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Berli S, Barbagallo M, Keller E, Esposito G, Pagnamenta A, Brandi G. Sex-Related Differences in Mortality, Delayed Cerebral Ischemia, and Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:2781. [PMID: 38792323 PMCID: PMC11122382 DOI: 10.3390/jcm13102781] [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: 04/16/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objective: Sex-related differences among patients with aneurysmal subarachnoid hemorrhage (aSAH) and their potential clinical implications have been insufficiently investigated. To address this knowledge gap, we conduct a comprehensive systematic review and meta-analysis. Methods: Sex-specific differences in patients with aSAH, including mortality, delayed cerebral ischemia (DCI), and functional outcomes were assessed. The functional outcome was dichotomized into favorable or unfavorable based on the modified Rankin Scale (mRS), Glasgow Outcome Scale (GOS), and Glasgow Outcome Scale Extended (GOSE). Results: Overall, 2823 studies were identified in EMBASE, MEDLINE, PubMed, and by manual search on 14 February 2024. After an initial assessment, 74 studies were included in the meta-analysis. In the analysis of mortality, including 18,534 aSAH patients, no statistically significant differences could be detected (risk ratio (RR) 0.99; 95% CI, 0.90-1.09; p = 0.91). In contrast, the risk analysis for DCI, including 23,864 aSAH patients, showed an 11% relative risk reduction in DCI in males versus females (RR, 0.89; 95% CI, 0.81-0.97; p = 0.01). The functional outcome analysis (favorable vs. unfavorable), including 7739 aSAH patients, showed a tendency towards better functional outcomes in men than women; however, this did not reach statistical significance (RR, 1.02; 95% CI, 0.98-1.07; p = 0.34). Conclusions: In conclusion, the available data suggest that sex/gender may play a significant role in the risk of DCI in patients with aSAH, emphasizing the need for sex-specific management strategies.
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Affiliation(s)
- Sarah Berli
- Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Massimo Barbagallo
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Emanuela Keller
- Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Giuseppe Esposito
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
- Department of Neurosurgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Alberto Pagnamenta
- Clinical Trial Unit, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Division of Pneumology, University of Geneva, 1211 Geneva, Switzerland
| | - Giovanna Brandi
- Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland
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Li T, Lu J, Li R, Lin F, Chen Y, Yang J, Han H, Wang K, Wang S, Zhao Y, Chen X. Elevated cortical blood flow insufficiency volume as a predictor of adverse outcomes in aneurysmal subarachnoid hemorrhage: a large prospective quantitative computed tomography perfusion study. Eur J Radiol 2024; 175:111456. [PMID: 38640823 DOI: 10.1016/j.ejrad.2024.111456] [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: 01/14/2024] [Revised: 03/02/2024] [Accepted: 04/08/2024] [Indexed: 04/21/2024]
Abstract
PURPOSE Early hypoperfusion changes exist in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate a readily obtainable quantitative computed tomography perfusion (CTP) parameter that could assist in quickly identifying patients at risk of delayed cerebral ischemia (DCI) and poor 90-day functional outcomes on admission. METHODS We prospectively collected data between 2021.04 and 2022.12. Preoperative CTP data were post-processed using RAPID software. The cortical blood flow insufficiency (CBFI) was defined as Time-to-maximum > 4.0 s. Patients were categorized into four groups according to CBFI volume distribution. To minimize differences among the groups, we employed stabilized inverse probability of treatment weighting (sIPTW). The primary outcome was DCI and poor 90-day functional outcomes (modified Rankin Scale, 3-6) was the secondary outcome. Multivariable Cox or Logistic analysis were performed to estimate the association between CBFI volume and the study outcomes, both before and after sIPTW. RESULTS At baseline, the mean (SD) age of the 493 participants was 55.0 (11.8) years, and 299 (60.6%) were female. One hundred and seven participants with DCI and eighty-six participants with poor 90-day functional outcomes were identified. After sIPTW, CBFI volume demonstrated a significant association with DCI (Cox regression: Group 4 versus Group 1, HR 3.69, 95% CI 1.84-7.01) and poor 90-day functional outcomes (Logistic regression: Group 4 versus Group 1, OR 4.61, 95% CI 2.01-12.50). CONCLUSION In this study, an elevated preoperative CBFI volume was associated with adverse outcomes in aSAH patients. More well-designed studies are needed to confirm this association.
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Affiliation(s)
- Tu Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Pedrosa L, Hoyos J, Reyes L, Llull L, Santana D, de Riva N, Mellado R, Sala X, Rodríguez-Hernández A, Enseñat J, Amaro S, Torné R. MicroRNA cerebrospinal fluid profile during the early brain injury period as a biomarker in subarachnoid hemorrhage patients. Front Cell Neurosci 2022; 16:1016814. [PMID: 36505512 PMCID: PMC9732100 DOI: 10.3389/fncel.2022.1016814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Delayed cerebral ischemia (DCI) is a dreadful complication present in up to 30% of patients with spontaneous subarachnoid hemorrhage (SAH). Indeed, DCI is one of the main causes of long-term disability in SAH, yet its prediction and prevention are troublesome in poor-grade SAH cases. In this prospective study, we explored the potential role of micro ribonucleic acid (microRNA, abbreviated miRNAs)-small non-coding RNAs involved in clue gene regulation at the post-transcriptional level-as biomarkers of neurological outcomes in SAH patients. Methods We analyzed the expression of several miRNAs present in the cerebrospinal fluid (CSF) of SAH patients during the early stage of the disease (third-day post-hemorrhage). NanoString Technologies were used for the characterization of the CSF samples. Results We found an overexpression of miRNAs in the acute stage of 57 SAH in comparison with 10 non-SAH controls. Moreover, a differential expression of specific miRNAs was detected according to the severity of clinical onset, but also regarding the development of DCI and the midterm functional outcomes. Conclusion These observations reinforce the potential utility of miRNAs as prognostic and diagnostic biomarkers in SAH patients. In addition, the identification of specific miRNAs related to SAH evolution might provide insights into their regulatory functions of pathophysiological pathways, such as the TGF-β inflammatory pathway and blood-brain barrier disruption.
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Affiliation(s)
- Leire Pedrosa
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Jhon Hoyos
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Luis Reyes
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Daniel Santana
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Nicolás de Riva
- Neuroanesthesia Division, Department of Anesthesiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Ricard Mellado
- Department of Anesthesiology and Critical Care, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Xavier Sala
- Neuroanesthesia Division, Department of Anesthesiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Joaquim Enseñat
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergio Amaro
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain,Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain,*Correspondence: Sergio Amaro,
| | - Ramon Torné
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain,Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain,Ramon Torné,
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Han H, Chen Y, Li R, Lin F, Lu J, Chen X, Wang S. The value of early CT perfusion parameters for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:2517-2531. [PMID: 35377027 DOI: 10.1007/s10143-022-01779-3] [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: 09/28/2021] [Revised: 03/13/2022] [Accepted: 03/28/2022] [Indexed: 12/30/2022]
Abstract
Delayed cerebral ischemia (DCI) is a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). We aim to investigate the efficacy of early CT perfusion (CTP) parameters for predicting DCI in patients with aSAH. The search was conducted in five databases (PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and China Biology Medicine database). Studies were reviewed by two independent authors, and the included studies were assessed for methodological quality. Fifteen studies with 882 participants were included for the final analysis. The meta-analysis of quantitative parameters showed that mean transit time represented the most valuable predictor when the calculation of the mean value was uniformed (MD 0.30 s, 95% CI: 0.10 to 0.49 s, P = 0.003). Semi-quantitative parameters using relative values or index scores were also widely used to minimize undue variations derived from patients, operators, machines, and software. Studies also demonstrated that these relative parameters had better predictive accuracy than corresponding absolute parameters. Perfusion thresholds in each study were incomparable, and the results warranted further validation. The best threshold for the prediction was 0.9 using the relative cerebral blood flow parameter (sensitivity 97% and specificity 89%). We conclude that CTP in the early phase is a promising tool for predicting DCI in aSAH patients. However, the parameters require standardization. Future studies with prospective, multi-centered design and large sample size are needed to validate the thresholds and optimize the parameters.
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Affiliation(s)
- Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
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Ma YC, Chen AQ, Guo F, Yu J, Xu M, Shan DD, Zhang SH. The value of whole-brain CT perfusion imaging combined with dynamic CT angiography in the evaluation of pial collateral circulation with middle cerebral artery occlusion. Technol Health Care 2022; 30:967-979. [PMID: 35275581 DOI: 10.3233/thc-213118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Middle cerebral artery (MCA) occlusion is extremely common, especially unilateral artery, which can result in a significant incidence of cerebral infarction. OBJECTIVE To assess the value of whole-brain computed tomography perfusion (CTP) imaging combined with dynamic CT angiography (dCTA) in the evaluation of pial collateral circulation in patients with MCA occlusion. METHODS Whole-brain CTP and dCTA images were acquired in 58 patients with unilateral MCA occlusion. All patients were divided into three groups according to the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral score (by CTA). The CTP parameters were analysed, including relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), relative mean transit time (rMTT), and relative time to peak (rTTP). Patients were followed up with the modified Rankin scale (mRS). All cases in this study were confirmed by DSA. RESULTS The CTP parameters of the MCA blood supply area on the affected side of patients with different degrees of stenosis were significantly different from those on the unaffected side. There are significant differences in the CTP parameters and openings of the Willis circle in patients with different degrees of stenosis. Significant differences were found in the number of patients with good prognosis. CONCLUSIONS Whole-brain CT perfusion combined with dynamic CTA can structurally and functionally evaluate the establishment of pial collateral circulation and its effect on cerebral hemodynamic changes.
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Affiliation(s)
- Yi-Chuan Ma
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Ai-Qi Chen
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Fei Guo
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Juan Yu
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Min Xu
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Dan-Dan Shan
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Shun-Hua Zhang
- School of Medical Imaging, Bengbu Medical College, Bengbu, Anhui, China
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Wen L, Zhou L, Wu Q, Tang X, Ge J, Zhou X, Zhang X. Early Microcirculatory Hemodynamic Changes Are Correlated With Functional Outcomes at Discharge in Patients With Aneurysmal SAH. Front Neurol 2022; 12:793411. [PMID: 35126294 PMCID: PMC8811302 DOI: 10.3389/fneur.2021.793411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose The technique of color-coding blood flow analysis was used to explore the correlation between the microcirculatory hemodynamic changes on digital subtraction angiography (DSA) images in patients with aneurysmal subarachnoid hemorrhage (SAH) at the early stage and functional outcomes at discharge. Methods Data of 119 patients who underwent DSA examination due to SAH were retrospectively analyzed. The following hemodynamic parameters of the four region of interests (ROIs) [an ophthalmic segment of the internal carotid artery (ICA), frontal and parietal lobe, and superior sagittal sinus] were analyzed: the time-to-peak (TTP), the area under the curve (AUC), the full width at half maximum (FWHM), mean transit time (MTT), and circulation time. Multifactor regression analysis was performed to explore the correlation between the hemodynamic parameters and functional outcomes in patients at discharge. Results Of 119 patients with SAH, good and poor outcomes were found in 83 (69.7%) and 36 (30.3%) patients, respectively. The hemodynamic parameters including the FWHM, relative TTP (rTTP), and circulation time were significantly correlated with the Hunt–Hess grade (p < 0.005, p = 0.03, and p < 0.005) and the World Federation of Neurological Societies Scale grade (p < 0.005, p = 0.02, and p = 0.01). The FWHM was significantly prolonged with the increase of modified Fisher grade (p = 0.02). The multifactor analysis showed that the FWHM [odds ratio (OR) 17.56, 95% CI: 1.13–272.03, p = 0.04] was an independent risk factor predicting the functional outcomes in patients at discharge. Conclusion The technique of color-coding blood flow analysis could be suitable for the qualified evaluation of disease conditions at an early stage of SAH as well as the prediction of outcomes.
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Affiliation(s)
- Lili Wen
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Longjiang Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaoyu Tang
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jiajia Ge
- Advanced Therapies, Siemens Healthineers Ltd., Shanghai, China
| | - Xiaoming Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
- *Correspondence: Xin Zhang
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Naraoka M, Matsuda N, Shimamura N, Ohkuma H. Role of microcirculatory impairment in delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2022; 42:186-196. [PMID: 34496662 PMCID: PMC8721782 DOI: 10.1177/0271678x211045446] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Early brain injury (EBI) is considered an important cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). As a factor in EBI, microcirculatory dysfunction has become a focus of interest, but whether microcirculatory dysfunction is more important than angiographic vasospasm (aVS) remains unclear. Using data from 128 cases, we measured the time to peak (TTP) in several regions of interest on digital subtraction angiography. The intracerebral circulation time (iCCT) was obtained between the TTP in the ultra-early phase (the baseline iCCT) and in the subacute phase and/or at delayed cerebral ischemia (DCI) onset (the follow-up iCCT). In addition, the difference in the iCCT was calculated by subtracting the baseline iCCT from the follow-up iCCT. Univariate analysis showed that DCI was significantly increased in those patients with a prolonged baseline iCCT, prolonged follow-up iCCT, increased differences in the iCCT, and with severe aVS. Poor outcome was significantly increased in patients with prolonged follow-up iCCT and increased differences in the iCCT. Multivariate analysis revealed that increased differences in the iCCT were a significant risk factor that increased DCI and poor outcome. The results suggest that the increasing microcirculatory dysfunction over time, not aVS, causes DCI and poor outcome after aneurysmal aSAH.
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Affiliation(s)
- Masato Naraoka
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Naoya Matsuda
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Norihito Shimamura
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
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8
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Labak CM, Shammassian BH, Zhou X, Alkhachroum A. Multimodality Monitoring for Delayed Cerebral Ischemia in Subarachnoid Hemorrhage: A Mini Review. Front Neurol 2022; 13:869107. [PMID: 35493831 PMCID: PMC9043346 DOI: 10.3389/fneur.2022.869107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/14/2022] [Indexed: 12/13/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage is a disease with high mortality and morbidity due in large part to delayed effects of the hemorrhage, including vasospasm, and delayed cerebral ischemia. These two are now recognized as overlapping yet distinct entities, and supportive therapies for delayed cerebral ischemia are predicated on identifying DCI as quickly as possible. The purpose of this overview is to highlight diagnostic tools that are being used in the identification of DCI in the neurocritical care settings.
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Affiliation(s)
- Collin M. Labak
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Department of Neurosurgery, University Hospitals Cleveland Medicine Center, Cleveland, OH, United States
| | - Berje Haroutuon Shammassian
- Department of Neurology, Division of Neurocritical Care, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
| | - Xiaofei Zhou
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Department of Neurosurgery, University Hospitals Cleveland Medicine Center, Cleveland, OH, United States
| | - Ayham Alkhachroum
- Department of Neurology, Division of Neurocritical Care, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
- *Correspondence: Ayham Alkhachroum
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9
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Malinova V, Döring K, Psychogios MN, Rohde V, Mielke D. Impact of Implementing an Elaborated CT Perfusion Protocol for Aneurysmal SAH on Functional Outcome: CTP Protocol for SAH. AJNR Am J Neuroradiol 2021; 42:1956-1961. [PMID: 34556476 PMCID: PMC8583263 DOI: 10.3174/ajnr.a7279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/03/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE The acute phase of aneurysmal SAH is characterized by a plethora of impending complications with the potential to worsen patients' outcomes. The aim of this study was to evaluate whether an elaborated CTP-based imaging protocol during the acute aneurysmal SAH phase is able to prevent delayed infarctions and contribute to a better outcome. MATERIALS AND METHODS In 2012, an elaborated CTP-based protocol was implemented for the management of patients with aneurysmal SAH. Retrospective analysis of patients with aneurysmal SAH treated from 2010 to 2013 was performed, comparing the patients treated before (group one, 2010-2011) with those treated after the protocol implementation (group two, 2012-2013) with regard to delayed infarctions and outcome according to the mRS at 3-months' follow-up. RESULTS A total of 133 patients were enrolled, of whom 57 were included in group 1, and 76, in group 2. There were no significant differences between the groups concerning baseline characteristics. In the multivariate analysis, independent predictors of a good outcome (mRS ≤ 2) were younger age (P < .001), lower World Federation of Neurosurgical Societies grade (P < .001), absence of delayed infarction (P = .01), and management according to the CTP protocol (P = .01). Larger or multiple infarctions occurred significantly more often in group 1 compared with group 2 (88% versus 33% of all delayed infarctions, P = .03). The outcome in group 2 was significantly better compared with group 1 (P = .005). CONCLUSIONS The findings suggest that implementation of an elaborated CTP protocol is associated with a better outcome. An earlier initiation of further diagnostics and treatment with prevention of large territorial and/or multiple infarctions might have led to this finding.
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Affiliation(s)
- V. Malinova
- From the Departments of Neurosurgery (V.M., V.R., D.M.)
| | - K. Döring
- Neuroradiology (K.D., M.-N.P.), Georg-August-University, Göttingen, Germany
| | - M.-N. Psychogios
- Neuroradiology (K.D., M.-N.P.), Georg-August-University, Göttingen, Germany,Department of Neuroradiology (M.-N.P.), Clinic of Radiology and Nuclear Medicine, University Medicine Basel, Basel, Switzerland
| | - V. Rohde
- From the Departments of Neurosurgery (V.M., V.R., D.M.)
| | - D. Mielke
- From the Departments of Neurosurgery (V.M., V.R., D.M.)
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10
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Döring K, Mielke D, Moerer O, Stamm G, Karsch S, Psychogios MN, Rohde V, Malinova V. Radiation Exposure in the Acute Phase after Aneurysmal Subarachnoid Hemorrhage in the Era of CT Perfusion. Clin Neuroradiol 2021; 32:123-132. [PMID: 34505910 DOI: 10.1007/s00062-021-01087-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/06/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with a high risk of developing multiple complications requiring further diagnostics including imaging associated with radiation exposure (RE). Since aSAH often affects younger patients, the obtained cumulative RE may have serious long-term health consequences. The aim of this study was to calculate the cumulative RE in the acute phase after aSAH and to identify contributors to RE. Additionally, we investigated whether there is a correlation of RE with outcome. METHODS A retrospective analysis of patients with aSAH treated at our department from 2012 to 2018 was performed. The radiation dose of every single cranial radiological examination was calculated for every patient. The outcome was assessed according to the modified Rankin scale (mRS) 3 months after ictus. Factors associated with high RE were evaluated and the correlation of RE with outcome was assessed. RESULTS In 268 included consecutive patients, the mean cumulative RE per patient was 39.95 mSv, ranging from 2 to 265.5 mSv. A higher RE correlated with delayed cerebral ischemia (r = 0.52, p < 0.0001), delayed infarction (r = 0.25, p < 0.0001), delayed ischemic neurological deficits (r = 0.29, p < 0.0001) and transcranial Doppler (TCD)-vasospasm (r = 0.34, p < 0.0001). Independent predictors of outcome were age (p = 0.0001), World Federation of Neurosurgical Societies (WFNS) grade (p < 0.0001) and delayed infarction (p = 0.0004), while RE did not correlate with outcome. CONCLUSION There is a considerable imaging-related RE in aSAH patients. A meticulous decision-making process and imaging protocols with lower RE for the deployment of CT-based and fluoroscopy-based imaging is indicated in order to minimize the risk for radiation-mediated heath consequences in this patient population.
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Affiliation(s)
- Katja Döring
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Georg Stamm
- Department of Diagnostic Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Susanne Karsch
- Department of Diagnostic Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Neuroradiology, Clinic of radiology and nuclear medicine, University Basel, Basel, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
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11
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Abdel-Tawab M, Hasan AA, Ahmed MA, Seif HMA, Yousif HA. Prognostic factors of delayed cerebral ischemia after subarachnoid hemorrhage including CT perfusion: a prospective cohort study. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00180-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Abstract
Background
Delayed cerebral ischemia (DCI) is the worst sequel following subarachnoid hemorrhage (SAH), representing a challenge in prediction and prevention. The current study aims to identify the optimum predictors of DCI including CT perfusion (CTP) and to determine the best prognostic thresholds.
This prospective study included 49 SAH patients. All patients were treated with the standard therapy and underwent non-contrast CT, CTP, and CTA within 3 days after SAH. Hunt and Hess and Fisher scales were assessed besides quantitative CTP parameters. The primary endpoint was DCI within 21 days after SAH, defined as clinical deterioration or infarction.
Results
Out of 49 eligible patients with SAH, 9 patients developed DCI. Univariate analysis revealed that Hunt and Hess scale, Fisher scale, the presence of a cerebral aneurysm, and mean transit time (MTT) were predictive for DCI. Diagnostic threshold values by ROC curve analysis with optimal sensitivity and specificity were Hunt and Hess scale > 2, Fisher scale > 2, and MTT of 4.65 s.
Conclusion
MTT is a sensitive and specific predictor of DCI. However, Hunt and Hess scale has the optimal sensitivity and specificity to distinguish between patients who developed DCI and clinically stable patients.
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12
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Chen S, Xu P, Fang Y, Lenahan C. The Updated Role of the Blood Brain Barrier in Subarachnoid Hemorrhage: From Basic and Clinical Studies. Curr Neuropharmacol 2020; 18:1266-1278. [PMID: 32928088 PMCID: PMC7770644 DOI: 10.2174/1570159x18666200914161231] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke associated with high mortality and morbidity. The blood-brain-barrier (BBB) is a structure consisting primarily of cerebral microvascular endothelial cells, end feet of astrocytes, extracellular matrix, and pericytes. Post-SAH pathophysiology included early brain injury and delayed cerebral ischemia. BBB disruption was a critical mechanism of early brain injury and was associated with other pathophysiological events. These pathophysiological events may propel the development of secondary brain injury, known as delayed cerebral ischemia. Imaging advancements to measure BBB after SAH primarily focused on exploring innovative methods to predict clinical outcome, delayed cerebral ischemia, and delayed infarction related to delayed cerebral ischemia in acute periods. These predictions are based on detecting abnormal changes in BBB permeability. The parameters of BBB permeability are described by changes in computed tomography (CT) perfusion and magnetic resonance imaging (MRI). Kep seems to be a stable and sensitive indicator in CT perfusion, whereas Ktrans is a reliable parameter for dynamic contrast-enhanced MRI. Future prediction models that utilize both the volume of BBB disruption and stable parameters of BBB may be a promising direction to develop practical clinical tools. These tools could provide greater accuracy in predicting clinical outcome and risk of deterioration. Therapeutic interventional exploration targeting BBB disruption is also promising, considering the extended duration of post-SAH BBB disruption.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - PengLei Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - YuanJian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA,Center for Neuroscience Research, School of Medicine, Loma Linda University, Loma Linda, CA, USA
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13
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Imaging Predictors of Vasospasm and Delayed Cerebral Ischaemia After Subarachnoid Haemorrhage. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00653-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Four-dimensional computed tomography angiography analysis of internal carotid arteries opacification at the skull base to detect delayed cerebral ischemia: a feasibility study. Int J Comput Assist Radiol Surg 2020; 15:2005-2015. [PMID: 33026600 DOI: 10.1007/s11548-020-02268-y] [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: 04/29/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Delayed cerebral ischemia represents a significant cause of poor functional outcome for patients with vasospasm after subarachnoid hemorrhage. We investigated whether delayed cerebral ischemia could be detected by the arterial opacification of internal carotid artery at the level of the skull base. METHODS In this exploratory, nested retrospective cohort diagnostic accuracy study, patients with clinical and/or transcranial Doppler suspicion of vasospasm who underwent four-dimensional computed tomography angiography were included. They were split into two groups for the main endpoint analysis, according to the actually adopted morphological (cerebral infarction) and clinical criteria (neurologic deterioration) of delayed cerebral ischemia. Opacification with a temporal resolution of 0.15 s of both internal carotid arteries at the skull base level was obtained through a semi-automated segmentation method based on skeletonization, and analyzed by a wavelet transform (rbio2.2, level 1). The results obtained by k-means clustering were analyzed with regard to the state of delayed cerebral infarction. RESULTS Over ten patients included and analyzed, five patients presented a delayed cerebral ischemia, two of them in both side. The semi-automated processing and analysis clustered two different types of opacification curves. The obtaining of a nonlinear opacification pattern was associated (p < 0.001) with delayed cerebral ischemia. CONCLUSIONS The analysis of arterial opacification of internal carotid arteries at skull base by the proposed processing is feasible and leads to cluster two types of opacification that may help to early detect and prevent delayed cerebral ischemia, in particularly when examinations are artifacted by aneurysm treatment materials.
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Omoto K, Nakagawa I, Nishimura F, Yamada S, Motoyama Y, Nakase H. Computed tomography perfusion imaging after aneurysmal subarachnoid hemorrhage can detect cerebral vasospasm and predict delayed cerebral ischemia after endovascular treatment. Surg Neurol Int 2020; 11:233. [PMID: 32874736 PMCID: PMC7451166 DOI: 10.25259/sni_14_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
Background Endovascular treatment (ET) can improve angiographic cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage, but was unrelated to clinical outcomes in previous analyses. Appropriate detection of CV and precise indications for ET are required. This study investigated whether changes in computed tomography perfusion (CTP) parameter can determine indications for ET in CV and predict its effectiveness. Methods Participants comprised 140 patients who underwent neck clipping or coil embolization. CTP was performed a week after aneurysmal treatment or when clinical deterioration had occurred. Patients were divided into ET and non-ET groups by propensity score matching. In addition, the ET group was divided into subgroups with and without new cerebral infarction (CI). All CTP images in the three groups were retrospectively investigated qualitatively and quantitatively. CI was diagnosed from CT at 3 months postoperatively. Results Of the 121 patients examined, 15 patients (11%) needed ET. In qualitative analysis, all ET group patients displayed extension of time-to-peak (TTP) at the region of vasospastic change, regardless of the presence of CI. Quantitative analysis showed significant decreases in cerebral blood volume (P < 0.01), cerebral blood flow (CBF) (P < 0.001), and extension in TTP (P < 0.01) in the ET group compared with the non-ET group. A significant decrease in CBF (P < 0.001) and extension in mean transit time (P < 0.001) was seen in the ET with CI subgroup compared with the ET without CI subgroup. Conclusion CTP in the vasospastic period may be an indication for ET and predict the effectiveness of ET for CV to improve clinical outcomes.
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Affiliation(s)
- Koji Omoto
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
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16
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Malinova V, Iliev B, Tsogkas I, Rohde V, Psychogios MN, Mielke D. Assessment of tissue permeability by early CT perfusion as a surrogate parameter for early brain injury after subarachnoid hemorrhage. J Neurosurg 2020; 133:808-813. [PMID: 31443075 DOI: 10.3171/2019.5.jns19765] [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: 03/17/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The severity of early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH) correlates with delayed cerebral ischemia (DCI) and outcome. A disruption of the blood-brain barrier is part of EBI pathophysiology. The aim of this study was to assess tissue permeability (PMB) by CT perfusion (CTP) in the acute phase after aSAH and its impact on DCI and outcome. METHODS CTP was performed on day 3 after aSAH. Qualitative and quantitative analyses of all CTP parameters, including PMB, were performed. The areas with increased PMB were documented. The value of an early PMB increase as a predictor of DCI and outcome according to the modified Rankin Scale (mRS) grade 3 to 24 months after aSAH was assessed. Possible associations of increased PMB with the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) and with early perfusion deficits, as radiographic EBI markers, were evaluated. RESULTS A total of 69 patients were enrolled in the study. An increased PMB on early CTP was detected in 10.1% (7/69) of all patients. A favorable outcome (mRS grade ≤ 2) occurred in 40.6% (28/69) of all patients. DCI was detected in 25% (17/69) of all patients. An increased PMB was a predictor of DCI (logistic regression, p = 0.03) but not of outcome (logistic regression, p = 0.40). The detection of increased PMB predicted DCI with a sensitivity of 25%, a specificity of 94%, a positive predictive value of 57%, and a negative predictive value of 79% (chi-square test p = 0.03). Early perfusion deficits were seen in 68.1% (47/69) of the patients, a finding that correlated with DCI (p = 0.005) but not with the outcome. No correlation was found between the SEBES and increased PMB. CONCLUSIONS Changes in PMB can be detected by early CTP after aSAH, which correlates with DCI. Future studies are needed to evaluate the time course of PMB changes and their interaction with therapeutic measures.
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Affiliation(s)
| | | | - Ioannis Tsogkas
- 2Neuroradiology, Georg-August-University, Göttingen, Germany; and
| | | | - Marios-Nikos Psychogios
- 2Neuroradiology, Georg-August-University, Göttingen, Germany; and
- 3Department of Neuroradiology, University Hospital Basel, Switzerland
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17
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Shi D, Jin D, Cai W, Zhu Q, Dou X, Fan G, Shen J, Xu L. Serial low-dose quantitative CT perfusion for the evaluation of delayed cerebral ischaemia following aneurysmal subarachnoid haemorrhage. Clin Radiol 2020; 75:131-139. [DOI: 10.1016/j.crad.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
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18
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Fischer C, Goldberg J, Vulcu S, Wagner F, Schöni D, Söll N, Hänggi M, Schefold J, Fung C, Beck J, Raabe A, Z'Graggen WJ. Nimodipine-Induced Blood Pressure Changes Can Predict Delayed Cerebral Ischemia. Front Neurol 2019; 10:1161. [PMID: 31736865 PMCID: PMC6834786 DOI: 10.3389/fneur.2019.01161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/15/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Early diagnosis of delayed cerebral ischemia (DCI) in patients after aneurysmal subarachnoid hemorrhage (aSAH) still poses a leading problem in neurointensive care. The aim of this study was to analyze the effect of oral Nimodipine administration on systemic blood pressure in patients with evolving DCI compared to patients without DCI. Methods: Systolic (SBP), mean (MAP), and diastolic (DBP) blood pressures were analyzed at the time of Nimodipine administration and additionally 30, 60, and 120 min thereafter on days 1, 3, and 5 after aSAH. Additionally, the 24 h period preceding DCI and in patients without DCI day 10 after aSAH were analyzed. Statistical analysis was performed for SBP, MAP and DBP at time of Nimodipine administration and for the maximal drop in blood pressure after Nimodipine administration. Results: Thirty patients with aSAH were retrospectively analyzed with 17 patients developing DCI (“DCI”) and 13 patients who did not (“Non-DCI”). DCI patients showed a more pronounced rise in MAP and DBP over the examined time period as well as a higher decrease in SBP following Nimodipine administration. A fall of 18 mmHg in SBP after Nimodipine administration showed a sensitivity of 82.4% and specificity of 92.3% for occurrence of DCI. Conclusion: An increase of MAP and DBP after aSAH and a heightened sensitivity to Nimodipine administrations may serve as additional biomarkers for early detection of evolving DCI.
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Affiliation(s)
- Corinne Fischer
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sonja Vulcu
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Franca Wagner
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Schöni
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Hänggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jörg Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Neurosurgery, University Hospital Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Neurosurgery, University Hospital Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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19
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Saribekyan AS, Balitskaya NV, Rumyantsev YI, Tutova MS, Shnayder YG. [Significance of CT perfusion examination of cerebral blood flow for assessing the risk of brain ischemia in patients with intracranial arterial aneurysm ruptures]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 83:17-28. [PMID: 31339494 DOI: 10.17116/neiro20198303117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Prognosing the outcome of cerebral ischemia in the acute SAH phase still remains the topical issue for clinical practice because this largely affects the choice of an optimal timing of aneurysm clipping. The traditional criteria are often not effective enough to predict changes in cerebral ischemia, especially in patients in a compensated or subcompensated state who often develop delayed ischemia, which may lead to serious complications. The introduction of a CT perfusion technique for evaluating the volumetric cerebral blood flow stimulated the development of a new stage in investigation of cerebral ischemia in non-traumatic SAH. PURPOSE The study purpose was to evaluate the significance of cerebral blood flow indicators obtained by CT perfusion for prediction of delayed cerebral ischemia and postoperative ischemic complications to optimize treatment of patients with ruptures of intracranial arterial aneurysms. MATERIAL AND METHODS The study included 70 patients who underwent aneurysm clipping and 42 non-operated patients. The inclusion criteria were as follows: WFNS grade I-III condition, vasospasm according to transcranial Doppler sonography, and availability of CT scans, including CT perfusion data. The vasospasm severity and perfusion indicators _(rCBV and MTT) were evaluated. The severity of subarachnoid and ventricular hemorrhage was evaluated according to the A. Hijdra method. The final results were evaluated using a clinical-statistical method, including ROC analysis. RESULTS An analysis of the obtained data revealed that the risk of delayed cerebral ischemia and postoperative ischemia increases significantly if the baseline hemispheric CBF value is below a threshold of 40 ml/100 g/min, and the baseline MMT indicator is above a threshold of 5 s. There was asymmetry of these CT perfusion indicators due to a larger deviation from the threshold values in the homolateral hemisphere compared to the opposite side. The ROC analysis results demonstrated diagnostic sensitivity and diagnostic specificity of the CT perfusion technique. CONCLUSION The CT perfusion data together with the SAH severity and localization indicators may be used as predictors for the cerebral ischemia outcome in choosing the optimal timing of aneurysm clipping during the acute SAH period in patients in a WFNS grade I-III condition and with signs of mild or moderate vasospasm.
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Affiliation(s)
| | | | | | - M S Tutova
- Filatov City clinical Hospital #15, Moscow, Russia
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20
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Dong L, Zhou Y, Wang M, Yang C, Yuan Q, Fang X. Whole-brain CT perfusion on admission predicts delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. Eur J Radiol 2019; 116:165-173. [DOI: 10.1016/j.ejrad.2019.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/20/2019] [Accepted: 05/07/2019] [Indexed: 11/28/2022]
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21
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Fragata I, Alves M, Papoila AL, Nunes AP, Ferreira P, Diogo M, Canto-Moreira N, Canhão P. Computed tomography perfusion as a predictor of delayed cerebral ischemia and functional outcome in spontaneous subarachnoid hemorrhage: A single center experience. Neuroradiol J 2019; 32:179-188. [PMID: 30777482 DOI: 10.1177/1971400919829048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Computed tomography (CT) perfusion has been studied as a tool to predict delayed cerebral ischemia (DCI) and clinical outcome in spontaneous subarachnoid hemorrhage (SAH). The purpose of the study was to determine whether quantitative CT perfusion performed within 72 hours after admission can predict the occurrence of DCI and clinical outcome as measured with a modified Rankin scale (mRS) at 3 months after ictus. METHODS Cerebral perfusion was assessed in a prospective cohort of patients with acute SAH. CT perfusion parameters at <72 h post SAH were quantitatively measured in the main vascular territories and represented as whole-brain means. Spearman rank correlation coefficient and generalized additive regression models for binary outcome were used. RESULTS A total of 66 patients underwent CT perfusion at <72 h. Poor clinical grade on admission was correlated with worse cerebral perfusion in all parameters. Multivariable analysis yielded an association of time to peak (TTP; odds ratio (OR) = 0.89; 95% confidence interval (CI): 0.77, 1.02; p = 0.083) with the occurrence of DCI. We also found an association of TTP values with poor outcome, with an 8% increase in the odds of mRS > 3 for each one second increase in TTP at admission (OR = 1.08; 95% CI: 1.00, 1.17; p = 0.061). CONCLUSIONS We identified an association of early TTP changes with DCI and poor clinical outcome. However, there were no associations with cerebral blood flow or mean transit time and DCI/clinical outcome. CT perfusion still remains to be validated as a tool in predicting outcome in SAH.
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Affiliation(s)
- Isabel Fragata
- 1 Department of Neuroradiology, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Marta Alves
- 2 Centro de Investigação, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Ana Luísa Papoila
- 3 Biostatistics Department, Faculdade Ciências Médicas, Nova University Lisbon, Lisbon, Portugal
| | - Ana Paiva Nunes
- 4 Unidade Cérebro-Vascular, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Patrícia Ferreira
- 4 Unidade Cérebro-Vascular, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Mariana Diogo
- 1 Department of Neuroradiology, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Nuno Canto-Moreira
- 5 Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patrícia Canhão
- 1 Department of Neuroradiology, Centro Hospitalar Lisboa Central, Lisbon, Portugal.,6 Instituto Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
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Malinova V, Tsogkas I, Behme D, Rohde V, Psychogios MN, Mielke D. Defining cutoff values for early prediction of delayed cerebral ischemia after subarachnoid hemorrhage by CT perfusion. Neurosurg Rev 2019; 43:581-587. [DOI: 10.1007/s10143-019-01082-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/13/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
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Fragata I, Canhão P. Imaging predictors of outcome in acute spontaneous subarachnoid hemorrhage: a review of the literature. Acta Radiol 2019; 60:247-259. [PMID: 29792042 DOI: 10.1177/0284185118778877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Spontaneous subarachnoid hemorrhage (SAH) accounts for about 5% of strokes, but has a very high morbidity and mortality. Many survivors are left with important cognitive impairment and are severely incapacitated. Prediction of complications such as vasospasm and delayed cerebral ischemia, and of clinical outcome after SAH, is challenging. Imaging studies are essential in the initial evaluation of SAH patients and are increasingly relevant in assessing for complications and prognosis. In this article, we reviewed the role of imaging studies in evaluating early brain injury and predicting complications as well as clinical and neuropsychological prognosis after acute SAH.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Hospital São José, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Patrícia Canhão
- Department of Neurosciences and Mental Health, Department of Neurology, Hospital de Santa Maria, CHLN, Lisbon, Portugal
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24
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You C, Sun H, Ma J, Liu Y. CT Perfusion for Identification of Patients at Risk for Delayed Cerebral Ischemia during the Acute Phase after Aneurysmal Subarachnoid Hemorrhage: A Meta-analysis. Neurol India 2019; 67:1235-1239. [DOI: 10.4103/0028-3886.271235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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25
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Blood-Brain Barrier Permeability in Aneurysmal Subarachnoid Hemorrhage: Correlation With Clinical Outcomes. AJR Am J Roentgenol 2018; 211:891-895. [DOI: 10.2214/ajr.17.18237] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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26
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Murphy A, de Oliveira Manoel AL, Macdonald RL, Baker A, Lee TY, Marotta T, Montanera W, Aviv R, Bharatha A. Changes in Cerebral Perfusion with Induced Hypertension in Aneurysmal Subarachnoid Hemorrhage: A Pilot and Feasibility Study. Neurocrit Care 2018; 27:3-10. [PMID: 28244000 DOI: 10.1007/s12028-017-0379-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The effects of induced hypertension (IH) on cerebral perfusion after subarachnoid hemorrhage (SAH) are unclear. The objectives of this investigation are to: (1) determine whether there are differences in cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) measured with computed tomography perfusion (CTP) before and after IH; (2) evaluate differences in the presence of infarction and clinical outcome between patients with and without IH. METHODS We performed a retrospective cohort analysis of 25 aneurysmal SAH patients. IH was initiated as per the standard institutional protocol when patients showed clinical symptoms of delayed cerebral ischemia (DCI). Differences in CBF, CBV, and MTT between early (<72 h after aneurysm rupture) and late (7-10 days after aneurysm rupture) CTP were quantified in patients with (n = 13) and without IH (n = 12). Outcome measures included cerebral infarction and clinical outcome at 3 months. RESULTS Early MTT was significantly greater in the IH group compared to the no-IH group. There was no difference in early or late CBV or CBF between the two groups. In patients that received IH, there was a significant decrease in MTT between the early (7.0 ± 1.2 s) and late scans (5.8 ± 1.6 s; p = 0.005). There was no difference in the incidence of infarction (5/13 vs. 2/11) or poor outcome (3/11 vs. 6/13) between the IH and no-IH groups, respectively (p > 0.05). CONCLUSIONS Elevated MTT is a significant factor for the development of DCI in patients eventually requiring IH therapy and is improved by IH treatment. Therapies to prevent DCI and improve clinical outcome may need to be initiated earlier, when cerebral perfusion abnormalities are first identified.
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Affiliation(s)
- Amanda Murphy
- Department of Medical Imaging, University of Toronto, 30 Bond Street, Room 3-077CC, Toronto, ON, M5B 1W8, Canada.
| | | | - R Loch Macdonald
- Department of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew Baker
- Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Tom Marotta
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
| | - Walter Montanera
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
| | - Richard Aviv
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Aditya Bharatha
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
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27
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Fragata I, Canto-Moreira N, Canhão P. Comparison of cerebral perfusion in perimesencephalic subarachnoid hemorrhage and aneurysmal subarachnoid hemorrhage. Neuroradiology 2018. [PMID: 29523945 DOI: 10.1007/s00234-018-1997-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Perimesencephalic hemorrhage (PMH) is a benign subtype of nonaneurysmal subarachnoid hemorrhage (SAH). We aimed to investigate if cerebral perfusion in PMH is less affected than in aneurysmal SAH (aSAH). METHODS From a prospective cohort of 80 patients with spontaneous SAH, we included PMH patients (n = 15) and selected aSAH patients (n = 39) with similar clinical grade at admission (World Federation of Neurosurgeons Scale-WFNS I/II). Computed tomography (CT) perfusion was performed at < 72 h and/or at 8-10 days. Cerebral perfusion parameter values were compared between groups with nonparametric tests. Subgroup analyses compared PMH and aSAH patients stratified according to aneurysmal location (anterior or posterior circulation) and blood burden (Fisher grade). RESULTS At < 72 h, no significant differences in perfusion parameters were found between PMH and aSAH patients. At 8-10 days, PMH patients had lower MTT than aSAH patients, and a trend for higher CBF. PMH patients had higher CBF and CBV at < 72 h when compared to posterior circulation aSAH patients. When compared to aSAH patients with similar blood burden, PMH patients had higher CBF and lower MTT at < 72 h, and lower MTT at 8-10 days. CONCLUSION PMH patients had better cerebral perfusion compared to patients with aSAH, particularly during the vasospasm time window. After stratifying for the amount of blood, PMH patients also had better cerebral perfusion in the first 72 h after SAH. These results are in line with the better clinical presentation and prognosis of PMH, and possibly with a different etiology.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Hospital São José, Centro Hospitalar Lisboa Central, NOVA Medical School, Lisbon, Portugal.
| | - Nuno Canto-Moreira
- Department of Neuroradiology, Department of Pediatric Radiology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Patrícia Canhão
- Department of Neurosciences and Mental Health, Neurology, Faculty of Medicine, Hospital de Santa Maria, CHLN, University of Lisbon, Lisbon, Portugal
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Foreman B, Albers D, Schmidt JM, Falo CM, Velasquez A, Connolly ES, Claassen J. Intracortical electrophysiological correlates of blood flow after severe SAH: A multimodality monitoring study. J Cereb Blood Flow Metab 2018; 38:506-517. [PMID: 28387139 PMCID: PMC5851141 DOI: 10.1177/0271678x17700433] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a devastating form of stroke. Approximately one in four patients develop progressive neurological deterioration and silent infarction referred to as delayed cerebral ischemia (DCI). DCI is a complex, multifactorial secondary brain injury pattern and its pathogenesis is not fully understood. We aimed to study the relationship between cerebral blood flow (CBF) and neuronal activity at both the cortex and in scalp using electroencephalography (EEG) in poor-grade SAH patients undergoing multimodality intracranial neuromonitoring. Twenty patients were included, of whom half had DCI median 4.7 days (interquartile range (IQR): 4.0-5.6) from SAH bleed. The rate of decline in regional cerebral blood flow (rCBF) was significant in both those with and without DCI and occurred between days 4 and 7 post-SAH. The scalp EEG alpha-delta ratio declined early in those with DCI. In the group without DCI, CBF and cortical EEG alpha-delta ratio were correlated (r = 0.53; p < 0.01) and in the group without DCI, inverse neurovascular coupling was observed at CPP < 80 mmHg. We found preliminary evidence that as patients enter the period of highest risk for the development of DCI, the absence of neurovascular coupling may act as a possible pathomechanism in the development of ischemia following SAH.
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Affiliation(s)
- Brandon Foreman
- 1 Department of Neurology, Columbia University, New York, USA.,2 Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, USA
| | - David Albers
- 3 Department of Biomedical Informatics, Columbia University, New York, USA
| | | | | | | | | | - Jan Claassen
- 1 Department of Neurology, Columbia University, New York, USA.,4 Department of Neurosurgery, Columbia University, New York, USA
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Afat S, Brockmann C, Nikoubashman O, Müller M, Thierfelder KM, Kunz WG, Haberland U, Brockmann MA, Nikolaou K, Wiesmann M, Othman AE. Diagnostic performance of different perfusion algorithms for the detection of angiographical spasm. J Neuroradiol 2018; 45:290-294. [PMID: 29412162 DOI: 10.1016/j.neurad.2017.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 06/16/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess the diagnostic utility of different perfusion algorithms for the detection of angiographical terial spasm. METHOD During a 2-year period, 45 datasets from 29 patients (54.2±10,75y, 20F) with suspected cerebral vasospasm after aneurysmal subarachnoid hemorrhage were included. Volume Perfusion CT (VPCT), Non-enhanced CT (NCT) and angiography were performed within 6hours post-ictus. Perfusion maps were generated using a maximum slope (MS) and a deconvolution-based approach (DC). Two blinded neuroradiologists independently evaluated MS and DC maps regarding vasospasm-related perfusion impairment on a 3-point Likert-scale (0=no impairment, 1=impairment affecting <50%, 2=impairment affecting >50% of vascular territory). A third independent neuroradiologist assessed angiography for presence and severity of arterial narrowing on a 3-point Likert scale (0=no narrowing, 1=narrowing affecting <50%, 2=narrowing affecting>50% of artery diameter). MS and DC perfusion maps were evaluated regarding diagnostic accuracy for angiographical arterial spasm with angiography as reference standard. Correlation analysis of angiography findings with both MS and DC perfusion maps was additionally performed. Furthermor, the agreement between MS and DC and inter-reader agreement was assessed. RESULTS DC maps yielded significantly higher diagnostic accuracy than MS perfusion maps (DC:AUC=.870; MS:AUC=.805; P=0.007) with higher sensitivity for DC compared to MS (DC:sensitivity=.758; MS:sensitivity=.625). DC maps revealed stronger correlation with angiography than MS (DC: R=.788; MS: R=694;=<0.001). MS and DC showed substantial agreement (Kappa=.626). Regarding inter-reader analysis, (almost) perfect inter-reader agreement was observed for both MS and DC maps (Kappa≥981). CONCLUSION DC yields significantly higher diagnostic accuracy for the detection of angiographic arterial spasm and higher correlation with angiographic findings compared to MS.
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Affiliation(s)
- Saif Afat
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Hospital Mainz, 55131 Mainz, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany; Department of Diagnostic and Interventional Radiology, RWTH Aachen University, 52074 Aachen, Germany
| | - Marguerite Müller
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany
| | - Kolja M Thierfelder
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Wolfgang G Kunz
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistr. 15, 81377 Munich, Germany
| | | | - Marc A Brockmann
- Department of Neuroradiology, University Hospital Mainz, 55131 Mainz, Germany
| | - Konstantin Nikolaou
- Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, 72076 Tübingen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany
| | - Ahmed E Othman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany; Siemens Healthcare GmbH, 91052 Forchheim, Germany.
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Takahashi Y, Sasahara A, Yamazaki K, Inazuka M, Kasuya H. Disturbance of CT perfusion within 24 h after onset is associated with WFNS grade but not development of DCI in patients with aneurysmal SAH. Acta Neurochir (Wien) 2017; 159:2319-2324. [PMID: 29058091 DOI: 10.1007/s00701-017-3362-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/10/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is a serious complication following aneurysmal SAH (aSAH) and remains a leading cause of morbidity and mortality. We investigated whether data from CT perfusion (CTP) within 24 h after onset are associated with DCI and its outcome. METHODS We retrospectively examined plain CT, CTP, and CT angiography (CTA) of aSAH patients on arrival. We measured the average mean transit time (aMTT) and compared it with several clinical factors, such as the age, WFNS grade, Fisher group, delayed cerebral infarction, cerebral vasospasm, and modified Rankin scale (mRS), at 1 month. Regions of interest (ROIs) were quantitatively determined in cortical and two basal ganglia areas. RESULTS Delayed cerebral ischemia (DCI) developed in 11 patients and cerebral vasospasm in 28 patients out of a total of 86 aSAH patients scanned within 24 h after onset. The average MTT was correlated with the WFNS grade (p = 0.000), but not mRS (p = 0.128), age (p = 0.759), DCI (p = 0.669), or cerebral vasospasm (p = 0.306). On the other hand, DCI was associated with the Fisher group (p = 0.0056), mRS (p = 0.0052), and cerebral vasospasm (p = 0.000). Moreover, there were no significant differences in the average MTT within 24 h after onset between territories with and without DCI, or between patients with and without DCI. CONCLUSIONS The current findings suggest that disturbance of CT perfusion soon after the onset is associated with the WFNS grade but not with the development of DCI. Delayed cerebral ischemia may be solely caused by cerebral vasospasm due to a clot in the cistern, but not associated with early brain injury.
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Affiliation(s)
- Yuichi Takahashi
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Atsushi Sasahara
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan.
| | - Kei Yamazaki
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Mayuko Inazuka
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
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Ivanidze J, Charalel RA, Shuryak I, Brenner D, Pandya A, Kallas ON, Kesavabhotla K, Segal AZ, Simon MS, Sanelli PC. Effects of Radiation Exposure on the Cost-Effectiveness of CT Angiography and Perfusion Imaging in Aneurysmal Subarachnoid Hemorrhage. AJNR Am J Neuroradiol 2017; 38:462-468. [PMID: 28082263 DOI: 10.3174/ajnr.a5034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/03/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE CT angiography and perfusion imaging is an important prognostic tool in the management of patients with aneurysmal subarachnoid hemorrhage. The purpose of this study was to perform a cost-effectiveness analysis of advanced imaging in patients with SAH, incorporating the risks of radiation exposure from CT angiography and CT perfusion imaging. MATERIALS AND METHODS The risks of radiation-induced brain cancer and cataracts were incorporated into our established decision model comparing the cost-effectiveness of CT angiography and CT perfusion imaging and transcranial Doppler sonography in SAH. Cancer risk was calculated by using National Cancer Institute methodology. The remaining input probabilities were based on literature data and a cohort at our institution. Outcomes were expected quality-adjusted life years gained, costs, and incremental cost-effectiveness ratios. One-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS CT angiography and CT perfusion imaging were the dominant strategies, resulting in both better health outcomes and lower costs, even when incorporating brain cancer and cataract risks. Our results remained robust in 2-way sensitivity analyses varying the prolonged latency period up to 30 years, with either brain cancer risk up to 50 times higher than the upper 95% CI limit or the probability of cataracts from 0 to 1. Results were consistent for scenarios that considered either symptomatic or asymptomatic patients with SAH. Probabilistic sensitivity analysis confirmed our findings over a broad range of selected input parameters. CONCLUSIONS While risks of radiation exposure represent an important consideration, CT angiography and CT perfusion imaging remained the preferred imaging compared with transcranial Doppler sonography in both asymptomatic and symptomatic patients with SAH, with improved health outcomes and lower health care costs, even when modeling a significantly higher risk and shorter latency period for both cataract and brain cancer than that currently known.
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Affiliation(s)
- J Ivanidze
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
| | - R A Charalel
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
| | - I Shuryak
- Department of Radiology (I.S., D.B.), NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - D Brenner
- Department of Radiology (I.S., D.B.), NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - A Pandya
- Department of Health Policy and Management (A.P.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - O N Kallas
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
| | - K Kesavabhotla
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
| | | | - M S Simon
- Internal Medicine and Public Health (M.S.S.), Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
- Department of Radiology (M.S.S., P.C.S.), Northwell Health, Manhasset, New York
| | - P C Sanelli
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
- Department of Radiology (M.S.S., P.C.S.), Northwell Health, Manhasset, New York
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Sun H, Li W, Ma J, Liu Y, You C. CT perfusion diagnoses delayed cerebral ischemia in the early stage of the time-window after aneurysmal subarachnoid hemorrhage. J Neuroradiol 2017; 44:313-318. [PMID: 28237366 DOI: 10.1016/j.neurad.2016.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/21/2016] [Accepted: 12/30/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE It has been acknowledged that delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) can be diagnosed by CT perfusion (CTP) in the DCI time-window. We evaluated the diagnostic accuracy of CTP for DCI during the early stage of the time-window. MATERIALS AND METHODS We prospectively enrolled patients with aneurysmal SAH. DCI was defined as both new cerebral infarction and clinical deterioration after SAH. CTP was performed by using a standardized protocol with predefined regions of interest in 4 to 6 days after SAH. We quantitatively evaluated the diagnostic accuracy of eight CTP parameters (4 for absolute parameters and 4 for relative parameters). The receiver operator characteristic (ROC) curves of all parameters were generated and the optimal threshold values were derived for the calculation of sensitivities and specificities. RESULTS Fifty-three patients were enrolled and 20 patients were diagnosed with DCI. In the analysis of absolute CTP parameters, CBF and MTT had areas under the curve (AUC) >0.75 and the optimal threshold value was 40.4mL/100g/min and 3.78seconds, respectively. Through the evaluation of relative CTP parameters, all 4 parameters had AUC >0.75 and the optimal threshold value was 0.9 for CBV ratio, 0.85 for CBF ratio, 0.32seconds for MTT difference and 1.31seconds for TTP difference. CONCLUSIONS Besides two absolute CTP parameters (CBV and TTP), all six CTP parameters can be used as good diagnostic tests for DCI in the early stage of the time-window.
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Affiliation(s)
- Haogeng Sun
- Department of Neurosurgery, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China
| | - Wanjiang Li
- Department of Radiology, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China
| | - Junpeng Ma
- Department of Neurosurgery, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China.
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China
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Abstract
Cerebral vasospasm is a potentially devastating complication in patients with aneurysmal subarachnoid hemorrhage. The purpose of this article is to review the use of computed tomogram (CT) angiography and CT perfusion in the diagnosis of cerebral vasospasm after aneurysmal subarachnoid hemorrhage and also assess their use in guiding treatment decisions. Both techniques are widely used for other indications but their use in cerebral vasospasm has not been well defined. Computed tomogram angiography can directly visualize arterial narrowing and CT perfusion is able to evaluate differences in perfusion parameters after aneurysmal subarachnoid hemorrhage with high sensitivity and specificity. CT perfusion is better at predicting which patients require endovascular treatment.
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Prognostic Assessment of Aneurysmal Subarachnoid Patients with WFNS Grade V by CT Perfusion on Arrival. World Neurosurg 2016; 92:1-6. [PMID: 27155385 DOI: 10.1016/j.wneu.2016.04.097] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/25/2016] [Accepted: 04/25/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) depends on their condition on arrival at the hospital. However, a small number of patients recover from an initially poor condition. We investigated the correlation between quantitative measures of computed tomography (CT) perfusion (CTP) on arrival and the outcomes of patients with World Federation of Neurosurgical Society (WFNS) grade V aSAH. METHODS We performed plain CT, CTP, and CT angiography (CTA) in all patients with aSAH on arrival. Aneurysms were surgically obliterated in patients with stable vital signs and the presence of a brain stem response. We measured the average mean transit time (aMTT) and compared it with the modified Rankin Scale (mRS) score at 1 month. Regions of interest were identified as 24 areas in the bilateral anterior, middle, and posterior cerebral artery territories and 2 areas in the basal ganglia. RESULTS A total of 57 patients were treated between 2007 and 2014. None of the 21 patients with aMTT >6.385 seconds achieved a favorable outcome, whereas 8 of the 36 patients with aMTT <6.385 seconds did achieve a favorable outcome (P = 0.015). Furthermore, comparing the number of areas showing a mean transit time (MTT) >7.0 seconds among the aforementioned 8 areas and mRS, favorable outcomes were not seen in 24 patients with more than 2 such areas (P = 0.009). CONCLUSION We cannot expect a favorable outcome for patients with WFNS grade V aSAH with aMTT >6.385 seconds or more than 2 of 8 areas with MTT >7.0 seconds.
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Ivanidze J, Kallas ON, Gupta A, Weidman E, Baradaran H, Mir D, Giambrone A, Segal AZ, Claassen J, Sanelli PC. Application of Blood-Brain Barrier Permeability Imaging in Global Cerebral Edema. AJNR Am J Neuroradiol 2016; 37:1599-603. [PMID: 27127002 DOI: 10.3174/ajnr.a4784] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 02/22/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Blood-brain barrier permeability is not routinely evaluated in the clinical setting. Global cerebral edema occurs after SAH and is associated with BBB disruption. Detection of global cerebral edema using current imaging techniques is challenging. Our purpose was to apply blood-brain barrier permeability imaging in patients with global cerebral edema by using extended CT perfusion. MATERIALS AND METHODS Patients with SAH underwent CTP in the early phase after aneurysmal rupture (days 0-3) and were classified as having global cerebral edema or nonglobal cerebral edema using established noncontrast CT criteria. CTP data were postprocessed into blood-brain barrier permeability quantitative maps of PS (permeability surface-area product), K(trans) (volume transfer constant from blood plasma to extravascular extracellular space), Kep (washout rate constant of the contrast agent from extravascular extracellular space to intravascular space), VE (extravascular extracellular space volume per unit of tissue volume), VP (plasmatic volume per unit of tissue volume), and F (plasma flow) by using Olea Sphere software. Mean values were compared using t tests. RESULTS Twenty-two patients were included in the analysis. Kep (1.32 versus 1.52, P < .0001), K(trans) (0.15 versus 0.19, P < .0001), VP (0.51 versus 0.57, P = .0007), and F (1176 versus 1329, P = .0001) were decreased in global cerebral edema compared with nonglobal cerebral edema while VE (0.81 versus 0.39, P < .0001) was increased. CONCLUSIONS Extended CTP was used to evaluate blood-brain barrier permeability in patients with SAH with and without global cerebral edema. Kep is an important indicator of altered blood-brain barrier permeability in patients with decreased blood flow, as Kep is flow-independent. Further study of blood-brain barrier permeability is needed to improve diagnosis and monitoring of global cerebral edema.
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Affiliation(s)
- J Ivanidze
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - O N Kallas
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - A Gupta
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - E Weidman
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - H Baradaran
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - D Mir
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - A Giambrone
- Healthcare Policy and Research (A.Giambrone)
| | - A Z Segal
- Neurology (A.Z.S.), Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - J Claassen
- Department of Neurology (J.C.), New York-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - P C Sanelli
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
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Cheng XQ, Chen Q, Zhou CS, Li JR, Zhang ZJ, Zhang LJ, Huang W, Lu GM. Whole-brain CT perfusion combined with CT angiography for ischemic complications following microsurgical clipping and endovascular coiling of ruptured intracranial aneurysms. J Clin Neurosci 2016; 26:50-6. [PMID: 26775148 DOI: 10.1016/j.jocn.2015.05.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/13/2015] [Accepted: 05/22/2015] [Indexed: 10/22/2022]
Abstract
Ischemic complications associated with microsurgical clipping and endovascular coiling affects the outcome of patients with intracranial aneurysms. We prospectively evaluated 58 intracranial aneurysm patients who had neurological deterioration or presented with poor grade (Hunt-Hess grades III and IV), aneurysm size >13 mm and multiple aneurysms after clipping or coiling. Thirty patients had ischemic complications (52%) as demonstrated by whole-brain CT perfusion (WB-CTP) combined with CT angiography (CTA). Half of these 30 patients had treatment-associated reduction in the diameter of the parent vessels (n=6), ligation of the parent vessels or perforating arteries (n=2), and unexplained or indistinguishable vascular injury (n=7); seven of these 15 (73%) patients suffered infarction. The remaining 15 patients had disease-associated cerebral ischemia caused by generalized vasospasm (n=6) and focal vessel vasospasm (n=9); six of these 15 (40%) patients developed infarction. Three hemodynamic patterns of ischemic complications were found on WB-CTP, of which increased time to peak, time to delay and mean transit time associated with decreased cerebral blood flow and cerebral blood volume were the main predictors of irreversible ischemic lesions. In conclusion, WB-CTP combined with CTA can accurately determine the cause of neurological deterioration and classify ischemic complications. This combined approach may be helpful in assessing hemodynamic patterns and monitoring operative outcomes.
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Affiliation(s)
- Xiao Qing Cheng
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Qian Chen
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Chang Sheng Zhou
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Jian Rui Li
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Zong Jun Zhang
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Wei Huang
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China.
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Malinova V, Dolatowski K, Schramm P, Moerer O, Rohde V, Mielke D. Early whole-brain CT perfusion for detection of patients at risk for delayed cerebral ischemia after subarachnoid hemorrhage. J Neurosurg 2015; 125:128-36. [PMID: 26684786 DOI: 10.3171/2015.6.jns15720] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This prospective study investigated the role of whole-brain CT perfusion (CTP) studies in the identification of patients at risk for delayed ischemic neurological deficits (DIND) and of tissue at risk for delayed cerebral infarction (DCI). METHODS Forty-three patients with aneurysmal subarachnoid hemorrhage (aSAH) were included in this study. A CTP study was routinely performed in the early phase (Day 3). The CTP study was repeated in cases of transcranial Doppler sonography (TCD)-measured blood flow velocity (BFV) increase of > 50 cm/sec within 24 hours and/or on Day 7 in patients who were intubated/sedated. RESULTS Early CTP studies revealed perfusion deficits in 14 patients, of whom 10 patients (72%) developed DIND, and 6 of these 10 patients (60%) had DCI. Three of the 14 patients (21%) with early perfusion deficits developed DCI without having had DIND, and the remaining patient (7%) had neither DIND nor DCI. There was a statistically significant correlation between early perfusion deficits and occurrence of DIND and DCI (p < 0.0001). A repeated CTP was performed in 8 patients with a TCD-measured BFV increase > 50 cm/sec within 24 hours, revealing a perfusion deficit in 3 of them (38%). Two of the 3 patients (67%) developed DCI without preceding DIND and 1 patient (33%) had DIND without DCI. In 4 of the 7 patients (57%) who were sedated and/or comatose, additional CTP studies on Day 7 showed perfusion deficits. All 4 patients developed DCI. CONCLUSIONS Whole-brain CTP on Day 3 after aSAH allows early and reliable identification of patients at risk for DIND and tissue at risk for DCI. Additional CTP investigations, guided by TCD-measured BFV increase or persisting coma, do not contribute to information gain.
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Affiliation(s)
| | | | - Peter Schramm
- Neuroradiology, and.,Department of Neuroradiology, University of Lübeck, Germany
| | - Onnen Moerer
- Anaesthesiology, Georg-August-University, Göttingen; and
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Rodriguez-Régent C, Hafsa M, Turc G, Ben Hassen W, Edjlali M, Sermet A, Laquay N, Trystram D, Al-Shareef F, Meder JF, Devaux B, Oppenheim C, Naggara O. Early quantitative CT perfusion parameters variation for prediction of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. Eur Radiol 2015; 26:2956-63. [PMID: 26670321 DOI: 10.1007/s00330-015-4135-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 11/20/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To prospectively evaluate the predictive value of cerebral perfusion-computerized tomography (CTP) parameters variation between day0 and day4 after aneurysmal subarachnoid haemorrhage (aSAH). METHODS Mean transit time (MTT) and cerebral blood flow (CBF) values were compared between patients with delayed cerebral ischemia (DCI+ group) and patients without DCI (DCI- group) for previously published optimal cutoff values and for variations of MTT (ΔMTT) and of CBF (ΔCBF) values between day0 and day4. DCI+ was defined as a cerebral infarction on 3-months follow-up MRI. RESULTS Among 47 included patients, 10 suffered DCI+. Published optimal cutoff values did not predict DCI, either at day0 or at day4. Conversely, ΔMTT and ΔCBF significantly differed between the DCI+ and DCI- groups, with optimal ΔMTT and ΔCBF values of 0.91 seconds (83.9 % sensitivity, 79.5 % specificity, AUC 0.84) and -7.6 mL/100 g/min (100 % sensitivity, 71.4 % specificity, AUC 0.86), respectively. In multivariate analysis, ΔCBF (OR = 1.91, IC95% 1.13-3.23 per each 20 % decrease of ΔCBF) and ΔMTT values (OR = 14.70, IC95% 4.85-44.52 per each 20 % increase of ΔMTT) were independent predictors of DCI. CONCLUSIONS Assessment of MTT and CBF value variations between day0 and day4 may serve as an early imaging surrogate for prediction of DCI in aSAH. KEY POINTS • CT perfusion values are an imaging surrogate for prediction of DCI. • Early variations (day0-day4) after aneurysmal subarachnoid haemorrhage predicted DCI. • A CBF decrease of 7.6 mL/min/100 g predicted DCI with 100 % sensitivity. • An MTT increase of 0.91 seconds predicted DCI with 83.9 % sensitivity. • DCI risk multiplied by 2 per 20 % ΔCBF decrease and by 15 per 20 % ΔMTT increase.
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Affiliation(s)
- Christine Rodriguez-Régent
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France
| | - Monia Hafsa
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France
| | - Guillaume Turc
- Department of Neurology, Centre Hospitalier Sainte-Anne, Université Paris-Descartes, INSERM U894, Paris, France
| | - Wagih Ben Hassen
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France
| | - Myriam Edjlali
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France
| | - Alain Sermet
- Department of Reanimation, Centre Hospitalier Sainte-Anne, Paris, France
| | - Nathalie Laquay
- Department of Reanimation, Centre Hospitalier Sainte-Anne, Paris, France
| | - Denis Trystram
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France
| | - Fawaz Al-Shareef
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France
| | - Jean-Francois Meder
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France
| | - Bertrand Devaux
- Department of Neurosurgery, Centre Hospitalier Sainte-Anne, Université Paris-Descartes, Paris, France
| | - Catherine Oppenheim
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France
| | - Olivier Naggara
- Departments of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, 1 rue Cabanis, 75014, Paris, France.
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Flynn L, Andrews P. Advances in the understanding of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage. F1000Res 2015; 4:F1000 Faculty Rev-1200. [PMID: 26937276 PMCID: PMC4752028 DOI: 10.12688/f1000research.6635.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2015] [Indexed: 12/23/2022] Open
Abstract
Delayed cerebral ischaemia has been described as the single most important cause of morbidity and mortality in patients who survive the initial aneurysmal subarachnoid haemorrhage. Our understanding of the pathophysiology of delayed cerebral ischaemia is meagre at best and the calcium channel blocker nimodipine remains the only intervention to consistently improve functional outcome after aneurysmal subarachnoid haemorrhage. There is substantial evidence to support cerebral vessel narrowing as a causative factor in delayed cerebral ischaemia, but contemporary research demonstrating improvements in vessel narrowing has failed to show improved functional outcomes. This has encouraged researchers to investigate other potential causes of delayed cerebral ischaemia, such as early brain injury, microthrombosis, and cortical spreading depolarisation. Adherence to a common definition of delayed cerebral ischaemia is needed in order to allow easier assessment of studies using multiple different terms. Furthermore, improved recognition of delayed cerebral ischaemia would not only allow for faster treatment but also better assessment of interventions. Finally, understanding nimodipine's mechanism of action may allow us to develop similar agents with improved efficacy.
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Affiliation(s)
- Liam Flynn
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Cremers CHP, Vos PC, van der Schaaf IC, Velthuis BK, Vergouwen MDI, Rinkel GJE, Dankbaar JW. CT perfusion during delayed cerebral ischemia after subarachnoid hemorrhage: distinction between reversible ischemia and ischemia progressing to infarction. Neuroradiology 2015; 57:897-902. [PMID: 26032925 PMCID: PMC4572064 DOI: 10.1007/s00234-015-1543-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 05/14/2015] [Indexed: 12/05/2022]
Abstract
Introduction Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) can be reversible or progress to cerebral infarction. In patients with a deterioration clinically diagnosed as DCI, we investigated whether CT perfusion (CTP) can distinguish between reversible ischemia and ischemia progressing to cerebral infarction. Methods From a prospectively collected series of aSAH patients, we included those with DCI, CTP on the day of clinical deterioration, and follow-up imaging. In qualitative CTP analyses (visual assessment), we calculated positive and negative predictive value (PPV and NPV) with 95 % confidence intervals (95%CI) of a perfusion deficit for infarction on follow-up imaging. In quantitative analyses, we compared perfusion values of the least perfused brain tissue between patients with and without infarction by using receiver-operator characteristic curves and calculated a threshold value with PPV and NPV for the perfusion parameter with the highest area under the curve. Results In qualitative analyses of 33 included patients, 15 of 17 patients (88 %) with and 6 of 16 patients (38 %) without infarction on follow-up imaging had a perfusion deficit during clinical deterioration (p = 0.002). Presence of a perfusion deficit had a PPV of 71 % (95%CI: 48–89 %) and NPV of 83 % (95%CI: 52–98 %) for infarction on follow-up. Quantitative analyses showed that an absolute minimal cerebral blood flow (CBF) threshold of 17.7 mL/100 g/min had a PPV of 63 % (95%CI: 41–81 %) and a NPV of 78 % (95%CI: 40–97 %) for infarction. Conclusions CTP may differ between patients with DCI who develop infarction and those who do not. For this purpose, qualitative evaluation may perform marginally better than quantitative evaluation.
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Affiliation(s)
- Charlotte H P Cremers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, Utrecht, The Netherlands. .,Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Pieter C Vos
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, Utrecht, The Netherlands
| | - Jan Willem Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Ivanidze J, Kesavabhotla K, Kallas ON, Mir D, Baradaran H, Gupta A, Segal AZ, Claassen J, Sanelli PC. Evaluating blood-brain barrier permeability in delayed cerebral infarction after aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2015; 36:850-4. [PMID: 25572949 DOI: 10.3174/ajnr.a4207] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/05/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patients with SAH are at increased risk of delayed infarction. Early detection and treatment of delayed infarction remain challenging. We assessed blood-brain barrier permeability, measured as permeability surface area product, by using CTP in patients with SAH with delayed infarction. MATERIALS AND METHODS We performed a retrospective study of patients with SAH with delayed infarction on follow-up NCCT. CTP was performed before the development of delayed infarction. CTP data were postprocessed into permeability surface area product, CBF, and MTT maps. Coregistration was performed to align the infarcted region on the follow-up NCCT with the corresponding location on the CTP maps obtained before infarction. Permeability surface area product, CBF, and MTT values were then obtained in the location of the subsequent infarction. The contralateral noninfarcted region was compared with the affected side in each patient. Wilcoxon signed rank tests were performed to determine statistical significance. Clinical data were collected at the time of CTP and at the time of follow-up NCCT. RESULTS Twenty-one patients with SAH were included in the study. There was a statistically significant increase in permeability surface area product in the regions of subsequent infarction compared with the contralateral control regions (P < .0001). However, CBF and MTT values were not significantly different in these 2 regions. Subsequent follow-up NCCT demonstrated new delayed infarction in all 21 patients, at which time 38% of patients had new focal neurologic deficits. CONCLUSIONS Our study reveals a statistically significant increase in permeability surface area product preceding delayed infarction in patients with SAH. Further investigation of early permeability changes in SAH may provide new insights into the prediction of delayed infarction.
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Affiliation(s)
- J Ivanidze
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - K Kesavabhotla
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - O N Kallas
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - D Mir
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - H Baradaran
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - A Gupta
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | | | - J Claassen
- Department of Neurology (J.C.), New York-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - P C Sanelli
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.) Public Health (P.C.S.), Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
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Early CT perfusion changes and blood-brain barrier permeability after aneurysmal subarachnoid hemorrhage. Neuroradiology 2015; 57:767-73. [PMID: 25868518 DOI: 10.1007/s00234-015-1529-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 04/01/2015] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Early brain injury (EBI) can occur within 72 h of aneurysmal subarachnoid hemorrhage (aSAH). The objective of this study was to determine if there are differences in early CTP parameters (<72 h) with respect to delayed cerebral ischemia (DCI), cerebral infarction, and functional outcome. METHODS We performed a prospective cohort study of aSAH patients admitted to a single tertiary care center. MTT, CBF and blood-brain barrier permeability (PS) were quantified with CTP within 72 h of aneurysm rupture. Primary outcomes were functional outcome by the Modified Rankin Scale (mRS) at 3 months and cerebral infarction. Secondary outcome was the development of DCI. Differences between early CTP parameters were determined with respect to primary and secondary outcomes. RESULTS Fifty aSAH patients were included in the final analysis. MTT was significantly higher in patients who developed DCI (6.7 ± 1.2 vs 5.9 ± 1.0; p = 0.03) and cerebral infarction (7.0 ± 1.2 vs 5.9 ± 0.9; p = 0.007); however, no difference in MTT was found between patients with and without a poor outcome (mRS > 2). Early CBF and PS did not differ with respect to functional outcome, DCI, and cerebral infarction. CONCLUSIONS Elevated MTT within 72 h of aneurysm rupture is associated with DCI and cerebral infarction but not with long-term functional outcome. Blood-brain barrier permeability, as assessed by CT perfusion, was not associated with DCI or worse outcome in this cohort.
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Different CT perfusion algorithms in the detection of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neuroradiology 2015; 57:469-74. [PMID: 25614332 PMCID: PMC4412839 DOI: 10.1007/s00234-015-1486-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 01/05/2015] [Indexed: 11/27/2022]
Abstract
Introduction Tracer delay-sensitive perfusion algorithms in CT perfusion (CTP) result in an overestimation of the extent of ischemia in thromboembolic stroke. In diagnosing delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH), delayed arrival of contrast due to vasospasm may also overestimate the extent of ischemia. We investigated the diagnostic accuracy of tracer delay-sensitive and tracer delay-insensitive algorithms for detecting DCI. Methods From a prospectively collected series of aSAH patients admitted between 2007–2011, we included patients with any clinical deterioration other than rebleeding within 21 days after SAH who underwent NCCT/CTP/CTA imaging. Causes of clinical deterioration were categorized into DCI and no DCI. CTP maps were calculated with tracer delay-sensitive and tracer delay-insensitive algorithms and were visually assessed for the presence of perfusion deficits by two independent observers with different levels of experience. The diagnostic value of both algorithms was calculated for both observers. Results Seventy-one patients were included. For the experienced observer, the positive predictive values (PPVs) were 0.67 for the delay-sensitive and 0.66 for the delay-insensitive algorithm, and the negative predictive values (NPVs) were 0.73 and 0.74. For the less experienced observer, PPVs were 0.60 for both algorithms, and NPVs were 0.66 for the delay-sensitive and 0.63 for the delay-insensitive algorithm. Conclusion Test characteristics are comparable for tracer delay-sensitive and tracer delay-insensitive algorithms for the visual assessment of CTP in diagnosing DCI. This indicates that both algorithms can be used for this purpose.
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Sanelli PC, Kishore S, Gupta A, Mangat H, Rosengart A, Kamel H, Segal A. Delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: proposal of an evidence-based combined clinical and imaging reference standard. AJNR Am J Neuroradiol 2014; 35:2209-14. [PMID: 24263697 DOI: 10.3174/ajnr.a3782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SUMMARY Aneurysmal subarachnoid hemorrhage is associated with high morbidity and mortality, with delayed neurologic deficits from delayed cerebral ischemia contributing to a large portion of the adverse outcomes in this patient population. There is currently no consensus reference standard for establishing the diagnosis of delayed cerebral ischemia either in the research or clinical settings, ultimately limiting strategies for preventing delayed infarction and permanent neurologic deficits. There are currently both clinical and imaging-based criteria for the diagnosis of delayed neurologic deficits and vasospasm, respectively, however, neither clinical nor angiographic assessment alone has been shown to identify patients who develop adverse outcomes from delayed infarction. Thus, the purpose of this work is to propose a 3-tiered combined imaging and clinical reference standard based on evidence from the literature to standardize the diagnosis of delayed cerebral ischemia, both to allow consistency across research studies and to ultimately improve outcomes in the clinical setting.
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Affiliation(s)
- P C Sanelli
- From the Departments of Radiology, Division of Neuroradiology (P.C.S., S.K., A.G.) Public Health (P.C.S.)
| | - S Kishore
- From the Departments of Radiology, Division of Neuroradiology (P.C.S., S.K., A.G.)
| | - A Gupta
- From the Departments of Radiology, Division of Neuroradiology (P.C.S., S.K., A.G.)
| | - H Mangat
- Neurology, Division of Stroke and Critical Care (H.M., A.R., H.K., A.S.), NewYork-Presbyterian Hospital-Weill Cornell Campus, New York, New York
| | - A Rosengart
- Neurology, Division of Stroke and Critical Care (H.M., A.R., H.K., A.S.), NewYork-Presbyterian Hospital-Weill Cornell Campus, New York, New York
| | - H Kamel
- Neurology, Division of Stroke and Critical Care (H.M., A.R., H.K., A.S.), NewYork-Presbyterian Hospital-Weill Cornell Campus, New York, New York
| | - A Segal
- Neurology, Division of Stroke and Critical Care (H.M., A.R., H.K., A.S.), NewYork-Presbyterian Hospital-Weill Cornell Campus, New York, New York
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de Oliveira Manoel AL, Mansur A, Murphy A, Turkel-Parrella D, Macdonald M, Macdonald RL, Montanera W, Marotta TR, Bharatha A, Effendi K, Schweizer TA. Aneurysmal subarachnoid haemorrhage from a neuroimaging perspective. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:557. [PMID: 25673429 PMCID: PMC4331293 DOI: 10.1186/s13054-014-0557-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Neuroimaging is a key element in the management of patients suffering from subarachnoid haemorrhage (SAH). In this article, we review the current literature to provide a summary of the existing neuroimaging methods available in clinical practice. Noncontrast computed tomography is highly sensitive in detecting subarachnoid blood, especially within 6 hours of haemorrhage. However, lumbar puncture should follow a negative noncontrast computed tomography scan in patients with symptoms suspicious of SAH. Computed tomography angiography is slowly replacing digital subtraction angiography as the first-line technique for the diagnosis and treatment planning of cerebral aneurysms, but digital subtraction angiography is still required in patients with diffuse SAH and negative initial computed tomography angiography. Delayed cerebral ischaemia is a common and serious complication after SAH. The modern concept of delayed cerebral ischaemia monitoring is shifting from modalities that measure vessel diameter to techniques focusing on brain perfusion. Lastly, evolving modalities applied to assess cerebral physiological, functional and cognitive sequelae after SAH, such as functional magnetic resonance imaging or positron emission tomography, are discussed. These new techniques may have the advantage over structural modalities due to their ability to assess brain physiology and function in real time. However, their use remains mainly experimental and the literature supporting their practice is still scarce.
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Mutoh T, Kazumata K, Terasaka S, Taki Y, Suzuki A, Ishikawa T. Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage. Stroke 2014; 45:1280-4. [PMID: 24692480 DOI: 10.1161/strokeaha.114.004739] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The results of previous studies suggest that early goal-directed fluid therapy (EGDT) reduces delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, but the effects of EGDT on clinical outcomes are still unclear. This study aimed to determine whether EGDT improves outcomes compared with standard less-invasive hemodynamic therapy. METHODS This study included 160 patients treated within 24 hours after subarachnoid hemorrhage, randomized to receive either (1) EGDT guided by preload volume and cardiac output monitored by transpulmonary thermodilution (treatment group) or (2) standard therapy guided by fluid balance or central venous pressure, assisted by uncalibrated less-invasive cardiac output monitoring during hyperdynamic therapy in patients with clinical or radiological indications of DCI (control group). DCI determined by clinical or radiological findings and functional outcome determined by the modified Rankin Scale score at 3 months were compared between groups. RESULTS For all clinical grades combined, there were no significant differences in the rates of DCI (33% versus 42%; P=0.33) or modified Rankin Scale score of 0 to 3 at 3 months (67% versus 57%; P=0.22) between the 2 groups. For patients with poor clinical grade, those who received EGDT had a significantly lower rate of DCI (5% versus 14%; P=0.036), modified Rankin Scale score of 0 to 3 at 3 months (52% versus 36%; P=0.026), and shorter length of intensive care unit stay (14 versus 17 days; P=0.043) than those who received standard therapy. CONCLUSIONS EGDT is beneficial for reducing DCI and improving postoperative functional outcome in patients with poor clinical grade. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: UMIN000007509.
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Affiliation(s)
- Tatsushi Mutoh
- From the Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan (T.M., A.S., T.I.); Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Japan (K.K.); Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan (T.M., Y.T.); and Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan (K.K., S.T.)
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Zheng R, Qin L, Li S, Xu K, Geng H. CT perfusion-derived mean transit time of cortical brain has a negative correlation with the plasma level of Nitric Oxide after subarachnoid hemorrhage. Acta Neurochir (Wien) 2014; 156:527-33. [PMID: 24366481 DOI: 10.1007/s00701-013-1968-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 11/28/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Vasospasm of both large and small parenchymal arteries may contribute to the occurrence of delayed ischemic neurological deficits, and nitric oxide(NO) is an important mediators in the development of cerebral vasospasm after subarachnoid hemorrhage (SAH). We used a rabbit two-hemorrhage model to investigate changes in plasma NO after SAH, and the relationship between NO and brain microcirculation. METHODS SAH was induced in rabbits and a control group was sham operated. There were 32 rabbits in each group that survived the second operation, and they were randomly assigned to four groups of eight rabbits each for follow-up assessments on Days 1, 4, 7, or 14, respectively. Cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) were calculated at six regions of interest (ROIs): symmetrical areas of the frontal, parietal-occipital, and temporal lobes. Before the contrast CT scan, blood was drawn from the central artery of the ear for measurement of plasma NO. RESULTS In the control group, there was no difference in CBV, CBF, and MTT in the six ROIs, and plasma NO was unchanged. Compared to controls, in the SAH group, CBV decreased slightly in the six ROIs (P > 0.05), frontal lobe CBF decreased, MTT increased (P < 0.05, for both), and NO plasma levels were significantly lower (P < 0.01). CONCLUSIONS There was a significant correlation between the increase in MTT and the decrease in plasma NO (P < 0.05), We hypothesized that normalization of NO might have a positive influence on brain microcirculation following SAH.
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Cremers CHP, van der Schaaf IC, Wensink E, Greving JP, Rinkel GJE, Velthuis BK, Vergouwen MDI. CT perfusion and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Cereb Blood Flow Metab 2014; 34:200-7. [PMID: 24281744 PMCID: PMC3915217 DOI: 10.1038/jcbfm.2013.208] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 01/17/2023]
Abstract
Delayed cerebral ischemia (DCI) is at presentation a diagnosis per exclusionem, and can only be confirmed with follow-up imaging. For treatment of DCI a diagnostic tool is needed. We performed a systematic review to evaluate the value of CT perfusion (CTP) in the prediction and diagnosis of DCI. We searched PubMed, Embase, and Cochrane databases to identify studies on the relationship between CTP and DCI. Eleven studies totaling 570 patients were included. On admission, cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-peak (TTP) did not differ between patients who did and did not develop DCI. In the DCI time-window (4 to 14 days after subarachnoid hemorrhage (SAH)), DCI was associated with a decreased CBF (pooled mean difference -11.9 mL/100 g per minute (95% confidence interval (CI): -15.2 to -8.6)) and an increased MTT (pooled mean difference 1.5 seconds (0.9-2.2)). Cerebral blood volume did not differ and TTP was rarely reported. Perfusion thresholds reported in studies were comparable, although the corresponding test characteristics were moderate and differed between studies. We conclude that CTP can be used in the diagnosis but not in the prediction of DCI. A need exists to standardize the method for measuring perfusion with CTP after SAH, and optimize and validate perfusion thresholds.
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Affiliation(s)
- Charlotte H P Cremers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Emerens Wensink
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology , University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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Abate MG, Citerio G. Management of subarachnoid hemorrhage. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0810-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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50
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Mir DIA, Gupta A, Dunning A, Puchi L, Robinson CL, Epstein HAB, Sanelli PC. CT perfusion for detection of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. AJNR Am J Neuroradiol 2013; 35:866-71. [PMID: 24309123 DOI: 10.3174/ajnr.a3787] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia is a significant cause of morbidity and mortality after aneurysmal SAH, leading to poor outcomes. The purpose of this study was to evaluate the usefulness of CTP in determining delayed cerebral ischemia in patients with aneurysmal SAH. MATERIALS AND METHODS We conducted a systematic review evaluating studies that assessed CTP in patients with aneurysmal SAH for determining delayed cerebral ischemia. Studies using any of the following definitions of delayed cerebral ischemia were included in the systematic review: 1) new onset of clinical deterioration, 2) cerebral infarction identified on follow-up CT or MR imaging, and 3) functional disability. A random-effects meta-analysis was performed assessing the strength of association between a positive CTP result and delayed cerebral ischemia. RESULTS The systematic review identified 218 studies that met our screening criteria, of which 6 cohort studies met the inclusion criteria. These studies encompassed a total of 345 patients, with 155 (45%) of 345 patients classified as having delayed cerebral ischemia and 190 (55%) of 345 patients as not having delayed cerebral ischemia. Admission disease severity was comparable across all groups. Four cohort studies reported CTP test characteristics amenable to the meta-analysis. The weighted averages and ranges of the pooled sensitivity and specificity of CTP in the determination of delayed cerebral ischemia were 0.84 (0.7-0.95) and 0.77 (0.66-0.82), respectively. The pooled odds ratio of 23.14 (95% CI, 5.87-91.19) indicates that patients with aneurysmal SAH with positive CTP test results were approximately 23 times more likely to experience delayed cerebral ischemia compared with patients with negative CTP test results. CONCLUSIONS Perfusion deficits on CTP are a significant finding in determining delayed cerebral ischemia in aneurysmal SAH. This may be helpful in identifying patients with delayed cerebral ischemia before development of infarction and neurologic deficits.
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Affiliation(s)
- D I A Mir
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)
| | - A Gupta
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)
| | | | - L Puchi
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)
| | - C L Robinson
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)
| | - H-A B Epstein
- the Samuel J. Wood Library and C.V. Starr Biomedical Information Center (H.-A.B.E.), Weill Cornell Medical College, New York, NY
| | - P C Sanelli
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)Public Health (A.D., P.C.S.)
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