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Lolli VE, Guenego A, Sadeghi N, Jodaitis L, Lubicz B, Taccone FS, Gouvea Bogossian E. CT perfusion imaging in aneurysmal subarachnoid hemorrhage. State of the art. FRONTIERS IN RADIOLOGY 2024; 4:1445676. [PMID: 39434941 PMCID: PMC11491345 DOI: 10.3389/fradi.2024.1445676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 09/02/2024] [Indexed: 10/23/2024]
Abstract
CT perfusion (CTP) images can be easily and rapidly obtained on all modern CT scanners and have become part of the routine imaging protocol of patients with aneurysmal subarachnoid haemorrhage (aSAH). There is a growing body of evidence supporting the use of CTP imaging in these patients, however, there are significant differences in the software packages and methods of analysing CTP. In. addition, no quantitative threshold values for tissue at risk (TAR) have been validated in this patients' population. Here we discuss the contribution of the technique in the identification of patients at risk of aSAH-related delayed cerebral ischemia (DCI) and in the assessment of the response to endovascular rescue therapy (ERT). We also address the limitations and pitfalls of automated CTP postprocessing that are specific to aSAH patients as compared to acute ischemic stroke (AIS).
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Affiliation(s)
| | - Adrien Guenego
- Radiology Department, Hôpital Erasme- H.U.B., Brussels, Belgium
- Interventional Neuroradiology Department, Hôpital Erasme- H.U.B., Brussels, Belgium
| | | | - Lise Jodaitis
- Neurology Department, Hôpital Erasme- H.U.B., Brussels, Belgium
| | - Boris Lubicz
- Interventional Neuroradiology Department, Hôpital Erasme- H.U.B., Brussels, Belgium
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Bergin B, Ragulojan M, Trivedi A, Kesserwan M, Farrokhyar F, Sharma S. Computed Tomography Angiography Compared with Computed Tomography Perfusion in the Diagnosis of Cerebral Vasospasm: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 170:e340-e350. [PMID: 36368456 DOI: 10.1016/j.wneu.2022.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/04/2022] [Accepted: 11/05/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Cerebral vasospasm (CV) is a serious complication after subarachnoid hemorrhage; however, swift identification can be challenging. Computed tomography perfusion (CTP) directly measures tissue perfusion and may better screen for CV compared with other modalities. This systematic review summarizes studies assessing the diagnostic performance of computed tomography angiography (CTA) and CTP in identifying CV. METHODS The search strategy drew from English language publications in the PubMed, Embase, Medline, and Cochrane databases from January 1996 to September 2021. Diagnosis of CV by digital subtraction angiography was the reference standard. Pooled sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), positive likelihood ratios, negative likelihood ratios, and summary receiver operating characteristic curve were calculated. The methodological index for nonrandomized studies tool was employed to assess the quality of the studies. RESULTS The search generated 22 studies. Seven CTA studies and 6 CTP investigations provided sufficient data for meta-analysis. Following pooled estimates, CTA carried a sensitivity of 0.76 (95% confidence interval [CI], 0.72-0.80), specificity of 0.93 (95% CI, 0.92-0.95), PPV of 0.77 (95%, 0.76-0.79), and NPV of 0.81 (95%, 0.79-0.82). CTP carried a sensitivity of 0.86 (95%, 0.81-0.92), specificity of 0.97 (95%, 0.95-0.98), PPV of 0.94 (0.89-0.98), and NPV of 0.94 (0.91-0.97). Using the methodological index for nonrandomized studies tool, the evidence was rated as overall moderate quality. CONCLUSIONS This meta-analysis on the diagnostic performance of CTA and CTP in identifying CV suggests that CTP may carry greater diagnostic accuracy compared with CTA. The clinical significance of this difference should be delineated through future prospective studies.
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Affiliation(s)
- Brad Bergin
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; CRANI Group, McMaster University, Hamilton, Ontario, Canada
| | - Malavan Ragulojan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; CRANI Group, McMaster University, Hamilton, Ontario, Canada.
| | - Arunachala Trivedi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; CRANI Group, McMaster University, Hamilton, Ontario, Canada
| | - Mohamad Kesserwan
- CRANI Group, McMaster University, Hamilton, Ontario, Canada; Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- CRANI Group, McMaster University, Hamilton, Ontario, Canada; Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- CRANI Group, McMaster University, Hamilton, Ontario, Canada; Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Wen L, Zhou L, Wu Q, Zhou X, Zhang X. Feasibility of FDCT Early Brain Parenchymal Blood Volume Maps in Predicting Short-Term Prognosis in Patients With Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 13:888369. [PMID: 35911895 PMCID: PMC9329812 DOI: 10.3389/fneur.2022.888369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Aneurysmal subarachnoid hemorrhage (SAH) is accompanied by cerebral perfusion changes. We aimed to measure the parenchymal blood volume (PBV) maps acquired by C-arm flat-panel detector CT (FDCT) to assess the cerebral blood volume at an early stage in aneurysmal SAH and to explore the correlation with the outcomes at discharge. Methods Data of 66 patients with aneurysmal SAH who underwent FDCT PBV examination were retrospectively analyzed. The PBV of regions of interest, including the cortices of the bilateral frontal lobe, the parietal lobe, the occipital lobe, and the cerebral hemisphere, as well as the basal ganglia, were measured and quantitatively analyzed. The clinical and imaging data of the patients were also collected, and logistic regression analysis was performed to explore the correlation between the perfusion parameters and outcomes at discharge. Results The favorable and poor outcomes at discharge were found in 37 (56.06%) and 29 (43.94%) patients, respectively. The whole-brain PBV was significantly correlated with the Hunt-Hess grades (p < 0.005) and the WFNSS grades (p < 0.005). The whole-brain PBV of the poor prognosis was significantly higher than that of the favorable prognosis (35.17 ± 7.66 vs. 29.78 ± 5.54, p < 0.005). The logistic regression analysis showed that the PBV of the parietal lobe at the bleeding side (OR = 1.10, 95%CI: 1.00-1.20, p = 0.04) was an independent risk factor predicting the short-term prognosis. Conclusions Parenchymal blood volume (PBV) maps could reflect the cerebral blood volume throughout the brain to characterize its perfusion status at an early stage in aneurysmal SAH. It enables a one-stop imaging evaluation and treatment in the same angio-suite and may serve as a reliable technique in clinical assessment of aneurysmal SAH.
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Affiliation(s)
- Lili Wen
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Longjiang Zhou
- Medical Imaging Center, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 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
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Fung C, Z'Graggen WJ, Jakob SM, Gralla J, Haenggi M, Rothen HU, Mordasini P, Lensch M, Söll N, Terpolilli N, Feiler S, Oertel MF, Raabe A, Plesnila N, Takala J, Beck J. Inhaled Nitric Oxide Treatment for Aneurysmal SAH Patients With Delayed Cerebral Ischemia. Front Neurol 2022; 13:817072. [PMID: 35250821 PMCID: PMC8894247 DOI: 10.3389/fneur.2022.817072] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
Background We demonstrated experimentally that inhaled nitric oxide (iNO) dilates hypoperfused arterioles, increases tissue perfusion, and improves neurological outcome following subarachnoid hemorrhage (SAH) in mice. We performed a prospective pilot study to evaluate iNO in patients with delayed cerebral ischemia after SAH. Methods SAH patients with delayed cerebral ischemia and hypoperfusion despite conservative treatment were included. iNO was administered at a maximum dose of 40 ppm. The response to iNO was considered positive if: cerebral artery diameter increased by 10% in digital subtraction angiography (DSA), or tissue oxygen partial pressure (PtiO2) increased by > 5 mmHg, or transcranial doppler (TCD) values decreased more than 30 cm/sec, or mean transit time (MTT) decreased below 6.5 secs in CT perfusion (CTP). Patient outcome was assessed at 6 months with the modified Rankin Scale (mRS). Results Seven patients were enrolled between February 2013 and September 2016. Median duration of iNO administration was 23 h. The primary endpoint was reached in all patients (five out of 17 DSA examinations, 19 out of 29 PtiO2 time points, nine out of 26 TCD examinations, three out of five CTP examinations). No adverse events necessitating the cessation of iNO were observed. At 6 months, three patients presented with a mRS score of 0, one patient each with an mRS score of 2 and 3, and two patients had died. Conclusion Administration of iNO in SAH patients is safe. These results call for a larger prospective evaluation.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Ulrich Rothen
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Lensch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Sergej Feiler
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
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Wen L, Zhou L, Wu Q, Tang X, Ge J, Zhou X, Zhang X. Early Microcirculatory Hemodynamic Changes Are Correlated With Functional Outcomes at Discharge in Patients With Aneurysmal SAH. Front Neurol 2022; 12:793411. [PMID: 35126294 PMCID: PMC8811302 DOI: 10.3389/fneur.2021.793411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose The technique of color-coding blood flow analysis was used to explore the correlation between the microcirculatory hemodynamic changes on digital subtraction angiography (DSA) images in patients with aneurysmal subarachnoid hemorrhage (SAH) at the early stage and functional outcomes at discharge. Methods Data of 119 patients who underwent DSA examination due to SAH were retrospectively analyzed. The following hemodynamic parameters of the four region of interests (ROIs) [an ophthalmic segment of the internal carotid artery (ICA), frontal and parietal lobe, and superior sagittal sinus] were analyzed: the time-to-peak (TTP), the area under the curve (AUC), the full width at half maximum (FWHM), mean transit time (MTT), and circulation time. Multifactor regression analysis was performed to explore the correlation between the hemodynamic parameters and functional outcomes in patients at discharge. Results Of 119 patients with SAH, good and poor outcomes were found in 83 (69.7%) and 36 (30.3%) patients, respectively. The hemodynamic parameters including the FWHM, relative TTP (rTTP), and circulation time were significantly correlated with the Hunt–Hess grade (p < 0.005, p = 0.03, and p < 0.005) and the World Federation of Neurological Societies Scale grade (p < 0.005, p = 0.02, and p = 0.01). The FWHM was significantly prolonged with the increase of modified Fisher grade (p = 0.02). The multifactor analysis showed that the FWHM [odds ratio (OR) 17.56, 95% CI: 1.13–272.03, p = 0.04] was an independent risk factor predicting the functional outcomes in patients at discharge. Conclusion The technique of color-coding blood flow analysis could be suitable for the qualified evaluation of disease conditions at an early stage of SAH as well as the prediction of outcomes.
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Affiliation(s)
- Lili Wen
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Longjiang Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaoyu Tang
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jiajia Ge
- Advanced Therapies, Siemens Healthineers Ltd., Shanghai, China
| | - Xiaoming Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
- *Correspondence: Xin Zhang
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Neumann A, Küchler J, Ditz C, Krajewski K, Leppert J, Schramm P, Schacht H. Non-compliant and compliant balloons for endovascular rescue therapy of cerebral vasospasm after spontaneous subarachnoid haemorrhage: experiences of a single-centre institution with radiological follow-up of the treated vessel segments. Stroke Vasc Neurol 2021; 6:16-24. [PMID: 32709603 PMCID: PMC8005899 DOI: 10.1136/svn-2020-000410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/06/2020] [Accepted: 06/24/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND For endovascular rescue therapy (ERT) of cerebral vasospasm (CVS) due to spontaneous subarachnoid haemorrhage (sSAH), non-compliant (NCB) and compliant (CB) balloons are used with both balloon types bearing the risk of vessel injury due to specific mechanical properties. Although severe delayed arterial narrowing after transluminal balloon angioplasty (TBA) for CVS has sporadically been described, valid data concerning incidence and relevance are missing. Our aim was to analyse the radiological follow-up (RFU) of differently TBA-treated arteries (CB or NCB). METHODS Twelve patients with utilisation of either NCB or CB for CVS were retrospectively analysed for clinical characteristics, ERT, functional outcome after 3 months and RFU. Compared with the initial angiogram, we classified delayed arterial narrowing as mild, moderate and severe (<30%, 30%-60%, respectively >60% calibre reduction). RESULTS Twenty-three arteries were treated with CB, seven with NCB. The median first RFU was 11 months after TBA with CB and 10 after NCB. RFU was performed with catheter angiography in 18 arteries (78%) treated with CB and in five (71%) after NCB; magnetic resonance angiography was acquired in five vessels (22%) treated with CB and in two (29%) after NCB. Mild arterial narrowing was detected in three arteries (13%) after CB and in one (14%) after NCB. Moderate or severe findings were neither detected after use of CB nor NCB. CONCLUSION We found no relevant delayed arterial narrowing after TBA for CVS after sSAH. Despite previous assumptions that CB provides for more dilatation in segments adjacent to CVS, we observed no disadvantages concerning long-term adverse effects. Our data support TBA as a low-risk treatment option.
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Affiliation(s)
- Alexander Neumann
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Jan Küchler
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Claudia Ditz
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Kara Krajewski
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Jan Leppert
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Peter Schramm
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Hannes Schacht
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
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7
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Engquist H, Lewén A, Hillered L, Ronne-Engström E, Nilsson P, Enblad P, Rostami E. CBF changes and cerebral energy metabolism during hypervolemia, hemodilution, and hypertension therapy in patients with poor-grade subarachnoid hemorrhage. J Neurosurg 2021; 134:555-564. [PMID: 31923897 DOI: 10.3171/2019.11.jns192759] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite the multifactorial pathogenesis of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), augmentation of cerebral blood flow (CBF) is still considered essential in the clinical management of DCI. The aim of this prospective observational study was to investigate cerebral metabolic changes in relation to CBF during therapeutic hypervolemia, hemodilution, and hypertension (HHH) therapy in poor-grade SAH patients with DCI. METHODS CBF was assessed by bedside xenon-enhanced CT at days 0-3, 4-7, and 8-12, and the cerebral metabolic state by cerebral microdialysis (CMD), analyzing glucose, lactate, pyruvate, and glutamate hourly. At clinical suspicion of DCI, HHH therapy was instituted for 5 days. CBF measurements and CMD data at baseline and during HHH therapy were required for study inclusion. Non-DCI patients with measurements in corresponding time windows were included as a reference group. RESULTS In DCI patients receiving HHH therapy (n = 12), global cortical CBF increased from 30.4 ml/100 g/min (IQR 25.1-33.8 ml/100 g/min) to 38.4 ml/100 g/min (IQR 34.2-46.1 ml/100 g/min; p = 0.006). The energy metabolic CMD parameters stayed statistically unchanged with a lactate/pyruvate (L/P) ratio of 26.9 (IQR 22.9-48.5) at baseline and 31.6 (IQR 22.4-35.7) during HHH. Categorized by energy metabolic patterns during HHH, no patient had severe ischemia, 8 showed derangement corresponding to mitochondrial dysfunction, and 4 were normal. The reference group of non-DCI patients (n = 11) had higher CBF and lower L/P ratios at baseline with no change over time, and the metabolic pattern was normal in all these patients. CONCLUSIONS Global and regional CBF improved and the cerebral energy metabolic CMD parameters stayed statistically unchanged during HHH therapy in DCI patients. None of the patients developed metabolic signs of severe ischemia, but a disturbed energy metabolic pattern was a common occurrence, possibly explained by mitochondrial dysfunction despite improved microcirculation.
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Affiliation(s)
- Henrik Engquist
- Departments of1Neuroscience/Neurosurgery and
- 2Surgical Sciences/Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | | | | | | | | | - Per Enblad
- Departments of1Neuroscience/Neurosurgery and
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Kumagai K, Tomiyama A, Takeuchi S, Otani N, Fujita M, Fujii K, Wada K, Mori K. New endovascular perforation subarachnoid hemorrhage model for investigating the mechanisms of delayed brain injury. J Neurosurg 2021; 134:84-94. [PMID: 31756704 DOI: 10.3171/2019.9.jns191934] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delayed brain injury (DBI) is considered one of the most important causes of mortality and morbidity after subarachnoid hemorrhage (SAH). However, no suitable experimental rat endovascular perforation (EVP) SAH model was available for investigating DBI. The authors added early cerebral hypoperfusion to a mild EVP SAH model by unilateral common carotid artery occlusion (UCCAO) 24 hours after induction of SAH to mimic the clinical course of early cerebral hypoperfusion after SAH. METHODS A total of 109 adult male Sprague-Dawley rats were randomly divided into 2 groups: no SAH and SAH. Next, no-SAH rats were randomly divided on day 1 into 2 groups: sham and UCCAO. SAH rats with a neurological score of 15 or greater were randomly divided into 2 groups: SAH - UCCAO and SAH + UCCAO group. RESULTS The mild SAH model had a lower mortality rate of 5.4% within the first 24 hours. No rat died in the SAH + UCCAO group until day 7. DBI as well as early brain injury (EBI), reactive astrogliosis, and cerebral vasospasm significantly worsened in the SAH + UCCAO group. CONCLUSIONS The present SAH + UCCAO model can simulate EBI with aggravation of reactive astrogliosis, cerebral vasospasm, and DBI but without high mortality.
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Affiliation(s)
| | | | | | | | - Masanori Fujita
- 2Division of Environmental Medicine, National Defense Medical College, Tokorozawa, Saitama; and
| | | | | | - Kentaro Mori
- 1Department of Neurosurgery and
- 3Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan
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9
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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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10
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Fragata I, Bustamante A, Penalba A, Ferreira P, Nunes AP, Canhão P, Montaner J. TNF-R1 Correlates with Cerebral Perfusion and Acute Ischemia Following Subarachnoid Hemorrhage. Neurocrit Care 2020; 33:679-687. [PMID: 32820384 DOI: 10.1007/s12028-020-01082-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early cerebral hypoperfusion and ischemia occur after subarachnoid hemorrhage (SAH) and influence clinical prognosis. Pathophysiological mechanisms possibly involve inflammatory mediators. TNF-α has been associated with complications and prognosis after SAH. We investigated the relation of perfusion parameters and ischemic lesions, with levels of TNF-α main receptor, TNF-R1, after SAH, and their association with prognosis. METHODS We included consecutive SAH patients admitted within the first 72 h of SAH onset. Blood samples were simultaneously collected from a peripheral vein and from the parent artery of the aneurysm. Levels of TNF-R1 were measured using ELISA (R&D Systems Inc., USA). CT perfusion and MRI studies were performed in the first 72 h. Correlation and logistic regression analysis were used to identify outcome predictors. RESULTS We analyzed 41 patients. Increased levels of TNF-R1 correlated with increased Tmax (arterial: r = -0.37, p = 0.01) and prolonged MTT (arterial: r = 0.355, p = 0.012; venous: r = 0.306, p = 0.026). Increased levels of both arterial and venous TNF-R1 were associated with increased number of lesions on DWI (p = 0.006). In multivariate analysis, venous TNFR1 levels > 1742.2 pg/mL (OR 1.78; 95%CI 1.18-2.67; p = 0.006) and DWI lesions (OR 14.01; 95%CI 1.19-165.3; p = 0.036) were both independent predictors of poor outcome (mRS ≥ 3) at 6 months. CONCLUSION Increased levels of TNF-R1 in arterial and venous blood correlate with worse cerebral perfusion and with increased burden of acute ischemic lesions in the first 72 h after SAH. Venous levels of TNF-R1 and DWI lesions were associated with poor outcome at 6 months. These results highlight the pathophysiological role of TNF-α pathways in SAH and suggest a possible role of combined imaging and laboratorial markers in determining prognosis in acute SAH.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Centro Hospitalar Lisboa Central, Rua Jose Antonio Serrano, 1150-099, Lisbon, Portugal.
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Ana Penalba
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Patrícia Ferreira
- Unidade Cérebro-Vascular, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Ana Paiva Nunes
- Unidade Cérebro-Vascular, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Patrícia Canhão
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria, Lisbon, Portugal.,Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.,Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain.,Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
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11
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Chen CT, Chen CC, Wang AYC, Wu YM, Chin SC, Hsieh PC, Yeap MC, Hsu SY, Lin YJ. Early strategy of scepter XC balloon angioplasty and simultaneous Nimodipine infusion for vasospasm following ruptured aneurysm. BMC Neurol 2020; 20:271. [PMID: 32635892 PMCID: PMC7339531 DOI: 10.1186/s12883-020-01856-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/02/2020] [Indexed: 12/26/2022] Open
Abstract
Background Cerebral vasospasm still results in high morbidity and mortality rates in patients after aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to establish a protocol for the management of vasospasm and demonstrate our experience of angioplasty using the Scepter XC balloon catheter. Methods In this retrospective study, a computed tomography angiography and perfusion image was arranged if early symptoms occurred or on the 7th day following aneurysmal SAH. In patients with clear consciousness, balloon angioplasties were performed for symptomatic vasospasms, which were not improved within 6–12 h after maximal medical treatments. In unconscious patients, balloon angioplasties were performed for all patients with angiographic vasospasms. Results Fifty patients underwent Scepter XC balloon angioplasty among 396 consecutive patients who accepted endovascular or surgical treatments for ruptured aneurysms. All angioplasty procedures were successful without complications. 100% angiographic improvement and 94% clinical improvement were reached immediately after the angioplasties. A favorable functional outcome (modified Rankin Score of ≤2) could be achieved in 82% of patients. Even in patients with poor clinical grading (Hunt–Hess grade 4–5), a clinical improvement rate of 87.5% and favorable outcome rate was 70.8% could be achieved. Conclusion Balloon angioplasty with Scepter XC balloon catheter is safe and effective for post-SAH vasospasm. This device’s extra-compliant characteristics could considerably improve the quality of angioplasty procedures. For all patients, even those with poor neurological status, early treatment with combined protocol of nimodipine and angioplasty can have good clinical outcomes.
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Affiliation(s)
- Chun-Ting Chen
- Department of Neurosurgery, Stroke Center & Neurointervention, Chang Gung Memorial Hospital, Chang Gung Medical Center and University, 5, Fu-Shin Street, Kwei-Shan Hsiang, Taoyuan, 333, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Stroke Center & Neurointervention, Chang Gung Memorial Hospital, Chang Gung Medical Center and University, 5, Fu-Shin Street, Kwei-Shan Hsiang, Taoyuan, 333, Taiwan.
| | - Alvin Yi-Chou Wang
- Department of Neurosurgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yi-Ming Wu
- Department of Radiology, Division of Neuroradiology, Linkou Chang Gung Memorial Hospital & Chang Gung University, Taoyuan City, Taiwan
| | - Shy-Chyi Chin
- Department of Radiology, Division of Neuroradiology, Linkou Chang Gung Memorial Hospital & Chang Gung University, Taoyuan City, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Stroke Center & Neurointervention, Chang Gung Memorial Hospital, Chang Gung Medical Center and University, 5, Fu-Shin Street, Kwei-Shan Hsiang, Taoyuan, 333, Taiwan
| | - Mun-Chun Yeap
- Department of Neurosurgery, Stroke Center & Neurointervention, Chang Gung Memorial Hospital, Chang Gung Medical Center and University, 5, Fu-Shin Street, Kwei-Shan Hsiang, Taoyuan, 333, Taiwan
| | - Shih-Yuan Hsu
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
| | - Ya-Jui Lin
- Department of Neurosurgery, Stroke Center & Neurointervention, Chang Gung Memorial Hospital, Chang Gung Medical Center and University, 5, Fu-Shin Street, Kwei-Shan Hsiang, Taoyuan, 333, Taiwan
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12
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Fragata I, Alves M, Papoila AL, Diogo M, Canhão P, Canto-Moreira N. Temporal evolution of cerebral computed tomography perfusion after acute subarachnoid hemorrhage: a prospective cohort study. Acta Radiol 2020; 61:376-385. [PMID: 31265319 DOI: 10.1177/0284185119858701] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Changes in cerebral perfusion occur in subarachnoid hemorrhage that possibly relate to clinical presentation and complications. Purpose To evaluate changes in computed tomography perfusion (CTP) parameters between the acute and subacute stage of subarachnoid hemorrhage. To analyze correlation of these parameters to SAH severity and delayed cerebral ischemia. Material and Methods Cerebral CT perfusion was assessed in a prospective cohort of 44 patients with acute subarachnoid hemorrhage at < 72 h (CTP1) and 8–10 days (CTP2), using the mean of all regions of interest. Regions of interest were located at arterial territories of the anterior, middle, and posterior cerebral artery and basal ganglia and midpons cerebellar hemispheres. Linear regression models (univariable and multivariable) were used to explore the association between changes in perfusion parameters (absolute and relative differences) and relevant clinical data. Results Worse perfusion parameters on the first 72 h were correlated with poor admission clinical scores: cerebral blood flow positively correlated with Glasgow Coma Scale (rS = 0.398, P = 0.008), and negatively correlated with Hunt & Hess scale (rS = −0.348, P = 0.020) and World Federation of Neurosurgeons scale (rS = −0.384, P = 0.010). Cerebral blood volume positively correlated with Glasgow Coma Scale (rS = 0.332, P = 0.028) and negatively correlated with World Federation of Neurosurgeons scale (rS = −0.353, P = 0.019). Mean transit time negatively correlated with Glasgow Coma Scale (rS = −0.415, P = 0.005) and positively correlated with Hunt & Hess scale (rS = 0.471, P = 0.001) and World Federation of Neurosurgeons scale (rS = 0.386, P = 0.010) scores. There were no differences between absolute CTP1/CTP2 parameters. Patients with delayed cerebral ischemia had ΔTmax mean decrease of 2.08 s (95% CI = −4.04–−0.12; P = 0.038). Conclusion Early cerebral hypoperfusion correlates with poor clinical grade at admission in subarachnoid hemorrhage and with higher amounts of blood. Tmax was decreased at 8–10 days, in patients with delayed cerebral ischemia, which may favor the application value of Tmax in signaling delayed cerebral ischemia.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department Hospital São José, Centro Hospitalar Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Lisbon, Portugal
| | - Marta Alves
- Epidemiology and Statistics Unit, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Ana Luísa Papoila
- Epidemiology and Statistics Unit, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Mariana Diogo
- Neuroradiology Department Hospital São José, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Patrícia Canhão
- Department of Neurosciences and Mental Health, Neurology, Hospital de Santa Maria, CHLN, Lisbon, Portugal
- Faculty of Medicine, University of Lisbon, Portugal
| | - Nuno Canto-Moreira
- Department of Neuroradiology, Karolinska University Hospital; Department of Pediatric Radiology, Astrid Lindgren Children's Hospital Stockholm, Sweden
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13
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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: 1.0] [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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14
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Starnoni D, Maduri R, Hajdu SD, Pierzchala K, Giammattei L, Rocca A, Grosfilley SB, Saliou G, Messerer M, Daniel RT. Early Perfusion Computed Tomography Scan for Prediction of Vasospasm and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 130:e743-e752. [PMID: 31284055 DOI: 10.1016/j.wneu.2019.06.213] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We investigated the ability of early alteration of cerebral perfusion-computed tomography (PCT) parameters to predict the risk of vasospasm, delayed cerebral ischemia (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective cohort study of 38 aSAH patients investigated with PCT within 48 hours after hemorrhage. Cerebral blood flow (CBF), cerebral blood volume, and mean transit time (MTT) values were recorded. Mean values were compared with clinical data. Vasospasm and DCI were determined by imaging and clinical criteria. Neurologic outcome was assessed by the modified Rankin Scale at discharge and 1-year follow-up visit. RESULTS More than a third (39.5%) of patients developed DCI, of whom 86.7% presented moderate-severe vasospasm. There was a significant correlation between perfusion parameters in the early phase and occurrence of DCI and vasospasm. The occurrence of DCI and vasospasm correlated significantly with lower mean early PCT values. DCI was correlated with lower mean early CBF values (P = 0.049) and vasospasm with lower mean CBF (P = 0.01) and MTT (P < 0.00001) values. MTT values of 5.5s were shown to have 94% specificity and 100% sensitivity for predicting the risk of developing vasospasm. The severity of the SAH according to the Barrow Neurological Institute scale correlated significantly with the risk of developing DCI and vasospasm, both significantly associated with unfavorable neurologic outcome (modified Rankin Scale score 3-6) (P = 0.0002 and P = 0.02, respectively). CONCLUSIONS Early alterations in PCT parameters and high Barrow Neurological Institute grade may identify a subgroup of patients at high risk of developing DCI and vasospasm after aSAH, thus prompting more robust preventative measures and treatment in this subgroup.
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Affiliation(s)
- Daniele Starnoni
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Rodolfo Maduri
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
| | - Steven David Hajdu
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | | | - Lorenzo Giammattei
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alda Rocca
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Sarah Beatrice Grosfilley
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Guillaume Saliou
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
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15
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Neutrophils mediate early cerebral cortical hypoperfusion in a murine model of subarachnoid haemorrhage. Sci Rep 2019; 9:8460. [PMID: 31186479 PMCID: PMC6560094 DOI: 10.1038/s41598-019-44906-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/28/2019] [Indexed: 02/07/2023] Open
Abstract
Cerebral hypoperfusion in the first hours after subarachnoid haemorrhage (SAH) is a major determinant of poor neurological outcome. However, the underlying pathophysiology is only partly understood. Here we induced neutropenia in C57BL/6N mice by anti-Ly6G antibody injection, induced SAH by endovascular filament perforation, and analysed cerebral cortical perfusion with laser SPECKLE contrast imaging to investigate the role of neutrophils in mediating cerebral hypoperfusion during the first 24 h post-SAH. SAH induction significantly increased the intracranial pressure (ICP), and significantly reduced the cerebral perfusion pressure (CPP). At 3 h after SAH, ICP had returned to baseline and CPP was similar between SAH and sham mice. However, in SAH mice with normal neutrophil counts cortical hypoperfusion persisted. Conversely, despite similar CPP, cortical perfusion was significantly higher at 3 h after SAH in mice with neutropenia. The levels of 8-iso-prostaglandin-F2α in the subarachnoid haematoma increased significantly at 3 h after SAH in animals with normal neutrophil counts indicating oxidative stress, which was not the case in neutropenic SAH animals. These results suggest that neutrophils are important mediators of cortical hypoperfusion and oxidative stress early after SAH. Targeting neutrophil function and neutrophil-induced oxidative stress could be a promising new approach to mitigate cerebral hypoperfusion early after SAH.
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16
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Artifact Reduction in the Diagnosis of Vasospasm in Computed Tomographic Perfusion: Potential of Iterative Metal Artifact Reduction. J Comput Assist Tomogr 2019; 43:553-558. [PMID: 31162229 DOI: 10.1097/rct.0000000000000879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to analyze the possibility of artifact reduction using a new iterative metal artifact reduction algorithm (iMAR) in the diagnosis of perfusion deficits due to vasospasms and to evaluate its clinical relevance. METHODS Sixty-one volume perfusion computed tomographies of 24 patients after coiling or aneurysm clipping were reconstructed using standard-filtered back-projection and iMAR retrospectively. The degree of artifacts was evaluated as well as the size of the nonevaluable area. Diagnostic performance was evaluated compared with digital subtraction angiography. RESULTS Artifacts were present in 39 of 61 volume perfusion computed tomography examinations. Image quality (score, 1.0 vs 1.6; P < 0.01) was higher and the size of the signal loss was reduced significantly by iMAR (intracranial metal artifacts, 887 mm vs 359 mm [P < 0.01]; cranial bolt, 3008 mm vs 837 mm [P < 0.01]). Digital subtraction angiography confirmed vasospasms in 11 (92%) of 12 patients. CONCLUSION The iMAR yields higher image quality by reducing artifacts compared with filtered back-projection.
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17
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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: 1.3] [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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18
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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: 0.8] [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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19
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Vulcu S, Wagner F, Santos AF, Reitmeir R, Söll N, Schöni D, Fung C, Wiest R, Raabe A, Beck J, Z’Graggen WJ. Repetitive Computed Tomography Perfusion for Detection of Cerebral Vasospasm–Related Hypoperfusion in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 121:e739-e746. [DOI: 10.1016/j.wneu.2018.09.208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 11/27/2022]
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20
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Petridis AK, Kamp MA, Cornelius JF, Beez T, Beseoglu K, Turowski B, Steiger HJ. Aneurysmal Subarachnoid Hemorrhage. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:226-236. [PMID: 28434443 DOI: 10.3238/arztebl.2017.0226] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 08/29/2016] [Accepted: 11/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is associated with a mortality of more than 30%. Only about 30% of patients with SAB recover sufficiently to return to independent living. METHODS This article is based on a selective review of pertinent literature retrieved by a PubMed search. RESULTS Acute, severe headache, typically described as the worst headache of the patient's life, and meningismus are the characteristic manifestations of SAH. Computed tomog raphy (CT) reveals blood in the basal cisterns in the first 12 hours after SAH with approximately 95% sensitivity and specificity. If no blood is seen on CT, a lumbar puncture must be performed to confirm or rule out the diagnosis of SAH. All patients need intensive care so that rebleeding can be avoided and the sequelae of the initial bleed can be minimized. The immediate transfer of patients with acute SAH to a specialized center is crucially important for their outcome. In such centers, cerebral aneurysms can be excluded from the circulation either with an interventional endovascular procedure (coiling) or by microneurosurgery (clipping). CONCLUSION SAH is a life-threatening condition that requires immediate diagnosis, transfer to a neurovascular center, and treatment without delay.
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Affiliation(s)
- Athanasios K Petridis
- Department of Neurosurgery, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital
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21
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Murphy A, Lee TY, Marotta TR, Spears J, Macdonald RL, Aviv RI, Baker A, Bharatha A. Prospective Multicenter Study of Changes in MTT after Aneurysmal SAH and Relationship to Delayed Cerebral Ischemia in Patients with Good- and Poor-Grade Admission Status. AJNR Am J Neuroradiol 2018; 39:2027-2033. [PMID: 30337436 DOI: 10.3174/ajnr.a5844] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/26/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE Patients with aneurysmal SAH and good clinical status at admission are considered at a lower risk for delayed cerebral ischemia. Prolonged MTT may be associated with an increased risk. It is unclear whether this is dependent on clinical status. Our purpose was to determine whether increased MTT within 3 days of aneurysmal SAH compared with baseline is associated with a higher risk of delayed cerebral ischemia in patients with good (World Federation of Neurosurgical Societies I-III) versus poor (World Federation of Neurosurgical Societies IV-V) admission status. MATERIALS AND METHODS This prolonged MTT was a multicenter, prospective cohort investigation of 87 patients with aneurysmal SAH. MTT was measured at admission before aneurysm treatment (MTT1) and following repair (MTT2) within 3 days of admission; MTTdiff was calculated as the difference between MTT2 and MTT1. Changes in MTT across time were assessed with repeated measures analyses. Risk of delayed cerebral ischemia or death was determined with multivariate logistic regression analysis. RESULTS In patients with a good grade (n = 49), MTT was prolonged in patients who developed delayed cerebral ischemia, with MTTdiff significantly greater (0.82 ± 1.5) compared with those who did not develop delayed cerebral ischemia (-0.14 ± 0.98) (P = .03). Prolonged MTT was associated with a significantly higher risk of delayed cerebral ischemia or death (OR = 3.1; 95% CI, 1.3-7.4; P = .014) on multivariate analysis. In patients with poor grades (n = 38), MTTdiff was not greater in patients who developed delayed cerebral ischemia; MTT1 was significantly prolonged compared with patients with a good grade. CONCLUSIONS Patients in good clinical condition following aneurysmal SAH but with increasing MTT in the first few days after aneurysmal SAH are at high risk of delayed cerebral ischemia and warrant close clinical monitoring.
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Affiliation(s)
- A Murphy
- From the Division of Diagnostic and Interventional Neuroradiology (A.M., T.R.M., A. Bharatha)
| | - T-Y Lee
- Lawson Health Research Institute and Robarts Research Institute (T.-Y.L.), University of Western Ontario, London, Ontario, Canada
| | - T R Marotta
- From the Division of Diagnostic and Interventional Neuroradiology (A.M., T.R.M., A. Bharatha)
- Division of Neurosurgery (T.R.M., J.S., A. Bharatha), Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - J Spears
- Division of Neurosurgery (T.R.M., J.S., A. Bharatha), Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - R L Macdonald
- Labatt Family Centre of Excellence in Brain Injury and Trauma Research (R.L.M.)
- Keenan Research Centre for Biomedical Science (R.L.M.)
- the Li Ka Shing Knowledge Institute (R.L.M.), St. Michael's Hospital, Toronto, Ontario, Canada
- Departments of Physiology and Surgery (R.L.M.)
| | - R I Aviv
- Department of Medical Imaging (R.I.A.), Sunnybrook Hospital, Toronto, Ontario, Canada
| | - A Baker
- Departments of Anesthesia and Critical Care Medicine (A. Baker)
| | - A Bharatha
- From the Division of Diagnostic and Interventional Neuroradiology (A.M., T.R.M., A. Bharatha)
- Division of Neurosurgery (T.R.M., J.S., A. Bharatha), Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Medical Imaging (A. Bharatha), University of Toronto, Toronto, Ontario, Canada
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22
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Malinova V, Schatlo B, Voit M, Suntheim P, Rohde V, Mielke D. The impact of temporary clipping during aneurysm surgery on the incidence of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 2018; 129:84-90. [PMID: 28946178 DOI: 10.3171/2017.3.jns162505] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clipping of a ruptured intracranial aneurysm requires some degree of vessel manipulation, which in turn is believed to contribute to vasoconstriction. One of the techniques used during surgery is temporary clipping of the parent vessel. Temporary clipping may either be mandatory in cases of premature rupture (rescue) or represent a precautionary or facilitating surgical step (elective). The aim of this study was to study the association between temporary clipping during aneurysm surgery and the incidence of vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) in a large clinical series. METHODS Seven hundred seventy-eight patients who underwent surgical aneurysm treatment after aSAH were retrospectively included in the study. In addition to surgical parameters, the authors recorded transcranial Doppler (TCD) sonography-documented vasospasm (TCD-vasospasm, blood flow acceleration > 120 cm/sec), delayed ischemic neurological deficits (DINDs), and delayed cerebral infarction (DCI). Multivariate binary logistic regression analysis was applied to assess the association between temporary clipping, vasospasm, DIND, and DCI. RESULTS Temporary clipping was performed in 338 (43.4%) of 778 patients during aneurysm surgery. TCD sonographic flow acceleration developed in 370 (47.6%), DINDs in 123 (15.8%), and DCI in 97 (12.5%). Patients with temporary clipping showed no significant increase in the incidence of TCD-vasospasm compared with patients without temporary clipping (49% vs 48%, respectively; p = 0.60). DINDs developed in 12% of patients with temporary clipping and 18% of those without temporary clipping (p = 0.01). DCI occurred in 9% of patients with temporary clipping and 15% of those without temporary clipping (p = 0.02). The need for rescue temporary clipping was a predictor for DCI; 19.5% of patients in the rescue temporary clipping group but only 11.3% in the elective temporary clipping group had infarcts (p = 0.02). Elective temporary clipping was not associated with TCD-vasospasm (p = 0.31), DIND (p = 0.18), or DCI (p = 0.06). CONCLUSIONS Temporary clipping did not contribute to a higher rate of TCD-vasospasm, DIND, or DCI in comparison with rates in patients without temporary clipping. In contrast, there was an association between temporary clipping and a lower incidence of DINDs and DCI. There is no reason to be hesitant in using elective temporary clipping if deemed appropriate.
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Affiliation(s)
- Vesna Malinova
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | - Bawarjan Schatlo
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | - Martin Voit
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | | | - Veit Rohde
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
- 2Department of Neurosurgery, RWTH University, Aachen, Germany
| | - Dorothee Mielke
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
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23
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van Lieshout JH, Dibué-Adjei M, Cornelius JF, Slotty PJ, Schneider T, Restin T, Boogaarts HD, Steiger HJ, Petridis AK, Kamp MA. An introduction to the pathophysiology of aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2017; 41:917-930. [PMID: 28215029 DOI: 10.1007/s10143-017-0827-y] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Abstract
Pathophysiological processes following subarachnoid hemorrhage (SAH) present survivors of the initial bleeding with a high risk of morbidity and mortality during the course of the disease. As angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important. However, a unifying theory for the pathophysiological changes following SAH has yet not been described. Some of these changes may be causally connected or present themselves as an epiphenomenon of an associated process. A causal connection between DCI and early brain injury (EBI) would mean that future therapies should address EBI more specifically. If the mechanisms following SAH display no causal pathophysiological connection but are rather evoked by the subarachnoid blood and its degradation production, multiple treatment strategies addressing the different pathophysiological mechanisms are required. The discrepancy between experimental and clinical SAH could be one reason for unsuccessful translational results.
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Affiliation(s)
- Jasper H van Lieshout
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Maxine Dibué-Adjei
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Toni Schneider
- Institute for Neurophysiology, Medical Faculty, University of Cologne, Robert-Koch-Str. 39, 50931, Köln, Germany
| | - Tanja Restin
- Zurich Centre for Integrative Human Physiology, Institute of Physiology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Institute of Anesthesiology, Medical Faculty, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Medical Faculty, Radboud University Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Athanasios K Petridis
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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van Lieshout JH, Bruland I, Fischer I, Cornelius JF, Kamp MA, Turowski B, Tortora A, Steiger HJ, Petridis AK. Increased mortality of patients with aneurysmatic subarachnoid hemorrhage caused by prolonged transport time to a high-volume neurosurgical unit. Am J Emerg Med 2017; 35:45-50. [DOI: 10.1016/j.ajem.2016.09.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/07/2016] [Accepted: 09/29/2016] [Indexed: 01/03/2023] Open
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Duan Y, Xu H, Li R, Zheng K, Hu Z, Wu N, Yang Y, Zhuge Q, Chen W. Computed Tomography Perfusion Deficits during the Baseline Period in Aneurysmal Subarachnoid Hemorrhage Are Predictive of Delayed Cerebral Ischemia. J Stroke Cerebrovasc Dis 2017; 26:162-168. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 08/09/2016] [Accepted: 09/03/2016] [Indexed: 10/20/2022] Open
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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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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: 3.4] [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: 34] [Impact Index Per Article: 3.4] [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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Othman AE, Afat S, Brockmann C, Nikoubashman O, Bier G, Brockmann MA, Nikolaou K, Tai JH, Yang ZP, Kim JH, Wiesmann M. Low-Dose Volume-Perfusion CT of the Brain: Effects of Radiation Dose Reduction on Performance of Perfusion CT Algorithms. Clin Neuroradiol 2015; 27:311-318. [PMID: 26669592 DOI: 10.1007/s00062-015-0489-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE We aimed to compare different computed tomography (CT) perfusion post-processing algorithms regarding image quality of perfusion maps from low-dose volume perfusion CT (VPCT) and their diagnostic performance regarding the detection of ischemic brain lesions. METHODS AND MATERIALS We included VPCT data of 21 patients with acute stroke (onset < 6h), which were acquired at 80 kV and 180 mAs. Low-dose VPCT datasets with 72 mAs (40 % of original dose) were generated using realistic low-dose simulation. Perfusion maps (cerebral blood volume (CBV); cerebral blood flow (CBF) from original and low-dose datasets were generated using two different commercially available post-processing methods: deconvolution-based method (DC) and maximum slope algorithm (MS). The resulting DC and MS perfusion maps were compared regarding perfusion values, signal-to-noise ratio (SNR) as well as image quality and diagnostic accuracy as rated by two blinded neuroradiologists. RESULTS Quantitative perfusion parameters highly correlated for both algorithms and both dose levels (r ≥ 0.613, p < 0.001). Regarding SNR levels and image quality of the CBV maps, no significant differences between DC and MS were found (p ≥ 0.683). Low-dose MS CBF maps yielded significantly higher SNR levels (p < 0.001) and quality scores (p = 0.014) than those of DC. Low-dose CBF and CBV maps from both DC and MS yielded high sensitivity and specificity for the detection of ischemic lesions (sensitivity ≥ 0.82, specificity ≥ 0.90). CONCLUSION Our results indicate that both methods produce diagnostically sufficient perfusion maps from simulated low-dose VPCT. However, MS produced CBF maps with significantly higher image quality and SNR than DC, indicating that MS might be more suitable for low-dose VPCT imaging.
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Affiliation(s)
- A E Othman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany.,Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, 72076, Tübingen, Germany
| | - S Afat
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - C Brockmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - O Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - G Bier
- Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, 72076, Tübingen, Germany
| | - M A Brockmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - K Nikolaou
- Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, 72076, Tübingen, Germany
| | - J H Tai
- Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, 433-270, Suwon, South Korea
| | - Z P Yang
- Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, 433-270, Suwon, South Korea
| | - J H Kim
- Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, 433-270, Suwon, South Korea. .,Department of Radiology, Seoul National University College of Medicine, 101 Daehak-Ro, Chongno-gu, 110-744, Seoul, South Korea. .,Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, 433-270, Suwon, South Korea.
| | - M Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
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Optimal Contrast of Cerebral Dual-Energy Computed Tomography Angiography in Patients With Spontaneous Subarachnoid Hemorrhage. J Comput Assist Tomogr 2015; 40:48-52. [PMID: 26571057 PMCID: PMC4718178 DOI: 10.1097/rct.0000000000000336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective The aim of this study was to investigate the image quality of cerebral dual-energy computed tomography (CT) angiography using a nonlinear image blending technique as compared with the conventional linear blending method in patients with spontaneous subarachnoid hemorrhage (SAH). Methods A retrospective review of 30 consecutive spontaneous SAH patients who underwent a dual-source, dual-energy (80 kV and Sn140 kV mode) cerebral CT angiography was performed with permission from hospital ethical committee. Optimized images using nonlinear blending method were generated and compared with the 0.6 linear blending images by evaluating cerebral artery enhancement, attenuation of SAH, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR), respectively. Two neuroradiologists independently assessed subjective vessel visualization per segment using a 5-point scale. Results The nonlinear blending images showed higher cerebral artery enhancement (307.24 ± 58.04 Hounsfield unit [HU]), lower attenuation of SAH (67.07 ± 6.79 HU), and image noise (7.18 ± 1.20 HU), thus achieving better SNR (43.92 ± 11.14) and CNR (34.34 ± 10.25), compared with those of linear blending images (235.47 ± 46.45 HU for cerebral artery enhancement, 70.00 ± 6.41 HU for attenuation of SAH, 8.39 ± 1.25 HU for image noise, 28.86 ± 8.43 for SNR, and 20.37 ± 7.74 for CNR) (all P < 0.01). The segmental scorings of the nonlinear blending image (31.6% segments with a score of 5, 57.4% segments with a score of 4, 11% segments with a score of 3) ranged significantly higher than those of linear blending images (11.5% segments with a score of 5, 77.5% segments with a score of 4, 11% segments with a score of 3) (P < 0.01). The interobserver agreement was good (κ = 0.762), and intraobserver agreement was excellent for both observers (κ = 0.844 and 0.858, respectively). Conclusions The nonlinear image blending technique improved vessel visualization of cerebral dual-energy CT angiography by optimizing contrast enhancement in spontaneous SAH patients.
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Effect of APOE Gene Polymorphism on Early Cerebral Perfusion After Aneurysmal Subarachnoid Hemorrhage. Transl Stroke Res 2015; 6:446-50. [DOI: 10.1007/s12975-015-0426-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
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Kidoh M, Hirai T, Oda S, Utsunomiya D, Kawano T, Yano S, Nakamura H, Makino K, Iryo Y, Azuma M, Hayashida E, Nakaura T, Yamashita Y. Can CT angiography reconstructed from CT perfusion source data on a 320-section volume CT scanner replace conventional CT angiography for the evaluation of intracranial arteries? Jpn J Radiol 2015; 33:353-9. [DOI: 10.1007/s11604-015-0429-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 04/24/2015] [Indexed: 10/23/2022]
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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: 24] [Impact Index Per Article: 2.4] [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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Beseoglu K, Etminan N, Hänggi D. The value of perfusion computed tomography (PCT) imaging after aneurysmal subarachnoid hemorrhage: a review of the current data. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:35-8. [PMID: 25366596 DOI: 10.1007/978-3-319-04981-6_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND PURPOSE The estimation of the extent of early brain injury (EBI) and sensitive detection of delayed cerebral ischemia (DCI) remains a major challenge in the context of aneurysmal subarachnoid hemorrhage (aSAH). Cerebral perfusion computed tomography (PCT) imaging is increasingly used as an additional diagnostic tool to monitor early brain injury as well as delayed cerebral ischemia after aSAH. Here, we review the current literature as well as the resulting implications and illustrate our institutional experience with PCT imaging in this context. METHODS The current literature on PCT imaging for SAH was identified based on a search of the PubMed database. Patient cohorts were dichotomized according to the time of PCT after ictus into early PCT (<72 h after ictus) and subsequent PCT (>72 h after ictus). The specific aspects and findings of PCT at different times are compared and discussed. RESULTS Sixteen relevant publications were identified, nine of which focused on early PCT and seven on subsequent PCT diagnostics after aSAH. Early PCT provided relevant details on the extent of EBI and identified patients at risk for developing DCI, whereas subsequent PCT imaging facilitated the monitoring and detection of DCI. CONCLUSIONS The present review demonstrates that PCT imaging is able to detect EBI as well as DCI in patients experiencing aSAH. As a consequence, this technique should be routinely implemented in monitoring strategies for this patient population.
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Affiliation(s)
- Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, Düsseldorf, 40225, Germany,
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Bacigaluppi S, Zona G, Secci F, Spena G, Mavilio N, Brusa G, Agid R, Krings T, Ottonello G, Fontanella M. Diagnosis of cerebral vasospasm and risk of delayed cerebral ischemia related to aneurysmal subarachnoid haemorrhage: an overview of available tools. Neurosurg Rev 2015; 38:603-18. [DOI: 10.1007/s10143-015-0617-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 11/16/2014] [Indexed: 01/01/2023]
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Kapinos G. Redefining secondary injury after subarachnoid hemorrhage in light of multimodal advanced neuroimaging, intracranial and transcranial neuromonitoring: beyond vasospasm. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:259-267. [PMID: 25366634 DOI: 10.1007/978-3-319-04981-6_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The classic idea that arterial narrowing, called vasospasm (VSP), represents the hallmark of secondary injury after subarachnoid hemorrhage, has been challenged. The more complex and pleiotropic pathophysiological repercussions from the irruption of arterial blood into the subarachnoid layers go beyond the ascribed VSP. Putting adjectives in front of this term, such as "symptomatic," "microdialytic," or "angiographic" VSP, is misleading. Delayed cerebral ischemia (DCI) is a better term but remains restrictive to severe hypoperfusive injury and neglects oligemia, edema, and metabolic nonischemic injuries. In recognition of these issues, the international conference on VSP integrated "neurovascular events" into its name ( www.vasospasm2013.com ) and a multidisciplinary research group was formed in 2010 to study subgroups of DCI/VSP and their respective significance.In three parts, this tiered article provides a broader definitional envelope for DCI and secondary neurovascular insults after SAH, with a rubric for each subtype of delayed neuronal dysfunction. First, it pinpoints the need for nosologic precision and covers current terminological inconsistency. Then, it highlights the input of neuroimaging and neuromonitoring in defining secondary injurious processes. Finally, a new categorization of deteriorating patients is proposed, going beyond a hierarchical or dichotomized definition of VSP/DCI, and common data elements are suggested for future trials.
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Affiliation(s)
- Gregory Kapinos
- Department of Neurosurgery, North Shore-LIJ Health System, 300 Community Drive, Tower, 9th floor, Manhasset, NY, 11030, USA,
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Dolatowski K, Malinova V, Frölich A, Schramm R, Haberland U, Klotz E, Mielke D, Knauth M, Schramm P. Volume perfusion CT (VPCT) for the differential diagnosis of patients with suspected cerebral vasospasm: Qualitative and quantitative analysis of 3D parameter maps. Eur J Radiol 2014; 83:1881-9. [DOI: 10.1016/j.ejrad.2014.06.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 06/24/2014] [Indexed: 11/16/2022]
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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: 69] [Impact Index Per Article: 5.8] [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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Zhang H, Zhang B, Li S, Liang C, Xu K, Li S. Whole brain CT perfusion combined with CT angiography in patients with subarachnoid hemorrhage and cerebral vasospasm. Clin Neurol Neurosurg 2013; 115:2496-501. [PMID: 24210268 DOI: 10.1016/j.clineuro.2013.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 09/24/2013] [Accepted: 10/08/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess cerebral vasospasm (CVS) and monitor cerebral microcirculatory changes in patients with acute subarachnoid hemorrhage (SAH) via CT angiography (CTA) combined with whole-brain CT perfusion (CTP) techniques. METHODS Sixty patients with SAH (SAH group) and 10 patients without SAH (control group) were selected for a prospective study. CTP combined with CTA and digital subtraction angiography (DSA) studies were performed on patients with initial onset of SAH less than three days. CTA and DSA as well as the CTP parameters such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time-to-peak (TTP) were acquired and analyzed. The relationship of CTA and CTP measurements was assessed in these acute SAH patients. RESULTS CTP techniques were used to achieve the perfusion maps of the whole brain in patients with acute SAH. Compared to the control group, mean CBF value was significantly lower while both MTT and TTP values were significantly higher in SAH group (all p<0.05). Further analysis revealed that mean CBF in patients with CVS, sCVS, Fisher III-IV and Hunt-Hess III-V significantly decreased when compared to patients with nCVS, asCVS, Fisher I-II and Hunt-Hess I-II (p<0.05). Furthermore both MTT and TTP values were also significantly reduced in patient with CVS, sCVS, Fisher III-IV and Hunt-Hess III-V (p<0.05). CONCLUSION The study demonstrated that changes of microcirculation in patients with SAH could be assessed by whole-brain CTP. CTP combined with CTA could detect both macroscopic evident vasospasm on CTA and alterations of microcirculation on CTP. Mean CBF was significantly lower in patients with SAH.
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Affiliation(s)
- He Zhang
- Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, PR China
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Long-term impact of perfusion CT data after subarachnoid hemorrhage. Neuroradiology 2013; 55:1323-31. [PMID: 24026709 DOI: 10.1007/s00234-013-1278-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Dynamic perfusion computed tomography (PCT) has been established as a diagnostic instrument for the detection of vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to assess the prognostic impact of PCT parameters after SAH on the long-term outcome of patients. METHODS Three hundred twelve patients were retrospectively interrogated with a questionnaire 23.06 ± 14.33 months after spontaneous subarachnoid hemorrhage. The modified Rankin scale (mRS) was determined, respectively. Scheduled PCT data sets from the first days after ictus were available for all patients. RESULTS The maximum mean transit time over several examinations per hemisphere (MTTPEAK) values were significantly correlated (p ≤ 0.001, r = 0.422) with the clinical long-term outcome (mRS). Corresponding to our linear regression analysis, MTTPEAK is the second most important regressor (behind clinical severity of the initial hemorrhage) for the prediction of long-term mRS. An MTTPEAK threshold of 3.98 s (identified by receiver operating characteristic analysis, area under the curve = 0.75) predicted an unfavorable long-term outcome (mRS ≥ 2) with a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 67.3, 74.3, 84.5, 52.1, and 69.6 %, respectively. CONCLUSION The presented data corroborate the relevance of PCT data for the clinical long-term outcome of SAH patients. By identification of patients who are at risk for a bad outcome and may need escalation of therapy, risk-benefit analysis is supported.
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Evidence-based cerebral vasospasm surveillance. Neurol Res Int 2013; 2013:256713. [PMID: 23862061 PMCID: PMC3686086 DOI: 10.1155/2013/256713] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 05/20/2013] [Indexed: 01/01/2023] Open
Abstract
Subarachnoid hemorrhage related to aneurysmal rupture (aSAH) carries significant morbidity and mortality, and its treatment is focused on preventing secondary injury. The most common—and devastating—complication is delayed cerebral ischemia resulting from vasospasm. In this paper, the authors review the various surveillance technologies available to detect cerebral vasospasm in the days following aSAH. First, evidence related to the most common modalities, including transcranial doppler ultrasonography and computed tomography, are reviewed. Continuous electroencephalography and older instruments such as positron emission tomography, xenon-enhanced CT, and single-photon emission computed tomography are also discussed. Invasive strategies including brain tissue oxygen monitoring, microdialysis, thermal diffusion, and jugular bulb oximetry are examined. Lastly, near-infrared spectroscopy, a recent addition to the field, is briefly reviewed. Each surveillance tool carries its own set of advantages and limitations, and the concomitant use of multiple modalities serves to improve diagnostic sensitivity and specificity.
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Muñoz-Guillén N, León-López R, Túnez-Fiñana I, Cano-Sánchez A. From vasospasm to early brain injury: New frontiers in subarachnoid haemorrhage research. NEUROLOGÍA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.nrleng.2011.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Etminan N, Beseoglu K, Heiroth HJ, Turowski B, Steiger HJ, Hänggi D. Early Perfusion Computerized Tomography Imaging as a Radiographic Surrogate for Delayed Cerebral Ischemia and Functional Outcome After Subarachnoid Hemorrhage. Stroke 2013; 44:1260-6. [DOI: 10.1161/strokeaha.111.675975] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nima Etminan
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Kerim Beseoglu
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hi-Jae Heiroth
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Bernd Turowski
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hans Jakob Steiger
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Daniel Hänggi
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
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Juluru K, Shih JC, Raj A, Comunale JP, Delaney H, Greenberg ED, Hermann C, Liu YB, Hoelscher A, Al-Khori N, Sanelli PC. Effects of increased image noise on image quality and quantitative interpretation in brain CT perfusion. AJNR Am J Neuroradiol 2013; 34:1506-12. [PMID: 23557960 DOI: 10.3174/ajnr.a3448] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is a desire within many institutions to reduce the radiation dose in CTP examinations. The purpose of this study was to simulate dose reduction through the addition of noise in brain CT perfusion examinations and to determine the subsequent effects on quality and quantitative interpretation. MATERIALS AND METHODS A total of 22 consecutive reference CTP scans were identified from an institutional review board-approved prospective clinical trial, all performed at 80 keV and 190 mAs. Lower-dose scans at 188, 177, 167, 127, and 44 mAs were generated through the addition of spatially correlated noise to the reference scans. A standard software package was used to generate CBF, CBV, and MTT maps. Six blinded radiologists determined quality scores of simulated scans on a Likert scale. Quantitative differences were calculated. RESULTS For qualitative analysis, the correlation coefficients for CBF (-0.34; P < .0001), CBV (-0.35; P < .0001), and MTT (-0.44; P < .0001) were statistically significant. Interobserver agreements in quality for the simulated 188-, 177-, 167-, 127-, and 44-mAs scans for CBF were 0.95, 0.98, 0.98, 0.95, and 0.52, respectively. Interobserver agreements in quality for the simulated CBV were 1, 1, 1, 1, and 0.83, respectively. For MTT, the interobserver agreements were 0.83, 0.86, 0.88, 0.74, and 0.05, respectively. For quantitative analysis, only the lowest simulated dose of 44 mAs showed statistically significant differences from the reference scan values for CBF (-1.8; P = .04), CBV (0.07; P < .0001), and MTT (0.46; P < .0001). CONCLUSIONS From a reference CTP study performed at 80 keV and 190 mAs, this simulation study demonstrates the potential of a 33% reduction in tube current and dose while maintaining image quality and quantitative interpretations. This work can be used to inform future studies by using true, nonsimulated scans.
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Affiliation(s)
- K Juluru
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY 10065, USA.
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Lev MH. Perfusion Imaging of Acute Stroke: Its Role in Current and Future Clinical Practice. Radiology 2013; 266:22-7. [DOI: 10.1148/radiol.12121355] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Malhotra K, Conners JJ, Lee VH, Prabhakaran S. Relative changes in transcranial Doppler velocities are inferior to absolute thresholds in prediction of symptomatic vasospasm after subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2012; 23:31-6. [PMID: 22959107 DOI: 10.1016/j.jstrokecerebrovasdis.2012.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 07/25/2012] [Accepted: 08/05/2012] [Indexed: 10/27/2022] Open
Abstract
The absolute transcranial Doppler (TCD) velocity threshold has been validated as a screening tool for vasospasm after subarchnoid hemorrhage (SAH). We assessed whether relative changes in velocity were superior to absolute TCD thresholds in the detection of symptomatic vasospasm. We reviewed consecutive patients with aneurysmal SAH who underwent serial TCD monitoring and survived at least 7 days. We recorded initial flow velocity (IFV) and maximal flow velocity (MFV) of the middle cerebral artery (MCA) serially up to 14 days from admission. We calculated relative flow velocity changes (MFV/IFV) and maximum change in mean flow velocity (FVmean) over any consecutive 2 days in addition to standard absolute measures of Lindegaard ratio (LR) and FVmean. We calculated receiver operating characteristic curve and area under curve (AUC) values, sensitivity, specificity, and positive predictive and negative predictive values for these parameters, optimal cutpoints, and various combinations. Forty-eight of 211 patients (23%) developed symptomatic MCA vasospasm. AUC values for various TCD parameters were 0.80 for MCA MFV >175 cm/s, 0.71 for LR >6, 0.64 for MFV/IFV >2, and 0.64 for >70% change in MFV over 2 days. The best characteristics were observed for the combination of MFV >175 cm/s and/or maximal LR >6 (AUC 0.81). Our data suggest that absolute thresholds of TCD FVmean provide the most accurate prediction of symptomatic MCA vasospasm after SAH. Other thresholds, including relative change from baseline and day-to-day changes, are inferior to established absolute thresholds.
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Affiliation(s)
- Konark Malhotra
- Department of Neurological Sciences, Allegheny General Hospital, Pittsburgh, Pennsylvania.
| | - James J Conners
- Section of Cerebrovascular Disease and Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
| | - Vivien H Lee
- Section of Cerebrovascular Disease and Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
| | - Shyam Prabhakaran
- Division of Stroke, Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
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Muñoz-Guillén NM, León-López R, Túnez-Fiñana I, Cano-Sánchez A. From vasospasm to early brain injury: new frontiers in subarachnoid haemorrhage research. Neurologia 2012; 28:309-16. [PMID: 22264777 DOI: 10.1016/j.nrl.2011.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 10/30/2011] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Delayed vasospasm has traditionally been considered the most important determinant of poor outcome after subarachnoid haemorrhage (SAH). Consequently, most of the research and therapies are directed towards reducing the incidence of vasospasm (VSP). To date, however, clinical trials based on this strategy have not delivered a definitive treatment for preventing or reducing brain injury after SAH. This fact has caused a paradigm shift in research, which now focuses on early brain injury (EBI) occurring in the first 72 hours after SAH. It has also changed the idea of VSP's role in brain damage, and suggests the need for re-evaluating the pathophysiological process of SAH. DEVELOPMENT This review examines the current state of knowledge on the pathophysiological mechanisms associated with EBI and summarises the diagnostic options currently available. CONCLUSION It seems that the research approach needs to be changed so that investigators will focus on prevention of EBI, reduction of secondary brain complications and ultimately, the optimisation neurological outcome.
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Affiliation(s)
- N M Muñoz-Guillén
- Unidad de Cuidados Intensivos, Hospital Universitario Reina Sofía, Córdoba, Spain.
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Detection and monitoring of vasospasm and delayed cerebral ischemia: a review and assessment of the literature. Neurocrit Care 2012; 15:312-7. [PMID: 21748499 DOI: 10.1007/s12028-011-9594-8] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Delayed cerebral ischemia (DCI) after subarachnoid hemorrhage can be evaluated using clinical assessment, non-invasive and invasive techniques. An electronic literature search was conducted on English-language articles investigating DCI in human subjects with subarachnoid hemorrhage. A total of 31 relevant papers were identified evaluating the role of clinical assessment, transcranial Doppler, computed tomographic angiography, and computed tomographic perfusion. Clinical assessment by bedside evaluations is limited, especially in patients initially in poorer clinical condition or who are receiving sedative medication for whom deterioration may be more difficult to identify. Transcranial Doppler is a useful screening tool for middle cerebral artery vasospasm, with less utility in evaluating other intracranial vessels. Computed tomographic angiography correlates well with digital subtraction angiography. Computed tomographic perfusion may help predict DCI when used early or identify DCI when used later.
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Kamp MA, Heiroth HJ, Beseoglu K, Turowski B, Steiger HJ, Hänggi D. Early CT Perfusion Measurement After Aneurysmal Subarachnoid Hemorrhage: A Screening Method to Predict Outcome? ACTA NEUROCHIRURGICA SUPPLEMENTUM 2012; 114:329-32. [DOI: 10.1007/978-3-7091-0956-4_63] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Greenberg ED, Gobin YP, Riina H, Johnson CE, Tsiouris AJ, Comunale J, Sanelli PC. Role of CT perfusion imaging in the diagnosis and treatment of vasospasm. ACTA ACUST UNITED AC 2011; 3:287-297. [PMID: 22773929 DOI: 10.2217/iim.11.19] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The current role of CT perfusion (CTP) imaging in the diagnosis and treatment of vasospasm in the setting of aneurysmal subarachnoid hemorrhage is discussed in this article, with specific attention directed towards defining the terminology of vasospasm and delayed cerebral ischemia. A commonly used CTP technique in clinical practice is described. A review of the literature regarding the usefulness of CTP for the diagnosis of vasospasm and its role in guiding treatment are discussed. Recent research advances in the utilization of CTP and associated ongoing challenges are also presented.
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Affiliation(s)
- Edward D Greenberg
- Division of Interventional Neuroradiology, Department of Neurosurgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, NY, USA
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