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Malinova V, Kranawetter B, Tuzi S, Rohde V, Mielke D. Early localization of tissue at risk for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: blood distribution on initial imaging vs early CT perfusion. Neurosurg Rev 2024; 47:223. [PMID: 38758245 PMCID: PMC11101576 DOI: 10.1007/s10143-024-02457-2] [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: 03/12/2024] [Revised: 04/20/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a potentially reversible adverse event after aneurysmal subarachnoid hemorrhage (aSAH), when early detected and treated. Computer tomography perfusion (CTP) is used to identify the tissue at risk for DCI. In this study, the predictive power of early CTP was compared with that of blood distribution on initial CT for localization of tissue at risk for DCI. METHODS A consecutive patient cohort with aSAH treated between 2012 and 2020 was retrospectively analyzed. Blood distribution on CT was semi-quantitatively assessed with the Hijdra-score. The vessel territory with the most surrounding blood and the one with perfusion deficits on CTP performed on day 3 after ictus were considered to be at risk for DCI, respectively. RESULTS A total of 324 patients were included. Delayed infarction occurred in 17% (56/324) of patients. Early perfusion deficits were detected in 82% (46/56) of patients, 85% (39/46) of them developed infarction within the predicted vessel territory at risk. In 46% (25/56) a vessel territory at risk was reliably determined by the blood distribution. For the prediction of DCI, blood amount/distribution was inferior to CTP. Concerning the identification of "tissue at risk" for DCI, a combination of both methods resulted in an increase of sensitivity to 64%, positive predictive value to 58%, and negative predictive value to 92%. CONCLUSIONS Regarding the DCI-prediction, early CTP was superior to blood amount/distribution, while a consideration of subarachnoid blood distribution may help identify the vessel territories at risk for DCI in patients without early perfusion deficits.
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Affiliation(s)
- Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany.
- Department of Neurosurgery, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Beate Kranawetter
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Sheri Tuzi
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
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Panni P, Simionato F, Cao R, Pedicelli A, Marchese E, Caricato A, Alexandre A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Aspide R, Lanterna AL, Ambrosi A, Mortini P, Azzolini ML, Calvi MR, Falini A. Hemorrhage Volume Drives Early Brain Injury and Outcome in Poor-Grade Aneurysmal SAH. AJNR Am J Neuroradiol 2024; 45:393-399. [PMID: 38453415 DOI: 10.3174/ajnr.a8135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 12/06/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Early brain injury is a major determinant of clinical outcome in poor-grade (World Federation of Neurosurgical Societies [WFNS] IV-V) aneurysmal SAH and is radiologically defined by global cerebral edema. Little is known, though, about the effect of global intracranial hemorrhage volume on early brain injury development and clinical outcome. MATERIALS AND METHODS Data from the multicentric prospective Poor-Grade Aneurysmal Subarachnoid Hemorrhage (POGASH) Registry of consecutive patients with poor-grade aneurysmal SAH admitted from January 1, 2015, to August 31, 2022, was retrospectively evaluated. Poor grade was defined according to the worst-pretreatment WFNS grade. Global intracranial hemorrhage volume as well as the volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH were calculated by means of analytic software in a semiautomated setting. Outcomes included severe global cerebral edema (defined by Subarachnoid Hemorrhage Early Brain Edema Score grades 3-4), in-hospital mortality (mRS 6), and functional independence (mRS 0-2) at follow-up. RESULTS Among 400 patients (median global intracranial hemorrhage volume of 91 mL; interquartile range, 59-128), severe global cerebral edema was detected in 218/400 (54.5%) patients. One hundred twenty-three (30.8%) patients died during the acute phase of hospitalization. One hundred fifty-five (38.8%) patients achieved mRS 0-2 at a median of 13 (interquartile range, 3-26) months of follow-up. Multivariable analyses showed global intracranial hemorrhage volume as independently associated with severe global cerebral edema (adjusted OR, 1.009; 95% CI, 1.004-1.014; P < .001), mortality (adjusted OR, 1.006; 95% CI, 1.001-1.01; P = .018) and worse clinical outcome (adjusted OR, 0.992; 95% CI, 0.98-0.996; P < .010). The effect of global intracranial hemorrhage volume on clinical-radiologic outcomes changed significantly according to different age groups (younger than 50, 50-70, older than 70 year of age). Volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH affected the 3 predefined outcomes differently. Intracerebral hemorrhage volume independently predicted global cerebral edema and long-term outcome, intraventricular hemorrhage volume predicted mortality and long-term outcome, and SAH volume predicted long-term clinical outcome. CONCLUSIONS Global intracranial hemorrhage volume plays a pivotal role in global cerebral edema development and emerged as an independent predictor of both mortality and long-term clinical outcome. Aging emerged as a reducing predictor in the relationship between global intracranial hemorrhage volume and global cerebral edema.
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Affiliation(s)
- Pietro Panni
- From the Department of Neuroradiology (P.P., F.S., R.C., A. Falini), Division of Interventional Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
- Department of Neurosurgery (P.P., P.M.), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Franco Simionato
- From the Department of Neuroradiology (P.P., F.S., R.C., A. Falini), Division of Interventional Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Cao
- From the Department of Neuroradiology (P.P., F.S., R.C., A. Falini), Division of Interventional Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Pedicelli
- Institute of Radiological Sciences (A.P., A. Alexandre). Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery (E.M.), Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care Medicine (A.C.), Fondazione Policlinico Universitario A. Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Andrea Alexandre
- Institute of Radiological Sciences (A.P., A. Alexandre). Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Alberto Feletti
- Institute of Neurosurgery (A. Feletti, M.T), Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mattia Testa
- Institute of Neurosurgery (A. Feletti, M.T), Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Zanatta
- Anesthesia and Intensive Care A (P.Z.), Integrated University Hospital, Verona, Italy
| | - Nicola Gitti
- Department of Anesthesia, Critical Care and Emergency (N.G., S.P.), Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency (N.G., S.P.), Spedali Civili University Hospital, Brescia, Italy
| | - Dikran Mardighian
- Department of Neuroradiology (D.M.), Spedali Civili University Hospital, Brescia, Italy
| | - Vittorio Semeraro
- Department of Radiology (V.S.), SS Annunziata Hospital, Taranto, Italy
| | - Giordano Nardin
- Department of Critical Care (G.N.), SS Annunziata Hospital, Taranto, Italy
| | - Emilio Lozupone
- Department of Neuroradiology (E.L.), Vito-Fazzi Hospital, Lecce, Italy
| | - Giafranco Paiano
- Department of Anaesthesia and Critical Care (G.P.), Vito-Fazzi Hospital, Lecce, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care (E.P., V.M., M.P), Parma University Hospital, Parma, Italy
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care (E.P., V.M., M.P), Parma University Hospital, Parma, Italy
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care (E.P., V.M., M.P), Parma University Hospital, Parma, Italy
| | - Carlo Bortolotti
- Department of Neurosurgery (C.B., A.S.), IRCCS Institute of Neurological Sciences "Bellaria," Bologna, Italy
| | - Antonino Scibilia
- Department of Neurosurgery (C.B., A.S.), IRCCS Institute of Neurological Sciences "Bellaria," Bologna, Italy
| | - Luigi Cirillo
- Department of Neuroradiology (L.C.), IRCCS Institute of Neurological Sciences "Bellaria," Bologna, Italy
| | - Raffaele Aspide
- Department of Neurointensive Care (R.A.), IRCCS Institute of Neurological Sciences "Bellaria," Bologna, Italy
| | | | - Alessandro Ambrosi
- Biostatistics, School of Medicine (A. Ambrosi), Vita-Salute San Raffaele University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery (P.P., P.M.), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Luisa Azzolini
- Deparment of Neurocritical Care (M.L.A., M.R.C.), San Raffaele University Hospital, Milan, Italy
| | - Maria Rosa Calvi
- Deparment of Neurocritical Care (M.L.A., M.R.C.), San Raffaele University Hospital, Milan, Italy
| | - Andrea Falini
- From the Department of Neuroradiology (P.P., F.S., R.C., A. Falini), Division of Interventional Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Scibilia A, Rustici A, Linari M, Zenesini C, Belotti LMB, Dall’Olio M, Princiotta C, Cuoci A, Aspide R, Migliorino E, Moneti M, Sturiale C, Castioni CA, Conti A, Bortolotti C, Cirillo L. Factors affecting 30-day mortality in poor-grade aneurysmal subarachnoid hemorrhage: a 10-year single-center experience. Front Neurol 2024; 15:1286862. [PMID: 38426166 PMCID: PMC10901988 DOI: 10.3389/fneur.2024.1286862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Abstract
Background The management of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is burdened by an unfavorable prognosis even with aggressive treatment. The aim of the present study is to investigate the risk factors affecting 30-day mortality in poor-grade aSAH patients. Methods We performed a retrospective analysis of a prospectively collected database of poor-grade aSAH patients (World Federation of Neurosurgical Societies, WFNS, grades IV and V) treated at our institution from December 2010 to December 2020. For all variables, percentages of frequency distributions were analyzed. Contingency tables (Chi-squared test) were used to assess the association between categorical variables and outcomes in the univariable analysis. Multivariable analysis was performed by using the multiple logistic regression method to estimate the odds ratio (OR) for 30-day mortality. Results A total of 149 patients were included of which 32% had WFNS grade 4 and 68% had WFNS grade 5. The overall 1-month mortality rate was 21%. On univariable analysis, five variables were found to be associated with the likelihood of death, including intraventricular hemorrhage (IVH ≥ 50 mL, p = 0.005), the total amount of intraventricular and intraparenchymal hemorrhage (IVH + ICH ≥ 90 mL, p = 0.019), the IVH Ratio (IVH Ratio ≥ 40%, p = 0.003), posterior circulation aneurysms (p = 0.019), presence of spot sign on initial CT scan angiography (p = 0.015).Nonetheless, when the multivariable analysis was performed, only IVH Ratio (p = 0.005; OR 3.97), posterior circulation aneurysms (p = 0.008; OR 4.05) and spot sign (p = 0.022; OR 6.87) turned out to be independent predictors of 30-day mortality. Conclusion The risk of mortality in poor-grade aSAH remains considerable despite maximal treatment. Notwithstanding the limitations of a retrospective study, our report highlights some neuroradiological features that in the emergency setting, combined with leading clinical and anamnestic parameters, may support the multidisciplinary team in the difficult decision-making process and communication with family members from the earliest stages of poor-grade aSAH. Further prospective studies are warranted.
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Affiliation(s)
- Antonino Scibilia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Arianna Rustici
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOSI di Neuroradiologia Ospedale Maggiore, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Università di Bologna, Bologna, Italy
| | - Marta Linari
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Università di Bologna, Bologna, Italy
| | - Corrado Zenesini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unità di Epidemiologia e Biostatistica, Bologna, Italy
| | | | - Massimo Dall’Olio
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuroradiologia, Bologna, Italy
| | - Ciro Princiotta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuroradiologia, Bologna, Italy
| | - Andrea Cuoci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Raffaele Aspide
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Anestesia e Rianimazione, Bologna, Italy
| | - Ernesto Migliorino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Anestesia e Rianimazione, Bologna, Italy
| | - Manuel Moneti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Anestesia e Rianimazione, Bologna, Italy
| | - Carmelo Sturiale
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Carlo Alberto Castioni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Anestesia e Rianimazione, Bologna, Italy
| | - Alfredo Conti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Università di Bologna, Bologna, Italy
| | - Carlo Bortolotti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Luigi Cirillo
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuroradiologia, Bologna, Italy
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García-García S, Cepeda S, Müller D, Mosteiro A, Torné R, Agudo S, de la Torre N, Arrese I, Sarabia R. Mortality Prediction of Patients with Subarachnoid Hemorrhage Using a Deep Learning Model Based on an Initial Brain CT Scan. Brain Sci 2023; 14:10. [PMID: 38248225 PMCID: PMC10812955 DOI: 10.3390/brainsci14010010] [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: 11/05/2023] [Revised: 12/10/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) entails high morbidity and mortality rates. Convolutional neural networks (CNN) are capable of generating highly accurate predictions from imaging data. Our objective was to predict mortality in SAH patients by processing initial CT scans using a CNN-based algorithm. METHODS We conducted a retrospective multicentric study of a consecutive cohort of patients with SAH. Demographic, clinical and radiological variables were analyzed. Preprocessed baseline CT scan images were used as the input for training using the AUCMEDI framework. Our model's architecture leveraged a DenseNet121 structure, employing transfer learning principles. The output variable was mortality in the first three months. RESULTS Images from 219 patients were processed; 175 for training and validation and 44 for the model's evaluation. Of the patients, 52% (115/219) were female and the median age was 58 (SD = 13.06) years. In total, 18.5% (39/219) had idiopathic SAH. The mortality rate was 28.5% (63/219). The model showed good accuracy at predicting mortality in SAH patients when exclusively using the images of the initial CT scan (accuracy = 74%, F1 = 75% and AUC = 82%). CONCLUSION Modern image processing techniques based on AI and CNN make it possible to predict mortality in SAH patients with high accuracy using CT scan images as the only input. These models might be optimized by including more data and patients, resulting in better training, development and performance on tasks that are beyond the skills of conventional clinical knowledge.
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Affiliation(s)
- Sergio García-García
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Santiago Cepeda
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Dominik Müller
- IT-Infrastructure for Translational Medical Research, University of Augsburg, 86159 Augsburg, Germany;
| | - Alejandra Mosteiro
- Neurosurgery Department, Hospital Clinic de Barcelona, 08036 Barcelona, Spain; (A.M.); (R.T.)
| | - Ramón Torné
- Neurosurgery Department, Hospital Clinic de Barcelona, 08036 Barcelona, Spain; (A.M.); (R.T.)
| | - Silvia Agudo
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Natalia de la Torre
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Ignacio Arrese
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Rosario Sarabia
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
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Predictive effects of admission white blood cell counts and hounsfield unit values on delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 212:107087. [PMID: 34929583 DOI: 10.1016/j.clineuro.2021.107087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/23/2021] [Accepted: 12/04/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Neuroinflammatory response is deemed the primary pathogenesis of delayed cerebral ischemia (DCI) caused by aneurysmal subarachnoid hemorrhage (aSAH). Both white blood cell (WBC) count and Hounsfield Unit (HU) are gradually considered can reflect inflammation in DCI. This study aims to identify the relationship between WBC count and HU value and investigate the effects of both indicators in predicting DCI after aSAH. METHODS We enrolled 109 patients with aSAH admitted within 24 h of onset in our study. A multivariate logistic regression analysis was used to evaluate the admission WBC count, HU value, and combined WBC-HU associated with DCI. The receiver operating characteristic curve and area under the curve (AUC) were used to determine thresholds and detect the predictive ability of these predictors. These indicators were also compared with the established inflammation markers. RESULTS Thirty-six (33%) patients developed DCI. Both WBC count and HU value were strongly associated with the admission glucose level (ρ = .303, p = .001; ρ = .273, p = .004), World Federation of Neurosurgical Societies grade (ρ = .452, p < .001; ρ = .578; p < .001), Hunt-Hess grade (ρ = .450, p < .001; ρ = .510, p < .001), and modified Fisher scale score (ρ = .357, p < .001; ρ = .330, p < .001). After controlling these public variables, WBC count (ρ = .300, p = .002) positively correlated with HU value. An early elevated WBC (odds ratio [OR] 1.449, 95% confidence interval [CI]: 1.183-1.774, p < .001) count and HU value (OR 1.304, 95%CI: 1.149-1.479, p < .001) could independently predict the occurrence of DCI. However, only these patients with both WBC count and HU value exceeding the cut-off points (OR 36.89, 95%CI: 5.606-242.78, p < .001) were strongly correlated with DCI. Compared with a single WBC count (AUC 0.811, 95%CI: 0.729-0.892, p < .001) or HU value (AUC 0.869, 95%CI: 0.803-0.936, p < .001), the combined WBC-HU (AUC 0.898, 95%CI: 0.839-0.957, p < .001) demonstrated a better ability to predict the occurrence of DCI. Inspiringly, the prediction performance of these indicators outperformed the established inflammatory markers. CONCLUSION An early elevated WBC count and HU value could independently predict DCI occurrence between 4 and 30 days after aSAH. Furthermore, WBC count was positively correlated with HU value, and the combined WBC-HU demonstrated a superior prediction ability for DCI development compared with the individual indicator.
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Munarriz PM, Navarro-Main B, Alén JF, Jiménez-Roldán L, Castaño-Leon AM, Moreno-Gómez LM, Paredes I, García-Pérez D, Panero I, Eiriz C, Esteban-Sinovas O, Bárcena E, Gómez PA, Lagares A. The influence of aneurysm morphology on the volume of hemorrhage after rupture. J Neurosurg 2021; 136:1015-1023. [PMID: 34534958 DOI: 10.3171/2021.3.jns21293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Factors determining the risk of rupture of intracranial aneurysms have been extensively studied; however, little attention is paid to variables influencing the volume of bleeding after rupture. In this study the authors aimed to evaluate the impact of aneurysm morphological variables on the amount of hemorrhage. METHODS This was a retrospective cohort analysis of a prospectively collected data set of 116 patients presenting at a single center with subarachnoid hemorrhage due to aneurysmal rupture. A volumetric assessment of the total hemorrhage volume was performed from the initial noncontrast CT. Aneurysms were segmented and reproduced from the initial CT angiography study, and morphology indexes were calculated with a computer-assisted approach. Clinical and demographic characteristics of the patients were included in the study. Factors influencing the volume of hemorrhage were explored with univariate correlations, multiple linear regression analysis, and graphical probabilistic modeling. RESULTS The univariate analysis demonstrated that several of the morphological variables but only the patient's age from the clinical-demographic variables correlated (p < 0.05) with the volume of bleeding. Nine morphological variables correlated positively (absolute height, perpendicular height, maximum width, sac surface area, sac volume, size ratio, bottleneck factor, neck-to-vessel ratio, and width-to-vessel ratio) and two correlated negatively (parent vessel average diameter and the aneurysm angle). After multivariate analysis, only the aneurysm size ratio (p < 0.001) and the patient's age (p = 0.023) remained statistically significant. The graphical probabilistic model confirmed the size ratio and the patient's age as the variables most related to the total hemorrhage volume. CONCLUSIONS A greater aneurysm size ratio and an older patient age are likely to entail a greater volume of bleeding after subarachnoid hemorrhage.
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Affiliation(s)
- Pablo M Munarriz
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre.,2Universidad Complutense de Madrid
| | | | - Jose F Alén
- 2Universidad Complutense de Madrid.,3Department of Neurosurgery, Hospital Universitario La Princesa; and
| | | | | | | | - Igor Paredes
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | | | - Irene Panero
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | - Carla Eiriz
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | | | - Eduardo Bárcena
- 4Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pedro A Gómez
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | - Alfonso Lagares
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre.,2Universidad Complutense de Madrid
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7
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Acute platelet response to aneurysmal subarachnoid hemorrhage depends on severity and distribution of bleeding: an observational cohort study. Neurosurg Rev 2020; 44:2647-2658. [PMID: 33241455 DOI: 10.1007/s10143-020-01444-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/21/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022]
Abstract
Microthrombosis after aneurysmal subarachnoid hemorrhage (aSAH) is considered to initiate neuroinflammation, vessel remodeling, and blood-brain barrier leakage. We aimed to verify the hypothesis that the intensity of thrombogenicity immediately after aSAH depends on the amount and distribution of extravasated blood. This observational cohort study included 37 consecutive aSAH patients admitted no longer than 24 h after ictus. Volumes of subarachnoid and intraventricular hemorrhages as well as the Subarachnoid Hemorrhage Early Brain Edema Scale (SEBES) score were calculated in each case. Platelet system status was described by platelet count (PLT), mean platelet volume (MPV), MPV to PLT ratio, and platelet-large cell ratio (P-LCR). Median hemorrhage volume amounted to 11.4 ml (interquartile range 2.8-26.8 ml). Patients with more severe hemorrhage had lower PLT and higher MPV to PLT ratio (ρ = - 0.49, p < .002; ρ = 0.50, p < .002, respectively). PLT decreased by 2.80 G/l per 1 ml of hemorrhage volume (95% CL 1.30-4.30, p < .001). Further analysis revealed that intraventricular hemorrhage volume was associated with P-LCR and MPV (ρ = 0.34, p < .039; ρ = 0.33, p < .048, respectively), whereas SAH volume with PLT and MPV:PLT ratio (ρ = - 0.40, p < .013; ρ = 0.41, p < .013, respectively). The odds of unfavorable neurological outcome increased 3.95 times per 1 fl of MPV (95% CI 1.19-13.12, p < .025). MPV was independently correlated with SEBES (ρ = 0.44, p < .006). This study demonstrated that the extent and distribution of aneurysmal subarachnoid hemorrhage are related to different types of acute platelet response, which may be interpreted as local and systemic thrombogenicity. Increased mean platelet volume measured in the acute phase of aSAH may identify patients at risk for unfavorable neurological outcomes and may serve as a marker of early brain injury.
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Ya X, Zhang C, Liu J, Zhang S, Zhang Q, Wang S, Cao Y, Zhao J. Risk Factors for Higher Volume of Hemorrhage in Ruptured Anterior Circulation Intracranial Aneurysms. Front Surg 2020; 7:587790. [PMID: 33282906 PMCID: PMC7688892 DOI: 10.3389/fsurg.2020.587790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose: To explore the influencing factors of volume hemorrhage in ruptured anterior circulation aneurysms, so as to identify the characteristics of anterior circulation aneurysms with high volume of hemorrhage, and to provide advice for clinical diagnosis and treatment for those aneurysms. Methods: We retrospectively reviewed 437 cases of ruptured anterior intracranial aneurysms in our center between the years 2012 and 2017. According to the inclusion criteria, a total of 100 qualified patients were screened out. We collected demographic characteristics, environmental exposure, and admission status of enrolled patients. In addition, morphological parameters and location of aneurysms were also included. The semiautomatic threshold method was used to measure the volume of hemorrhage. According to the results, the patients were divided into the group with high blood volume and low blood volume. Univariate and multivariate logistic regression analyses were used to discover the related factors affecting the bleeding volume. Results: In univariable analysis, pulse pressure (P = 0.014) showed a significant difference at the P < 0.05 test level. In terms of aneurysm morphology, the irregular shape (P < 0.001), calcification (P = 0.001), and flow angle (P = 0.006) showed significant statistical differences between the two groups at the P < 0.01 level (P < 0.01). Multivariate logistic regression analysis showed that irregular shape (OR = 5.370 P = 0.002 < 0.05), large flow angle (OR = 1.033 P = 0.016 < 0.05), and calcification (OR = 5.460 P = 0.003 < 0.05) were risk factors for volume of hemorrhage in ruptured anterior circulation aneurysms. The influence of hypertension history was at critical state (OR = 2.877 P = 0.051 > 005). Conclusions: According to our analysis results, intracranial anterior circulation aneurysms with irregular shapes, calcifications, and large flow angle are more dangerous. Aneurysms with these characteristics often have a large amount of hemorrhage, requiring timely treatment in clinical practice.
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Affiliation(s)
- Xiaolong Ya
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jichao Liu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qian Zhang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Cao
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jizong Zhao
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China
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9
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van der Steen WE, Marquering HA, Ramos LA, van den Berg R, Coert BA, Boers AMM, Vergouwen MDI, Rinkel GJE, Velthuis BK, Roos YBWEM, Majoie CBLM, Vandertop WP, Verbaan D. Prediction of Outcome Using Quantified Blood Volume in Aneurysmal SAH. AJNR Am J Neuroradiol 2020; 41:1015-1021. [PMID: 32409315 DOI: 10.3174/ajnr.a6575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/26/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In patients with SAH, the amount of blood is strongly associated with clinical outcome. However, it is commonly estimated with a coarse grading scale, potentially limiting its predictive value. Therefore, we aimed to develop and externally validate prediction models for clinical outcome, including quantified blood volumes, as candidate predictors. MATERIALS AND METHODS Clinical and radiologic candidate predictors were included in a logistic regression model. Unfavorable outcome was defined as a modified Rankin Scale score of 4-6. An automatic hemorrhage-quantification algorithm calculated the total blood volume. Blood was manually classified as cisternal, intraventricular, or intraparenchymal. The model was selected with bootstrapped backward selection and validated with the R 2, C-statistic, and calibration plots. If total blood volume remained in the final model, its performance was compared with models including location-specific blood volumes or the modified Fisher scale. RESULTS The total blood volume, neurologic condition, age, aneurysm size, and history of cardiovascular disease remained in the final models after selection. The externally validated predictive accuracy and discriminative power were high (R 2 = 56% ± 1.8%; mean C-statistic = 0.89 ± 0.01). The location-specific volume models showed a similar performance (R 2 = 56% ± 1%, P = .8; mean C-statistic = 0.89 ± 0.00, P = .4). The modified Fisher models were significantly less accurate (R 2 = 45% ± 3%, P < .001; mean C-statistic = 0.85 ± 0.01, P = .03). CONCLUSIONS The total blood volume-based prediction model for clinical outcome in patients with SAH showed a high predictive accuracy, higher than a prediction model including the commonly used modified Fisher scale.
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Affiliation(s)
- W E van der Steen
- From the Departments of Biomedical Engineering and Physics (W.E.v.d.S., H.A.M., L.A.R., A.M.M.B.)
- Radiology and Nuclear Medicine (W.E.v.d.S., H.A.M., R.v.d.B., C.B.L.M.M.)
- Neurology (W.E.v.d.S., Y.B.W.E.M.R.)
- Neurosurgical Center Amsterdam (W.E.v.d.S., B.A.C., W.P.V., D.V.), Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - H A Marquering
- From the Departments of Biomedical Engineering and Physics (W.E.v.d.S., H.A.M., L.A.R., A.M.M.B.)
- Radiology and Nuclear Medicine (W.E.v.d.S., H.A.M., R.v.d.B., C.B.L.M.M.)
| | - L A Ramos
- From the Departments of Biomedical Engineering and Physics (W.E.v.d.S., H.A.M., L.A.R., A.M.M.B.)
- Clinical Epidemiology, Biostatistics and Bioinformatics (L.A.R.)
| | - R van den Berg
- Radiology and Nuclear Medicine (W.E.v.d.S., H.A.M., R.v.d.B., C.B.L.M.M.)
| | - B A Coert
- Neurosurgical Center Amsterdam (W.E.v.d.S., B.A.C., W.P.V., D.V.), Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A M M Boers
- From the Departments of Biomedical Engineering and Physics (W.E.v.d.S., H.A.M., L.A.R., A.M.M.B.)
| | - M D I Vergouwen
- Departments of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.D.I.V., G.J.E.R.)
| | - G J E Rinkel
- Departments of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.D.I.V., G.J.E.R.)
| | - B K Velthuis
- Radiology (B.K.V.), University Medical Center, Utrecht University, Utrecht, the Netherlands
| | | | - C B L M Majoie
- Radiology and Nuclear Medicine (W.E.v.d.S., H.A.M., R.v.d.B., C.B.L.M.M.)
| | - W P Vandertop
- Neurosurgical Center Amsterdam (W.E.v.d.S., B.A.C., W.P.V., D.V.), Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - D Verbaan
- Neurosurgical Center Amsterdam (W.E.v.d.S., B.A.C., W.P.V., D.V.), Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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10
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Torné R, Culebras D, Sanchez-Etayo G, García-García S, Muñoz G, Llull L, Amaro S, Heering C, Blasco J, Zavala E, Enseñat J. Double hemispheric Microdialysis study in poor-grade SAH patients. Sci Rep 2020; 10:7466. [PMID: 32366972 PMCID: PMC7198586 DOI: 10.1038/s41598-020-64543-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 04/15/2020] [Indexed: 02/07/2023] Open
Abstract
Delayed cerebral ischemia (DCI) is a dreadful complication present in 30% of subarachnoid hemorrhage (SAH) patients. DCI prediction and prevention are burdensome in poor grade SAH patients (WFNS 4-5). Therefore, defining an optimal neuromonitoring strategy might be cumbersome. Cerebral microdialysis (CMD) offers near-real-time regional metabolic data of the surrounding brain. However, unilateral neuromonitoring strategies obviate the diffuse repercussions of SAH. To assess the utility, indications and therapeutic implications of bilateral CMD in poor grade SAH patients. Poor grade SAH patients eligible for multimodal neuromonitoring were prospectively collected. Aneurysm location and blood volume were assessed on initial Angio-CT scans. CMD probes were bilaterally implanted and maintained, at least, for 48 hours (h). Ischemic events were defined as a Lactate/Pyruvate ratio >40 and Glucose concentration <0.7 mmol/L. 16 patients were monitored for 1725 h, observing ischemic events during 260 h (15.1%). Simultaneous bilateral ischemic events were rare (5 h, 1.9%). The established threshold of ≥7 ischemic events displayed a specificity and sensitivity for DCI of 96.2% and 83.3%, respectively. Bilateral CMD is a safe and useful strategy to evaluate areas at risk of suffering DCI in SAH patients. Metabolic crises occur bilaterally but rarely simultaneously. Hence, unilateral neuromonitoring strategies underestimate the risk of infarction and the possibility to offset its consequences.
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Affiliation(s)
- Ramon Torné
- Neurological Surgery Department, Hospital Clinic of Barcelona, Barcelona, Spain.
| | - Diego Culebras
- Neurological Surgery Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Sergio García-García
- Neurological Surgery Department, Hospital Clinic of Barcelona, Barcelona, Spain. .,Neurological Surgery Department, Hospital Sant Joan de Deu, Barcelona, Spain.
| | - Guido Muñoz
- Intensive Care Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Laura Llull
- Neurology Department, Comprehensive Stroke Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergio Amaro
- Neurology Department, Comprehensive Stroke Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Jordi Blasco
- Radiology Department, Angioradiology Section, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Elizabeth Zavala
- Intensive Care Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Neurological Surgery Department, Hospital Clinic of Barcelona, Barcelona, Spain
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11
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Takahashi S, Akiyama T, Horiguchi T, Miwa T, Takemura R, Yoshida K. Loss of consciousness at ictus and/or poor World Federation of Neurosurgical Societies grade on admission reflects the impact of EBI and predicts poor outcome in patients with SAH. Surg Neurol Int 2020; 11:40. [PMID: 32257566 PMCID: PMC7110405 DOI: 10.25259/sni_551_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/17/2020] [Indexed: 01/15/2023] Open
Abstract
Background: There are many scores and markers that predict poor outcome in patients with subarachnoid hemorrhage (SAH). However, parameters that can predict outcomes in patients with SAH with high specificity and sensitivity, which can be identified in the early postictal state and utilized as a clinical marker of early brain injury (EBI) have not been identified so far. Methods: Thirty-nine patients with SAH due to a saccular intracranial aneurysm rupture were reviewed. We retrospectively analyzed the relationships between patients’ baseline characteristics and patients’ outcomes to identify parameters that could predict patient outcomes in the early postictal state. Results: In the univariate analysis, older age (>65), loss of consciousness (LOC) at ictus, poor initial World Federation of Neurosurgical Societies (WFNS) grade (3–5), and delayed cerebral ischemia (DCI) were associated with poor outcome (GOS 1–3). Statistical analyses revealed that combined LOC at ictus and/or poor initial WFNS grade (3–5) was a more powerful surrogate marker of outcome (OR 15.2 [95% CI 3.1–75.5]) than either LOC at ictus or the poor initial WFNS grade (3–5) alone. Multivariate logistic regression analyses revealed that older age, combined LOC at ictus and/or poor initial WFNS grade, and DCI were independently associated with poor outcome. Conclusion: Combined LOC at ictus and/or poor initial WFNS grade (3–5) reflects the impact of EBI and was a useful surrogate marker of poor prognosis in SAH patients, independent of patients’ age and state of DCI.
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Affiliation(s)
| | | | | | - Tomoru Miwa
- Department of Neurosurgery, Keio University, School of Medicine
| | - Ryo Takemura
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
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12
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Chitinase-3-Like Protein 1, Serum Amyloid A1, C-Reactive Protein, and Procalcitonin Are Promising Biomarkers for Intracranial Severity Assessment of Traumatic Brain Injury: Relationship with Glasgow Coma Scale and Computed Tomography Volumetry. World Neurosurg 2019; 134:e120-e143. [PMID: 31606503 DOI: 10.1016/j.wneu.2019.09.143] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The volume and location of intracranial hematomas are well-known prognostic factors for traumatic brain injury. The aim of this study was to determine the relationship of serum biomarkers S100β, glial fibrillary acidic protein, neuron-specific enolase, total tau, phosphorylated neurofilament heavy chain, serum amyloid A1 (SAA1), C-reactive protein, procalcitonin (PCT), and chitinase-3-like protein 1 (YKL-40) with traumatic brain injury severity and the amount and location of hemorrhagic traumatic lesions. METHODS A prospective observational cohort of 115 patients with a Glasgow Coma Scale (GCS) score of 3-15 were evaluated. Intracranial lesion volume was measured from the semiautomatic segmentation of hematoma on computed tomography using Analyze software. The establishment of possible biomarker cutoff points for intracranial lesion detection was estimated using the Youden Index (J) obtained from the area under the receiver operating characteristic curve. RESULTS SAA1, YKL-40, PCT, and S100β showed the most robust association with level of consciousness, both with total GCS and motor score. Biomarkers significantly correlated with volumetric measurements of subdural hematoma, traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage, intraventricular hemorrhage, and total amount of bleeding. The type of intracranial hemorrhage was associated with various release patterns of neurobiochemical markers. CONCLUSIONS YKL-40, SAA1, C-reactive protein, and PCT combined with S100β were the most promising biomarkers to determine the presence, location, and extent of traumatic intracranial lesions. Combination of biomarkers further increased the discriminatory capacity for the detection of intracranial bleeding.
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13
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Kanazawa T, Takahashi S, Minami Y, Jinzaki M, Toda M, Yoshida K. Early prediction of clinical outcomes in patients with aneurysmal subarachnoid hemorrhage using computed tomography texture analysis. J Clin Neurosci 2019; 71:144-149. [PMID: 31493994 DOI: 10.1016/j.jocn.2019.08.098] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 08/25/2019] [Indexed: 10/26/2022]
Abstract
Radiological evaluation of subarachnoid hemorrhage (SAH) is often subject to interobserver variability. The aim of this study was to retrospectively detect computed tomography (CT) texture parameters in the early postictal state to predict cerebral vasospasm, delayed cerebral ischemia (DCI), and functional outcome in aneurysmal SAH using quantitative CT texture analysis (CTTA) via a commercially available software program and routine CT images. 40 patients with aneurysmal SAH surgically treated at the Keio University Hospital during a four-year period were analyzed. CT texture analyses were performed using a commercially available software program (Synapse Vincent). The following texture parameters of blood clots in the subarachnoid space and cerebral edema were assessed: mean CT value, entropy, skewness, and kurtosis. The mean CT value of blood clots in the subarachnoid space was significantly associated with cerebral vasospasm, DCI, and functional outcome. The mean CT value ≥ 49.64 Hounsfield units (HU) predicted cerebral vasospasm with a sensitivity and specificity of 85.7% and 61.5%, respectively (area under the curve [AUC] = 0.758). The mean CT value ≥ 49.95 HU predicted DCI with a sensitivity and specificity of 100% and 60.6%, respectively (AUC = 0.810). The mean CT value ≥ 53.00 HU predicted poor functional outcome with a sensitivity and specificity of 56.3% and 91.7%, respectively (AUC = 0.747). CTTA using a commercially available software program demonstrated that the mean CT value of clots in the subarachnoid space in the early postictal state could predict vasospasm, DCI, and clinical outcome with a high sensitivity and specificity.
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Affiliation(s)
- Tokunori Kanazawa
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Satoshi Takahashi
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yasuhiro Minami
- Department of Diagnostic Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masahiro Jinzaki
- Department of Diagnostic Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
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14
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Hemorrhagic burden in poor-grade aneurysmal subarachnoid hemorrhage: a volumetric analysis of different bleeding distributions. Acta Neurochir (Wien) 2019; 161:791-797. [PMID: 30790092 DOI: 10.1007/s00701-019-03846-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/12/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Volumetric assessment of aneurysmal bleeding has been evaluated in few studies and emerged as a promising outcome predictor. There is a lack of studies evaluating its impact in the poor-grade population. METHODS Retrospective review of 63 consecutive poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients, defined as grade IV and V according to the World Federation of Neurological Surgeons (WFNS) classifications. Global intracranial bleeding volume was calculated with its subarachnoid, intracerebral (ICH), and intraventricular (IVH) portions by means of analytical software. Univariate and multivariate analyses were performed in order to identify independent predictors of outcome. Good outcome was defined as modified Rankin Scale (mRS) 0-2 and mortality as mRS 6. The cutoff values of bleeding volumes were derived by receiver operating curve (ROC) analysis. RESULTS Mean follow-up was of 12.5 (± 1.5) months. Thirty (47.7%) patients achieved good outcome, whereas 19 (30.2) patients out of 63 died. Global intracranial bleeding resulted as an independent predictor of good outcome (cutoff 24 mL). Furthermore, ICH relative percentage of global volume (10% of total) and pure SAH (64% of total) emerged respectively as independent predictors of worsened and improved outcome. Global bleeding volume (cutoff 51 mL) along with global cerebral edema showed to independently predict mortality in the examined poor-grade aSAH population. CONCLUSIONS Volumetric assessment of aneurysmal bleeding has the potential for identifying cutoff values that independently predict outcome. Further insights into the relative importance of different bleeding volumes may be implicated in better tailoring the management of this dismal aSAH population.
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15
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García S, Torné R, Hoyos JA, Rodríguez-Hernández A, Amaro S, Llull L, López-Rueda A, Enseñat J. Quantitative versus qualitative blood amount assessment as a predictor for shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage. J Neurosurg 2018; 131:1743-1750. [PMID: 30579275 DOI: 10.3171/2018.7.jns18816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Reliable tools are lacking to predict shunt-dependent hydrocephalus (SDHC) development after aneurysmal subarachnoid hemorrhage (aSAH). Quantitative volumetric measurement of hemorrhagic blood is a good predictor of SDHC but might be impractical in the clinical setting. Qualitative assessment performed using scales such as the modified Fisher scale (mFisher) and the original Graeb scale (oGraeb) is easier to conduct but provides limited predictive power. In between, the modified Graeb scale (mGraeb) keeps the simplicity of the qualitative scales yet adds assessment of acute hydrocephalus, which might improve SDHC-predicting capabilities. In this study the authors investigated the likely capabilities of the mGraeb and compared them with previously validated methods. This research also aimed to define a tailored mGraeb cutoff point for SDHC prediction. METHODS The authors performed retrospective analysis of patients admitted to their institution with the diagnosis of aSAH between May 2013 and April 2016. Out of 168 patients, 78 were included for analysis after the application of predefined exclusion criteria. Univariate and multivariate analyses were conducted to evaluate the use of all 4 methods (quantitative volumetric assessment and the mFisher, oGraeb, and mGraeb scales) to predict the likelihood of SDHC development based on clinical data and blood amount assessment on initial CT scans. RESULTS The mGraeb scale was demonstrated to be the most robust predictor of SDHC, with an area under the curve (AUC) of 0.848 (95% CI 0.763-0.933). According to the AUC results, the performance of the mGraeb scale was significantly better than that of the oGraeb scale (χ2 = 4.49; p = 0.034) and mFisher scale (χ2 = 7.21; p = 0.007). No statistical difference was found between the AUCs of the mGraeb and the quantitative volumetric measurement models (χ2 = 12.76; p = 0.23), but mGraeb proved to be the simplest model since it showed the lowest Akaike information criterion (66.4), the lowest Bayesian information criterion (71.2), and the highest R2Nagelkerke coefficient (39.7%). The initial mGraeb showed more than 85% specificity for predicting the development of SDHC in patients presenting with a score of 12 or more points. CONCLUSIONS According to the authors' data, the mGraeb scale is the simplest model that correlates well with SDHC development. Due to limited scientific evidence of treatments aimed at SDHC prevention, we propose an mGraeb score higher than 12 to identify patients at risk with high specificity. This mGraeb cutoff point might also serve as a useful prognostic tool since patients with SDHC after aSAH have worse functional outcomes.
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Affiliation(s)
- Sergio García
- 1Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona
| | - Ramon Torné
- 1Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona
| | - Jhon Alexander Hoyos
- 1Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona
| | | | - Sergio Amaro
- 3Comprehensive Stroke Center, Department of Neurology, Hospital Clinic de Barcelona, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS); and
| | - Laura Llull
- 3Comprehensive Stroke Center, Department of Neurology, Hospital Clinic de Barcelona, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS); and
| | - Antonio López-Rueda
- 4Department of Radiology, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- 1Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona
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16
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Zheng J, Xu R, Liu G, Guo Z, Sun X. Effect of premorbid hypertension control on outcome of patients with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2018; 160:2401-2407. [PMID: 30315363 DOI: 10.1007/s00701-018-3699-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/03/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Hypertension is common in patients with aneurysmal subarachnoid hemorrhage (SAH). However, it is still unclear whether premorbid antihypertensive therapy can help to reduce the risk of severe aneurysmal bleeding. Therefore, this study aims to assess the effect of premorbid hypertension control on outcome of patients with aneurysmal SAH. METHODS We retrospectively reviewed the clinical data of patients with intracranial aneurysms admitted to our institution from February 2012 to December 2017. Based on premorbid hypertension history and use of antihypertensive agents, all patients with aneurysmal SAH were divided into antihypertensive group and uncontrolled group. Patient characteristics, imaging features, clinical complication, and outcome were analyzed between the two groups. RESULTS A total of 348 patients with ruptured aneurysms were included in this study. Compared to those with premorbid controlled hypertension, patients with premorbid uncontrolled hypertension presented worse clinical grade, with more severe aneurysmal SAH and more frequent intracerebral hematoma. Patients receiving a treatment for ACEI type or ARB type of drugs in the antihypertensive group suffered from less amount of aneurysmal bleeding, while patients with grade 3 hypertension in the uncontrolled group suffered from more amount of aneurysmal bleeding. Patients with premorbid controlled hypertension had a lower incidence of rebleeding, hydrocephalus, and cerebral vasospasm, and had a lower rate of disability and mortality. CONCLUSIONS Premorbid hypertension control is associated with favorable clinical outcome of patients with aneurysmal SAH. Besides, the ACEI type or ARB type of antihypertensive agents is associated with the less amount of bleeding after aneurysm rupture.
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Affiliation(s)
- Jianfeng Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No. 1 of Youyi Rd., Yuzhong District, Chongqing, China
| | - Rui Xu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No. 1 of Youyi Rd., Yuzhong District, Chongqing, China
| | - Guojing Liu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No. 1 of Youyi Rd., Yuzhong District, Chongqing, China
| | - Zongduo Guo
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No. 1 of Youyi Rd., Yuzhong District, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No. 1 of Youyi Rd., Yuzhong District, Chongqing, China.
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17
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Thresholds for Volume and Expansion in Intraparenchymal Hemorrhage: Predictors of Neurologic Deterioration and Mortality. World Neurosurg 2017; 106:131-138. [DOI: 10.1016/j.wneu.2017.06.131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 06/20/2017] [Accepted: 06/24/2017] [Indexed: 11/23/2022]
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18
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Dengler NF, Diesing D, Sarrafzadeh A, Wolf S, Vajkoczy P. The Barrow Neurological Institute Scale Revisited: Predictive Capabilities for Cerebral Infarction and Clinical Outcome in Patients With Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2017; 81:341-349. [DOI: 10.1093/neuros/nyw141] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 12/28/2016] [Indexed: 11/14/2022] Open
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