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Maldonado-Luna M, Castaño-León AM, Baciu AE, Alzamora-Llull L, Vallés-Núñez E, Lagares A. The role of Glucose/Potassium Ratio and Neutrophil/Lymphocyte Ratio in the prognosis of patients with aneurysmal subarachnoid hemorrhage. NEUROCIRUGIA (ENGLISH EDITION) 2025:500655. [PMID: 40043802 DOI: 10.1016/j.neucie.2025.500655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Revised: 01/20/2025] [Accepted: 01/22/2025] [Indexed: 04/05/2025]
Abstract
ANTECEDENTS AND OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Traditional factors strongly associated with poor outcome are neurological condition and the amount of bleeding. Inflammation is considered a relevant mechanism of brain injury after aSAH. This study aims to investigate the potential role of new laboratory indexes related to inflammation for predicting the prognosis of aSAH patients, complementing established prognostic models. MATERIALS AND METHODS We conducted a retrospective observational study including adults admitted for aSAH at a single neurosurgery center from 2002 to 2023. Demographic data, clinical parameters, and blood test results at admission were collected. The main outcome variable was Glasgow Outcome Scale (GOS) six month post-bleeding. A second outcome variable was in-hospital mortality. Univariable analyses were performed to identify new laboratory predictors of poor prognosis. The independent association with outcome was evaluated after adjustment of traditional risk factors by logistic regression analysis. The additional value of new laboratory predictors was determined by comparison of the area under the receiver operating curve (AUROC). RESULTS Among 542 patients with aSAH, 417 met inclusion criteria (age >18 years old and complete laboratory test available upon admission with aSAH confirmed by CT angiography (CTA) or digital subtraction angiography (DSA)). Elevated glucose/potassium ratio (GKR) in the first blood test at admission was significantly associated with unfavorable outcome and in-hospital mortality according to univariate analysis. The GKR was significantly associated with a worse final prognosis (OR 1.033, 95% CI 1.008-1.040) adjusted for age, WFNS and Fisher scales, history of diabetes mellitus and kidney disease, and prior use of diuretics, oral antidiabetic medications and insulin. Additionally, the inclusion of the GKR improved the predictive accuracy of a prognostic model compared to a model including only clinical and radiological data. The neutrophil-lymphocyte ratio (NLR) was not significantly different between subgroups of patients regarding their outcome. CONCLUSION GKR measured in the first 24 h after aSAH may improve the discrimination of patients with higher risk of experiencing poor outcome at six month after the bleeding.
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Affiliation(s)
| | - Ana María Castaño-León
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | | | - Luis Alzamora-Llull
- Hospital Universitario 12 de Octubre, Avenida de Córdoba, 28041, Madrid, Spain
| | - Elvira Vallés-Núñez
- Hospital Universitario 12 de Octubre, Avenida de Córdoba, 28041, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery Hospital Universitario 12 de Octubre, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
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Ezra M, Franko E, Spronk DB, Lamb C, Okell TW, Pattinson KT. Trial of the cerebral perfusion response to sodium nitrite infusion in patients with acute subarachnoid haemorrhage using arterial spin labelling MRI. Nitric Oxide 2024; 153:50-60. [PMID: 39369814 DOI: 10.1016/j.niox.2024.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 10/03/2024] [Accepted: 10/03/2024] [Indexed: 10/08/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (SAH) is a devastating subset of stroke. One of the major determinants of outcome is an evolving multifactorial injury occurring in the first 72 hours, known as early brain injury. Reduced nitric oxide (NO) bioavailability and an associated disruption to cerebral perfusion is believed to play an important role in this process. We sought to explore this relationship, by examining the effect on cerebral perfusion of the in vivo manipulation of NO levels using an exogenous NO donor (sodium nitrite). We performed a double blind placebo controlled randomised experimental medicine study of the cerebral perfusion response to sodium nitrite infusion during the early brain injury period in 15 low grade (World Federation of Neurosurgeons grade 1-2) SAH patients. Patients were randomly assigned to receive sodium nitrite at 10 mcg/kg/min or saline placebo. Assessment occurred following endovascular aneurysm occlusion, mean time after ictus 66h (range 34-90h). Cerebral perfusion was quantified before infusion commencement and after 3 hours, using multi-post labelling delay (multi-PLD) vessel encoded pseudocontinuous arterial spin labelling (VEPCASL) magnetic resonance imaging (MRI). Administration of sodium nitrite was associated with a significant increase in average grey matter cerebral perfusion. Group level voxelwise analysis identified that increased perfusion occurred within regions of the brain known to exhibit enhanced vulnerability to injury. These findings highlight the role of impaired NO bioavailability in the pathophysiology of early brain injury.
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Affiliation(s)
- Martyn Ezra
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | - Edit Franko
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Desiree B Spronk
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Catherine Lamb
- Neuro Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Thomas W Okell
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kyle Ts Pattinson
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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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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Mitchelle A, Gorolay VV, Aitken M, Hanneman K, Huo YR, Manning N, Tan I, Chan MV. CTP for the Screening of Vasospasm and Delayed Cerebral Ischemia in Aneurysmal SAH: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2024; 45:871-878. [PMID: 38816018 DOI: 10.3174/ajnr.a8249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/10/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Delayed cerebral ischemia and vasospasm are the most common causes of late morbidity following aneurysmal SAH, but their diagnosis remains challenging. PURPOSE This systematic review and meta-analysis investigated the diagnostic performance of CTP for detection of delayed cerebral ischemia and vasospasm in the setting of aneurysmal SAH. DATA SOURCES Studies evaluating the diagnostic performance of CTP in the setting of aneurysmal SAH were searched on the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Clinical Answers, Cochrane Methodology Register, Ovid MEDLINE, EMBASE, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, Health Technology Assessment, National Health Service Economic Evaluation Database, PubMed, and Google Scholar from their inception to September 2023. STUDY SELECTION Thirty studies were included, encompassing 1786 patients with aneurysmal SAH and 2302 CTP studies. Studies were included if they compared the diagnostic accuracy of CTP with a reference standard (clinical or radiologic delayed cerebral ischemia, angiographic spasm) for the detection of delayed cerebral ischemia or vasospasm in patients with aneurysmal SAH. The primary outcome was accuracy for the detection of delayed cerebral ischemia or vasospasm. DATA ANALYSIS Bivariate random effects models were used to pool outcomes for sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. Subgroup analyses for individual CTP parameters and early-versus-late study timing were performed. Bias and applicability were assessed using the modified QUADAS-2 tool. DATA SYNTHESIS For assessment of delayed cerebral ischemia, CTP demonstrated a pooled sensitivity of 82.1% (95% CI, 74.5%-87.8%), specificity of 79.6% (95% CI, 73.0%-84.9%), positive likelihood ratio of 4.01 (95% CI, 2.94-5.47), and negative likelihood ratio of 0.23 (95% CI, 0.12-0.33). For assessment of vasospasm, CTP showed a pooled sensitivity of 85.6% (95% CI, 74.2%-92.5%), specificity of 87.9% (95% CI, 79.2%-93.3%), positive likelihood ratio of 7.10 (95% CI, 3.87-13.04), and negative likelihood ratio of 0.16 (95% CI, 0.09-0.31). LIMITATIONS QUADAS-2 assessment identified 12 articles with low risk, 11 with moderate risk, and 7 with a high risk of bias. CONCLUSIONS For delayed cerebral ischemia, CTP had a sensitivity of >80%, specificity of >75%, and a low negative likelihood ratio of 0.23. CTP had better performance for the detection of vasospasm, with sensitivity and specificity of >85% and a low negative likelihood ratio of 0.16. Although the accuracy offers the potential for CTP to be used in limited clinical contexts, standardization of CTP techniques and high-quality randomized trials evaluating its impact are required.
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Affiliation(s)
- Amer Mitchelle
- From the Department of Radiology (A.M., Y.R.H., I.T., M.V.C.), Concord Repatriation and General Hospital, Sydney, Australia
- Concord Hospital Clinical School (A.M., M.V.C.), The University of Sydney, Sydney, Australia
| | - Vineet V Gorolay
- Department of Radiology (V.V.G.), University of California San Francisco, San Francisco, California
- Department of Radiology (V.V.G.), Royal Price Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Matthew Aitken
- Department of Medical Imaging (M.A.), Gold Coast University Hospital, Queensland, Australia
| | - Kate Hanneman
- Department of Medical Imaging (K.H.), University of Toronto, Joint Department of Medical Imaging, Toronto, Ontario, Canada
| | - Ya Ruth Huo
- From the Department of Radiology (A.M., Y.R.H., I.T., M.V.C.), Concord Repatriation and General Hospital, Sydney, Australia
| | - Nathan Manning
- Department of Neurointervention (N.M.), Liverpool Hospital, Sydney, Australia
| | - Irene Tan
- From the Department of Radiology (A.M., Y.R.H., I.T., M.V.C.), Concord Repatriation and General Hospital, Sydney, Australia
| | - Michael V Chan
- From the Department of Radiology (A.M., Y.R.H., I.T., M.V.C.), Concord Repatriation and General Hospital, Sydney, Australia
- Concord Hospital Clinical School (A.M., M.V.C.), The University of Sydney, Sydney, Australia
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Malinova V, Kranawetter B, Tuzi S, Moerer O, Rohde V, Mielke D. Optimal cerebral perfusion pressure in aneurysmal subarachnoid hemorrhage and its relation to perfusion deficits on CT-perfusion. J Cereb Blood Flow Metab 2024:271678X241237879. [PMID: 38708962 PMCID: PMC11572175 DOI: 10.1177/0271678x241237879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 05/07/2024]
Abstract
Preservation of optimal cerebral perfusion is a crucial part of the acute management after aneurysmal subarachnoid hemorrhage (aSAH). A few studies indicated possible benefits of maintaining a cerebral perfusion pressure (CPP) near the calculated optimal CPP (CPPopt), representing an individually optimal condition at which cerebral autoregulation functions at its best. This retrospective observational monocenter study was conducted to investigate, whether "suboptimal" perfusion with actual CPP deviating from CPPopt correlates with perfusion deficits detected by CT-perfusion (CTP). A consecutive cohort of aSAH-patients was reviewed and patients with available parameters for CPPopt-calculation, who simultaneously received CTP, were analyzed. By plotting the pressure reactivity index (PRx) versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. Perfusion deficits on CTP were documented. In 86 out of 324 patients, the inclusion criteria were met. Perfusion deficits were detected in 47% (40/86) of patients. In 43% of patients, CPP was lower than CPPopt, which correlated with detected perfusion deficits (r = 0.23, p = 0.03). Perfusion deficits were found in 62% of patients with CPPCPPopt (OR 3, p = 0.01). These findings support the hypothesis, that a deviation of CPP from CPPopt is an indicator of suboptimal cerebral perfusion.
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Affiliation(s)
- Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Beate Kranawetter
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Sheri Tuzi
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
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Vandenbulcke A, Messerer M, Daniel RT, Cossu G. The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review. Brain Sci 2023; 13:1580. [PMID: 38002540 PMCID: PMC10670052 DOI: 10.3390/brainsci13111580] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, 1015 Lausanne, Switzerland
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Hofmann BB, Rubbert C, Beseoglu K. Cerebral Autoregulation: Don't go with the Flow, be the Flow; Author's Response. Neurocrit Care 2023; 39:266-267. [PMID: 37291417 PMCID: PMC10499668 DOI: 10.1007/s12028-023-01759-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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Han H, Chen Y, Li R, Lin F, Lu J, Chen X, Wang S. The value of early CT perfusion parameters for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:2517-2531. [PMID: 35377027 DOI: 10.1007/s10143-022-01779-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/13/2022] [Accepted: 03/28/2022] [Indexed: 12/30/2022]
Abstract
Delayed cerebral ischemia (DCI) is a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). We aim to investigate the efficacy of early CT perfusion (CTP) parameters for predicting DCI in patients with aSAH. The search was conducted in five databases (PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and China Biology Medicine database). Studies were reviewed by two independent authors, and the included studies were assessed for methodological quality. Fifteen studies with 882 participants were included for the final analysis. The meta-analysis of quantitative parameters showed that mean transit time represented the most valuable predictor when the calculation of the mean value was uniformed (MD 0.30 s, 95% CI: 0.10 to 0.49 s, P = 0.003). Semi-quantitative parameters using relative values or index scores were also widely used to minimize undue variations derived from patients, operators, machines, and software. Studies also demonstrated that these relative parameters had better predictive accuracy than corresponding absolute parameters. Perfusion thresholds in each study were incomparable, and the results warranted further validation. The best threshold for the prediction was 0.9 using the relative cerebral blood flow parameter (sensitivity 97% and specificity 89%). We conclude that CTP in the early phase is a promising tool for predicting DCI in aSAH patients. However, the parameters require standardization. Future studies with prospective, multi-centered design and large sample size are needed to validate the thresholds and optimize the parameters.
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Affiliation(s)
- Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
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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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10
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Naraoka M, Matsuda N, Shimamura N, Ohkuma H. Role of microcirculatory impairment in delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2022; 42:186-196. [PMID: 34496662 PMCID: PMC8721782 DOI: 10.1177/0271678x211045446] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Early brain injury (EBI) is considered an important cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). As a factor in EBI, microcirculatory dysfunction has become a focus of interest, but whether microcirculatory dysfunction is more important than angiographic vasospasm (aVS) remains unclear. Using data from 128 cases, we measured the time to peak (TTP) in several regions of interest on digital subtraction angiography. The intracerebral circulation time (iCCT) was obtained between the TTP in the ultra-early phase (the baseline iCCT) and in the subacute phase and/or at delayed cerebral ischemia (DCI) onset (the follow-up iCCT). In addition, the difference in the iCCT was calculated by subtracting the baseline iCCT from the follow-up iCCT. Univariate analysis showed that DCI was significantly increased in those patients with a prolonged baseline iCCT, prolonged follow-up iCCT, increased differences in the iCCT, and with severe aVS. Poor outcome was significantly increased in patients with prolonged follow-up iCCT and increased differences in the iCCT. Multivariate analysis revealed that increased differences in the iCCT were a significant risk factor that increased DCI and poor outcome. The results suggest that the increasing microcirculatory dysfunction over time, not aVS, causes DCI and poor outcome after aneurysmal aSAH.
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Affiliation(s)
- Masato Naraoka
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Naoya Matsuda
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Norihito Shimamura
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
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Abdel-Tawab M, Hasan AA, Ahmed MA, Seif HMA, Yousif HA. Prognostic factors of delayed cerebral ischemia after subarachnoid hemorrhage including CT perfusion: a prospective cohort study. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00180-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Abstract
Background
Delayed cerebral ischemia (DCI) is the worst sequel following subarachnoid hemorrhage (SAH), representing a challenge in prediction and prevention. The current study aims to identify the optimum predictors of DCI including CT perfusion (CTP) and to determine the best prognostic thresholds.
This prospective study included 49 SAH patients. All patients were treated with the standard therapy and underwent non-contrast CT, CTP, and CTA within 3 days after SAH. Hunt and Hess and Fisher scales were assessed besides quantitative CTP parameters. The primary endpoint was DCI within 21 days after SAH, defined as clinical deterioration or infarction.
Results
Out of 49 eligible patients with SAH, 9 patients developed DCI. Univariate analysis revealed that Hunt and Hess scale, Fisher scale, the presence of a cerebral aneurysm, and mean transit time (MTT) were predictive for DCI. Diagnostic threshold values by ROC curve analysis with optimal sensitivity and specificity were Hunt and Hess scale > 2, Fisher scale > 2, and MTT of 4.65 s.
Conclusion
MTT is a sensitive and specific predictor of DCI. However, Hunt and Hess scale has the optimal sensitivity and specificity to distinguish between patients who developed DCI and clinically stable patients.
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12
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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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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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Temporal Dynamics of Cerebral Blood Flow During the Acute Course of Severe Subarachnoid Hemorrhage Studied by Bedside Xenon-Enhanced CT. Neurocrit Care 2020; 30:280-290. [PMID: 30790226 PMCID: PMC6420446 DOI: 10.1007/s12028-019-00675-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Compromised cerebral blood flow (CBF) is a crucial factor in delayed cerebral ischemia after subarachnoid hemorrhage (SAH). Repeated measurement of CBF may improve our understanding of the temporal dynamics following SAH. The aim of this study was to assess CBF at different phases of the acute course in poor-grade SAH patients, hypothesizing more pronounced disturbances at day 4–7, and that the initial level of CBF determines the following course of CBF. Methods Mechanically ventilated SAH patients were scheduled for bedside measurement of regional and global cortical CBF at day 0–3, 4–7, and 8–12, using xenon-enhanced computed tomography in a mobile setup. Patients were dichotomized depending on high or low initial global cortical CBF and cutoff level 30 ml/100 g/min. Results Eighty-one patients were included, and 51 had measurements at day 0–3 and 4–7. In patients with high initial CBF, the level was unchanged at day 4–7; 37.7 (IQR 32.6–46.7) ml/100 g/min versus 36.8 (IQR 29.5–44.8). The low-CBF group showed a slight increase from 23.6 (IQR 21.0–28.1) ml/100 g/min to 28.4 (IQR 22.7–38.3) (P = 0.025), still markedly lower than the high-CBF group (P = 0.016). In the low-CBF group, CBF increased in patients who received hypertension, hypervolemia, and hemodilution (HHH therapy) but remained low in standard treated patients. For the subset of 27 patients examined also at day 8–12, the differences depending on initial CBF level were no longer statistically significant. Among patients with still low CBF at day 4–7, the proportion who had poor short-term outcome was 55% compared to 35% (n.s.) for patients with high CBF. Conclusions CBF studied in poor-grade SAH patients at large did not show any statistically significant changes over time. Stratifying patients by high or low initial CBF and whether HHH therapy was given revealed an association between low initial CBF and persistent low CBF at day 4–7. These findings may be of clinical relevance in managing SAH patients with low early CBF.
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15
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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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16
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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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17
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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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18
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You C, Sun H, Ma J, Liu Y. CT Perfusion for Identification of Patients at Risk for Delayed Cerebral Ischemia during the Acute Phase after Aneurysmal Subarachnoid Hemorrhage: A Meta-analysis. Neurol India 2019; 67:1235-1239. [DOI: 10.4103/0028-3886.271235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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19
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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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20
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Fragata I, Canto-Moreira N, Canhão P. Comparison of cerebral perfusion in perimesencephalic subarachnoid hemorrhage and aneurysmal subarachnoid hemorrhage. Neuroradiology 2018. [PMID: 29523945 DOI: 10.1007/s00234-018-1997-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Perimesencephalic hemorrhage (PMH) is a benign subtype of nonaneurysmal subarachnoid hemorrhage (SAH). We aimed to investigate if cerebral perfusion in PMH is less affected than in aneurysmal SAH (aSAH). METHODS From a prospective cohort of 80 patients with spontaneous SAH, we included PMH patients (n = 15) and selected aSAH patients (n = 39) with similar clinical grade at admission (World Federation of Neurosurgeons Scale-WFNS I/II). Computed tomography (CT) perfusion was performed at < 72 h and/or at 8-10 days. Cerebral perfusion parameter values were compared between groups with nonparametric tests. Subgroup analyses compared PMH and aSAH patients stratified according to aneurysmal location (anterior or posterior circulation) and blood burden (Fisher grade). RESULTS At < 72 h, no significant differences in perfusion parameters were found between PMH and aSAH patients. At 8-10 days, PMH patients had lower MTT than aSAH patients, and a trend for higher CBF. PMH patients had higher CBF and CBV at < 72 h when compared to posterior circulation aSAH patients. When compared to aSAH patients with similar blood burden, PMH patients had higher CBF and lower MTT at < 72 h, and lower MTT at 8-10 days. CONCLUSION PMH patients had better cerebral perfusion compared to patients with aSAH, particularly during the vasospasm time window. After stratifying for the amount of blood, PMH patients also had better cerebral perfusion in the first 72 h after SAH. These results are in line with the better clinical presentation and prognosis of PMH, and possibly with a different etiology.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Hospital São José, Centro Hospitalar Lisboa Central, NOVA Medical School, Lisbon, Portugal.
| | - Nuno Canto-Moreira
- Department of Neuroradiology, Department of Pediatric Radiology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Patrícia Canhão
- Department of Neurosciences and Mental Health, Neurology, Faculty of Medicine, Hospital de Santa Maria, CHLN, University of Lisbon, Lisbon, Portugal
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21
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Takahashi Y, Sasahara A, Yamazaki K, Inazuka M, Kasuya H. Disturbance of CT perfusion within 24 h after onset is associated with WFNS grade but not development of DCI in patients with aneurysmal SAH. Acta Neurochir (Wien) 2017; 159:2319-2324. [PMID: 29058091 DOI: 10.1007/s00701-017-3362-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/10/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is a serious complication following aneurysmal SAH (aSAH) and remains a leading cause of morbidity and mortality. We investigated whether data from CT perfusion (CTP) within 24 h after onset are associated with DCI and its outcome. METHODS We retrospectively examined plain CT, CTP, and CT angiography (CTA) of aSAH patients on arrival. We measured the average mean transit time (aMTT) and compared it with several clinical factors, such as the age, WFNS grade, Fisher group, delayed cerebral infarction, cerebral vasospasm, and modified Rankin scale (mRS), at 1 month. Regions of interest (ROIs) were quantitatively determined in cortical and two basal ganglia areas. RESULTS Delayed cerebral ischemia (DCI) developed in 11 patients and cerebral vasospasm in 28 patients out of a total of 86 aSAH patients scanned within 24 h after onset. The average MTT was correlated with the WFNS grade (p = 0.000), but not mRS (p = 0.128), age (p = 0.759), DCI (p = 0.669), or cerebral vasospasm (p = 0.306). On the other hand, DCI was associated with the Fisher group (p = 0.0056), mRS (p = 0.0052), and cerebral vasospasm (p = 0.000). Moreover, there were no significant differences in the average MTT within 24 h after onset between territories with and without DCI, or between patients with and without DCI. CONCLUSIONS The current findings suggest that disturbance of CT perfusion soon after the onset is associated with the WFNS grade but not with the development of DCI. Delayed cerebral ischemia may be solely caused by cerebral vasospasm due to a clot in the cistern, but not associated with early brain injury.
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Affiliation(s)
- Yuichi Takahashi
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Atsushi Sasahara
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan.
| | - Kei Yamazaki
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Mayuko Inazuka
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
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Nelson S, Edlow BL, Wu O, Rosenthal ES, Westover MB, Rordorf G. Default Mode Network Perfusion in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2017; 25:237-42. [PMID: 26800697 DOI: 10.1007/s12028-016-0244-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The etiology of altered consciousness in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH) is not thoroughly understood. We hypothesized that decreased cerebral blood flow (CBF) in brain regions critical to consciousness may contribute. METHODS We retrospectively evaluated arterial-spin labeled (ASL) perfusion magnetic resonance imaging (MRI) measurements of CBF in 12 patients with aneurysmal SAH admitted to our neurocritical care unit. CBF values were analyzed within gray matter nodes of the default mode network (DMN), whose functional integrity has been shown to be necessary for consciousness. DMN nodes studied were the bilateral medial prefrontal cortices, thalami, and posterior cingulate cortices. Correlations between nodal CBF and admission Glasgow Coma Scale (GCS) score, admission Hunt and Hess (HH) class, and GCS score at the time of MRI (MRI GCS) were tested. RESULTS Spearman's correlation coefficients were not significant when comparing admission GCS, admission HH, and MRI GCS versus nodal CBF (p > 0.05). However, inter-rater reliability for nodal CBF was high (r = 0.71, p = 0.01). CONCLUSIONS In this retrospective pilot study, we did not identify significant correlations between CBF and admission GCS, admission HH class, or MRI GCS for any DMN node. Potential explanations for these findings include small sample size, ASL data acquisition at variable times after SAH onset, and CBF analysis in DMN nodes that may not reflect the functional integrity of the entire network. High inter-rater reliability suggests ASL measurements of CBF within DMN nodes are reproducible. Larger prospective studies are needed to elucidate whether decreased cerebral perfusion contributes to altered consciousness in SAH.
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Affiliation(s)
- Sarah Nelson
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Guy Rordorf
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
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23
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Carteron L, Patet C, Solari D, Messerer M, Daniel RT, Eckert P, Meuli R, Oddo M. Non-Ischemic Cerebral Energy Dysfunction at the Early Brain Injury Phase following Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2017; 8:325. [PMID: 28740479 PMCID: PMC5502330 DOI: 10.3389/fneur.2017.00325] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The pathophysiology of early brain injury following aneurysmal subarachnoid hemorrhage (SAH) is still not completely understood. OBJECTIVE Using brain perfusion CT (PCT) and cerebral microdialysis (CMD), we examined whether non-ischemic cerebral energy dysfunction may be a pathogenic determinant of EBI. METHODS A total of 21 PCTs were performed (a median of 41 h from ictus onset) among a cohort of 18 comatose mechanically ventilated SAH patients (mean age 58 years, median admission WFNS score 4) who underwent CMD and brain tissue PO2 (PbtO2) monitoring. Cerebral energy dysfunction was defined as CMD episodes with lactate/pyruvate ratio (LPR) >40 and/or lactate >4 mmol/L. PCT-derived global CBF was categorized as oligemic (CBF < 28 mL/100 g/min), normal (CBF 28-65 mL/100 g/min), or hyperemic (CBF 69-85 mL/100 g/min), and was matched to CMD/PbtO2 data. RESULTS Global CBF (57 ± 14 mL/100 g/min) and PbtO2 (25 ± 9 mm Hg) were within normal ranges. Episodes with cerebral energy dysfunction (n = 103 h of CMD samples, average duration 7.4 h) were frequent (66% of CMD samples) and were associated with normal or hyperemic CBF. CMD abnormalities were more pronounced in conditions of hyperemic vs. normal CBF (LPR 54 ± 12 vs. 42 ± 7, glycerol 157 ± 76 vs. 95 ± 41 µmol/L; both p < 0.01). Elevated brain LPR correlated with higher CBF (r = 0.47, p < 0.0001). CONCLUSION Cerebral energy dysfunction is frequent at the early phase following poor-grade SAH and is associated with normal or hyperemic brain perfusion. Our data support the notion that mechanisms alternative to ischemia/hypoxia are implicated in the pathogenesis of early brain injury after SAH.
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Affiliation(s)
- Laurent Carteron
- Department of Intensive Care Medicine, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland.,Neuroscience Critical Care Research Group, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Camille Patet
- Department of Intensive Care Medicine, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland.,Neuroscience Critical Care Research Group, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Daria Solari
- Department of Intensive Care Medicine, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland.,Neuroscience Critical Care Research Group, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Philippe Eckert
- Department of Intensive Care Medicine, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Reto Meuli
- Department of Radiology, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland.,Neuroscience Critical Care Research Group, CHUV-University Hospital, University of Lausanne, Lausanne, Switzerland
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Torné R, Rodríguez-Hernández A, Romero-Chala F, Arikan F, Vilalta J, Sahuquillo J. Prognosis of patients in coma after acute subdural hematoma due to ruptured intracranial aneurysm. J Clin Neurosci 2016; 26:126-9. [DOI: 10.1016/j.jocn.2015.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/21/2015] [Accepted: 06/14/2015] [Indexed: 11/29/2022]
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25
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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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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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Lagares A, Jiménez-Roldán L, Gomez PA, Munarriz PM, Castaño-León AM, Cepeda S, Alén JF. Prognostic Value of the Amount of Bleeding After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2015; 77:898-907; discussion 907. [DOI: 10.1227/neu.0000000000000927] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND:
Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a new tool of assessing prognosis.
OBJECTIVE:
To determine the prognostic value of the quantitative estimation of the amount of bleeding after aneurysmal subarachnoid hemorrhage, as well the relative importance of this factor related to other prognostic indicators, and to establish a possible cut-off value of volume of bleeding related to poor outcome.
METHODS:
A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume.
RESULTS:
Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding.
CONCLUSION:
Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk.
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Affiliation(s)
- Alfonso Lagares
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Luis Jiménez-Roldán
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Pedro A. Gomez
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Pablo M. Munarriz
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Ana M. Castaño-León
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Santiago Cepeda
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - José F. Alén
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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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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Moore SA, Rabinstein AA, Stewart MW, David Freeman W. Recognizing the signs and symptoms of aneurysmal subarachnoid hemorrhage. Expert Rev Neurother 2015; 14:757-68. [PMID: 24949896 DOI: 10.1586/14737175.2014.922414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Subarachnoid hemorrhage (SAH) is a devastating neurologic condition with a high mortality and long term neurological morbidity in 50% of survivors. In addition, SAH commonly affects young patients causing substantial loss of productive life years and resulting in significant long term healthcare costs. Early recognition of the signs and symptoms of SAH is absolutely critical to earlier intervention, and delays in diagnosis can have devastating consequences. To avoid such delays in SAH diagnosis, the medical provider should recognize its signs and symptoms. Neuroimgaging, cerebrospinal fluid examination and angiography (invasive or non-invasive) facilitate early diagnosis of SAH. The purpose of this review is not to provide an exhaustive critique of the available literature, rather, it is to provide an overview that will better enable a provider to recognize and initiate the workup of patients with SAH.
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Affiliation(s)
- S Arthur Moore
- Department of Neurology, Critical Care, Mayo Clinic, Rochester, MN 55902, USA
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Sorimachi T, Osada T, Aoki R, Nishiyama J, Hirayama A, Srivatanakul K, Matsumae M. Density of the cerebral cortex in computed tomography angiography source images and clinical outcomes in Grade V subarachnoid hemorrhage. Neurol Res 2015; 37:484-90. [DOI: 10.1179/1743132815y.0000000001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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de Oliveira Manoel AL, Mansur A, Murphy A, Turkel-Parrella D, Macdonald M, Macdonald RL, Montanera W, Marotta TR, Bharatha A, Effendi K, Schweizer TA. Aneurysmal subarachnoid haemorrhage from a neuroimaging perspective. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:557. [PMID: 25673429 PMCID: PMC4331293 DOI: 10.1186/s13054-014-0557-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Neuroimaging is a key element in the management of patients suffering from subarachnoid haemorrhage (SAH). In this article, we review the current literature to provide a summary of the existing neuroimaging methods available in clinical practice. Noncontrast computed tomography is highly sensitive in detecting subarachnoid blood, especially within 6 hours of haemorrhage. However, lumbar puncture should follow a negative noncontrast computed tomography scan in patients with symptoms suspicious of SAH. Computed tomography angiography is slowly replacing digital subtraction angiography as the first-line technique for the diagnosis and treatment planning of cerebral aneurysms, but digital subtraction angiography is still required in patients with diffuse SAH and negative initial computed tomography angiography. Delayed cerebral ischaemia is a common and serious complication after SAH. The modern concept of delayed cerebral ischaemia monitoring is shifting from modalities that measure vessel diameter to techniques focusing on brain perfusion. Lastly, evolving modalities applied to assess cerebral physiological, functional and cognitive sequelae after SAH, such as functional magnetic resonance imaging or positron emission tomography, are discussed. These new techniques may have the advantage over structural modalities due to their ability to assess brain physiology and function in real time. However, their use remains mainly experimental and the literature supporting their practice is still scarce.
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Cremers CHP, van der Schaaf IC, Wensink E, Greving JP, Rinkel GJE, Velthuis BK, Vergouwen MDI. CT perfusion and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Cereb Blood Flow Metab 2014; 34:200-7. [PMID: 24281744 PMCID: PMC3915217 DOI: 10.1038/jcbfm.2013.208] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 01/17/2023]
Abstract
Delayed cerebral ischemia (DCI) is at presentation a diagnosis per exclusionem, and can only be confirmed with follow-up imaging. For treatment of DCI a diagnostic tool is needed. We performed a systematic review to evaluate the value of CT perfusion (CTP) in the prediction and diagnosis of DCI. We searched PubMed, Embase, and Cochrane databases to identify studies on the relationship between CTP and DCI. Eleven studies totaling 570 patients were included. On admission, cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-peak (TTP) did not differ between patients who did and did not develop DCI. In the DCI time-window (4 to 14 days after subarachnoid hemorrhage (SAH)), DCI was associated with a decreased CBF (pooled mean difference -11.9 mL/100 g per minute (95% confidence interval (CI): -15.2 to -8.6)) and an increased MTT (pooled mean difference 1.5 seconds (0.9-2.2)). Cerebral blood volume did not differ and TTP was rarely reported. Perfusion thresholds reported in studies were comparable, although the corresponding test characteristics were moderate and differed between studies. We conclude that CTP can be used in the diagnosis but not in the prediction of DCI. A need exists to standardize the method for measuring perfusion with CTP after SAH, and optimize and validate perfusion thresholds.
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Affiliation(s)
- Charlotte H P Cremers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Emerens Wensink
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology , University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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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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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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Sanelli PC, Anumula N, Johnson CE, Comunale JP, Tsiouris AJ, Riina H, Segal AZ, Stieg PE, Zimmerman RD, Mushlin AI. Evaluating CT perfusion using outcome measures of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2013; 34:292-8. [PMID: 22859289 DOI: 10.3174/ajnr.a3225] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE DCI is a serious complication following aneurysmal SAH and remains a leading cause of morbidity and mortality. Our aim was to evaluate CTP in aneurysmal SAH by using outcome measures of DCI. MATERIALS AND METHODS This was a retrospective study of consecutive patients with SAH enrolled in a prospective institutional review board-approved clinical accuracy trial. Qualitative CTP deficits were determined by 2 neuroradiologists blinded to clinical and imaging data. Quantitative CTP was performed by using a standardized protocol with region-of-interest placement sampling of the cortex. Primary outcome measures were permanent neurologic deficits and infarction. The secondary outcome measure was DCI, defined as clinical deterioration. CTP test characteristics (95% CI) were determined for each outcome measure. Statistical significance was calculated by using the Fisher exact and Student t tests. ROC curves were generated to determine accuracy and threshold analysis. RESULTS Ninety-six patients were included. Permanent neurologic deficits developed in 33% (32/96). CTP deficits were seen in 78% (25/32) of those who developed permanent neurologic deficits and 34% (22/64) of those without (P < .0001). CTP deficits had 78% (61%-89%) sensitivity, 66% (53%-76%) specificity, and 53% (39%-67%) positive and 86% (73%-93%) negative predictive values. Infarction occurred in 18% (17/96). CTP deficits were seen in 88% (15/17) of those who developed infarction and 41% (32/79) of those without (P = .0004). CTP deficits had an 88% (66%-97%) sensitivity, 59% (48%-70%) specificity, and 32% (20%-46%) positive and 96% (86%-99%) negative predictive values. DCI was diagnosed in 50% (48/96). CTP deficits were seen in 81% (39/48) of patients with DCI and in 17% (8/48) of those without (P < .0001). CTP deficits had 81% (68%-90%) sensitivity, 83% (70%-91%) specificity, and 83% (70%-91%) positive and 82% (69%-90%) negative predictive values. Quantitative CTP revealed significantly reduced CBF and prolonged MTT for DCI, permanent neurologic deficits, and infarction. ROC analysis showed that CBF and MTT had the highest accuracy. CONCLUSIONS CTP may add prognostic information regarding DCI and poor outcomes in aneurysmal SAH.
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Affiliation(s)
- P C Sanelli
- Departments of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York 10065, USA.
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Jiménez-Roldán L, Alén JF, Gómez PA, Lobato RD, Ramos A, Munarriz PM, Lagares A. Volumetric analysis of subarachnoid hemorrhage: assessment of the reliability of two computerized methods and their comparison with other radiographic scales. J Neurosurg 2012; 118:84-93. [PMID: 22998059 DOI: 10.3171/2012.8.jns12100] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT There were two main purposes to this study: first, to assess the feasibility and reliability of 2 quantitative methods to assess bleeding volume in patients who suffered spontaneous subarachnoid hemorrhage (SAH), and second, to compare these methods to other qualitative and semiquantitative scales in terms of reliability and accuracy in predicting delayed cerebral ischemia (DCI) and outcome. METHODS A prospective series of 150 patients consecutively admitted to the Hospital 12 de Octubre over a 4-year period were included in the study. All of these patients had a diagnosis of SAH, and diagnostic CT was able to be performed in the first 24 hours after the onset of the symptoms. All CT scans were evaluated by 2 independent observers in a blinded fashion, using 2 different quantitative methods to estimate the aneurysmal bleeding volume: region of interest (ROI) volume and the Cavalieri method. The images were also graded using the Fisher scale, modified Fisher scale, Claasen scale, and the semiquantitative Hijdra scale. Weighted κ coefficients were calculated for assessing the interobserver reliability of qualitative scales and the Hijdra scores. For assessing the intermethod and interrater reliability of volumetric measurements, intraclass correlation coefficients (ICCs) were used as well as the methodology proposed by Bland and Altman. Finally, weighted κ coefficients were calculated for the different quartiles of the volumetric measurements to make comparison with qualitative scales easier. Patients surviving more than 48 hours were included in the analysis of DCI predisposing factors and analyzed using the chi-square or the Mann-Whitney U-tests. Logistic regression analysis was used for predicting DCI and outcome in the different quartiles of bleeding volume to obtain adjusted ORs. The diagnostic accuracy of each scale was obtained by calculating the area under the receiver operating characteristic curve (AUC). RESULTS Qualitative scores showed a moderate interobserver reproducibility (weighted κ indexes were always < 0.65), whereas the semiquantitative and quantitative scores had a very strong interobserver reproducibility. Reliability was very high for all quantitative measures as expressed by the ICCs for intermethod and interobserver agreement. Poor outcome and DCI occurred in 49% and 31% of patients, respectively. Larger bleeding volumes were related to a poorer outcome and a higher risk of developing DCI, and the proportion of patients suffering DCI or a poor outcome increased with each quartile, maintaining this relationship after adjusting for the main clinical factors related to outcome. Quantitative analysis of total bleeding volume achieved the highest AUC, and had a greater discriminative ability than the qualitative scales for predicting the development of DCI and outcome. CONCLUSIONS The use of quantitative measures may reduce interobserver variability in comparison with categorical scales. These measures are feasible using dedicated software and show a better prognostic capability in relation to outcome and DCI than conventional categorical scales.
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Affiliation(s)
- Luis Jiménez-Roldán
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid, Spain
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