göttingen, Germany
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Georg-August-University Göttingen, Göttingen, Germany
| | - Vesna Malinova
- Department of Neurosurgery, Georg-August-University Göttingen, Göttingen, Germany
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Ortega-Gutierrez S, Quispe-Orozco D, Schafer S, Farooqui M, Zevallos CB, Dandapat S, Mendez-Ruiz A, Aagaard-Kienitz B, Petersen N, Derdeyn CP. Angiography suite cone-beam CT perfusion for selection of thrombectomy patients: A pilot study. J Neuroimaging 2022; 32:493-501. [PMID: 35315169 PMCID: PMC9314685 DOI: 10.1111/jon.12988] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/07/2022] [Accepted: 02/26/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE The availability of cone-beam CT perfusion (CBCTP) in angiography suites may improve large-vessel occlusion (LVO) triage and reduce reperfusion times for patients presenting during extended time window. We aim to evaluate the perfusion maps correlation and agreement between multidetector CT perfusion (MDCTP) and CBCTP when obtained sequentially in patients undergoing endovascular therapy. METHODS This is a prospective, pilot, single-arm interventional cohort study of consecutive patients with anterior circulation LVO. All patients underwent MDCTP and CBCTP prior to endovascular therapy, generating cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum/time to peak contrast concentration maps. We compared the two imaging modalities using three different methods: (1) six regions of interest (ROIs) placed in the anterior circulation territory; (2) ROIs placed in all 10 Alberta Stroke Program Early CT Score regions; and (3) ROI drawn around the entire ischemic area. ROI ratios (unaffected/affected area) were compared for all sequences in each method. We used the intraclass correlation coefficient to calculate the correlation between the studies. Bland-Altman plots were also created to measure the degree of agreement. Finally, a sensitivity analysis was done comparing both modalities in patients with low infarct growth rate. RESULTS Fourteen patients were included (median age 81 years [74-87], 50% males, median National Institutes of Health Stroke Scale 19 [14-22]). Median time between studies was 42 minutes (interquartile range 29-61). Independently of the method used, we found moderate to excellent correlation in CBF, CBV, and MTT between modalities. CBF correlation further improved in patients with low infarct growth. CONCLUSION These results demonstrate promising accuracy of CBCTP in evaluating ischemic tissue in patients presenting with LVO ischemic stroke.
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Affiliation(s)
- Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | | | - Mudassir Farooqui
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | | | - Alan Mendez-Ruiz
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | - Beverly Aagaard-Kienitz
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nils Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Colin P Derdeyn
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
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Balança B, Bouchier B, Ritzenthaler T. The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Rev Neurol (Paris) 2021; 178:64-73. [PMID: 34961603 DOI: 10.1016/j.neurol.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 10/20/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a rare event affecting relatively young patients therefore leading to a high social impact. The management of SAH follows a biphasic course with early brain injuries in the first 72 hours followed by a phase at risk of secondary deterioration due to delayed cerebral ischemia (DCI) in 20 to 30% patients. Cerebral infarction from DCI is the most preventable cause of mortality and morbidity after SAH. DCI prevention, early detection and treatment is therefore advocated. Formerly limited to the occurrence of vasospasm, DCI is now associated with multiple pathophysiological processes involving for instance the macrocirculation, the microcirculation, neurovascular units, and inflammation. Therefore, the therapeutic targets and management strategies are also evolving and are not only focused on proximal vasospasm. In this review, we describe the current knowledge of DCI pathophysiology. We then discuss the diagnosis strategies that may guide physicians at the bedside with a multimodal approach in the unconscious patient. We will present the prevention strategies that have proven efficient as well as future targets and present the therapeutic approach that is currently being developed when a DCI occurs.
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Affiliation(s)
- B Balança
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France; Équipe TIGER, U1028, UMR5292, centre de recherche en neurosciences de Lyon, université de Lyon, 69500 Bron, France.
| | - B Bouchier
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France
| | - T Ritzenthaler
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France; InserMU1044, INSA-Lyon, CNRS UMR5220, Université Lyon 1, hospices civils de Lyon, université de Lyon CREATIS, Bron cedex, France
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Rass V, Helbok R. How to diagnose delayed cerebral ischaemia and symptomatic vasospasm and prevent cerebral infarction in patients with subarachnoid haemorrhage. Curr Opin Crit Care 2021; 27:103-114. [PMID: 33405414 DOI: 10.1097/mcc.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature. RECENT FINDINGS Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty. SUMMARY The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
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