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Mutoh T, Totsune T, Takenaka S, Tatewaki Y, Nakagawa M, Suarez JI, Taki Y, Ishikawa T. Reduced CBF recovery detected by longitudinal 3D-SSP SPECT analyses predicts outcome of postoperative patients after subarachnoid haemorrhage. Clin Exp Pharmacol Physiol 2017; 45:127-132. [PMID: 28981977 DOI: 10.1111/1440-1681.12867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 09/18/2017] [Accepted: 09/21/2017] [Indexed: 11/27/2022]
Abstract
The aim of this study was to evaluate the impact of cerebral blood flow (CBF) recovery obtained from brain single-photon emission computed tomography (SPECT) images on postoperative outcome after aneurysmal subarachnoid haemorrhage (SAH). Twenty-nine patients who had undergone surgical clipping for ruptured anterior communicating artery aneurysms were analyzed prospectively. Routine measurements of CBF were performed using technetium-99 m hexamethyl propyleneamine oxine SPECT on days 4 and 14 after SAH. Regional voxel data analyzed by three dimensional stereotactic surface projection (3D-SSP) were compared between patients and age-matched normal database (NDB). In 3D-SSP analysis of all patients, cortical hypoperfusion around the surgical site in bilateral frontal lobes was evident on day 4 (P < .05 vs NDB), which was improved significantly on day 14. However, the recovery was less complete in patients with poor clinical grades (P < .05) and presenting symptoms attributable to delayed cerebral ischaemia (DCI) (P < .05) than those without. Multivariate analysis showed that patients with mild to moderate CBF recovery (relative Z-score differences of <4) (P = .014; odds ratio, 2.5; 95% confidence interval, 1.93-3.31) was independently associated with poor functional outcome at 3 months. We conclude that reduced CBF recovery detected by serial 3D-SSP SPECT image analyses can be a potential predictor of poor prognosis in postoperative patients after SAH.
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Affiliation(s)
- Tatsushi Mutoh
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan.,Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Tomoko Totsune
- Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Shunsuke Takenaka
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
| | - Yasuko Tatewaki
- Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Manabu Nakagawa
- Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yasuyuki Taki
- Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
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Wang F, Yin YH, Jia F, Jiang JY. Effects of topical administration of nimodipine on cerebral blood flow following subarachnoid hemorrhage in pigs. J Neurotrauma 2013; 30:591-6. [PMID: 19558207 DOI: 10.1089/neu.2009.0890] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We sought to explore whether topical administration of nimodipine improves the abnormal cerebral perfusion following subarachnoid hemorrhage (SAH) in pigs. Fourteen pigs were randomly divided into three groups: sham (n=4), SAH (n=5), or SAH + nimodipine (n=5). The SAH model was established by injecting fresh autologous nonheparinized arterial blood into the suprasellae cistern. Nimodipine or saline placebo (0.04 g/mL) were administered to the operative area on the fourth day after the SAH model was established. The cerebral blood flow (CBF) was measured 60 min after topical administration of nimodipine by cranial SPECT/CT scans with 5 mCi 99mTc-ECD injected intravenously. The CCR (corticocebellar ratio) was calculated by dividing the counts/voxel of the whole cerebral hemisphere by the average count/voxel in the cerebellar region of reference and RD (relative dispersion). A predictor for impaired autoregulation of CBF was calculated by dividing standard deviation (SD) of regional perfusion by mean perfusion (RD=SD/Mean). CCR and RD were applied to describe hemisphere CBF and perfusion heterogeneity. Cerebral perfusion significantly decreased in the SAH group (CCR: 1.382±0.192, RD: 0.417±0.015) compared to sham (CCR: 1.988±0.346, RD 0.389±0.015) (p<0.05). Abnormal cerebral perfusion status, however, was not significantly improved in the nimodipine + SAH group (CCR: 1.503±0.107, RD: 0.425±0.018) compared to the SAH group (p>0.05). Topical administration of nimodipine did not significantly improve CBF following SAH. These findings were not consistent with our previous data demonstrating that the topical administration of nimodipine significantly alleviates cerebral vasospasm following SAH detected by TCD. Potential mechanisms governing these disparate outcomes require further investigation.
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Affiliation(s)
- Fei Wang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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The value of perfusion computed tomography in predicting clinically relevant vasospasm in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2012; 36:267-78; discussion 278. [DOI: 10.1007/s10143-012-0430-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 04/29/2012] [Accepted: 07/15/2012] [Indexed: 10/27/2022]
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Diedler J, Sykora M, Hacke W. Critical Care of the Patient with Acute Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Greenberg ED, Gold R, Reichman M, John M, Ivanidze J, Edwards AM, Johnson CE, Comunale JP, Sanelli P. Diagnostic accuracy of CT angiography and CT perfusion for cerebral vasospasm: a meta-analysis. AJNR Am J Neuroradiol 2010; 31:1853-60. [PMID: 20884748 PMCID: PMC3130003 DOI: 10.3174/ajnr.a2246] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 05/30/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In recent years, the role of CTA and CTP for vasospasm diagnosis in the setting of ASAH has been the subject of many research studies. The purpose of this study was to perform a meta-analysis of the diagnostic performance of CTA and CTP for vasospasm in patients with ASAH by using DSA as the criterion standard. MATERIALS AND METHODS The search strategy for research studies was based on the Cochrane Handbook for Systematic Reviews, including literature data bases (PubMed, Embase, Cochrane Database of Systematic Reviews, and the Web of Science) and reference lists of manuscripts published from January 1996 to February 2009. The inclusion criteria were the following: 1) published manuscripts, 2) original research studies with prospective or retrospective data, 3) patients with ASAH, 4) CTA or CTP as the index test, and 5) DSA as the reference standard. Three reviewers independently assessed the quality of these research studies by using the QUADAS tool. Pooled estimates of sensitivity, specificity, LR+, LR-, DOR, and the SROC curve were determined. RESULTS CTA and CTP searches yielded 505 and 214 manuscripts, respectively. Ten research studies met inclusion criteria for each CTA and CTP search. Six CTA and 3 CTP studies had sufficient data for statistical analysis. CTA pooled estimates had 79.6% sensitivity (95%CI, 74.9%-83.8%), 93.1%specificity (95%CI, 91.7%-94.3%), 18.1 LR+ (95%CI, 7.3-45.0), and 0.2 LR- (95%CI, 0.1-0.4); and CTP pooled estimates had 74.1% sensitivity (95%CI, 58.7%- 86.2%), 93.0% specificity (95% CI, 79.6%-98.7%), 9.3 LR+ (95%CI, 3.4-25.9), and 0.2 LR- (95%CI, 0.04-1.2). Overall DORs were 124.5 (95%CI, 28.4-546.4) for CTA and 43.0 (95%CI, 6.5-287.1) for CTP. Area under the SROC curve was 98 ± 2.0%for CTA and 97 ± 3.0% for CTP. CONCLUSIONS The high diagnostic accuracy determined for both CTA and CTP in this meta-analysis suggests that they are potentially valuable techniques for vasospasm diagnosis in ASAH. Awareness of these results may impact patient care by providing supportive evidence for more effective use of CTA and CTP imaging in ASAH.
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Affiliation(s)
- E D Greenberg
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York 10021, USA.
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Diagnóstico de la isquemia cerebral tardía y el vasospasmo cerebral en la hemorragia subaracnoidea. Neurologia 2010. [DOI: 10.1016/j.nrl.2009.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Perfusion CT to quantify the cerebral vasospasm following subarachnoid hemorrhage. J Neuroradiol 2010; 37:284-91. [PMID: 20416949 DOI: 10.1016/j.neurad.2010.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 01/28/2010] [Accepted: 03/08/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE After subarachnoid hemorrhage (SAH), vasospasm is frequent and increases the risk of stroke and poor clinical outcome. The purpose of this study was to identify the best perfusion parameters in perfusion-CT (PCT) able to predict vasospasm diagnosed by angiography after SAH. METHODS Seventy-six patients with SAH were investigated by PCT and cerebral angiography. Using regions of interest (ROI) on parametric maps of mean transit time (MTT), time to peak (TTP), cerebral blood volume (CBV) and cerebral blood flow (CBF), PCT data were compared to an arteriographic score in two categories (severe vasospasm: ≥ 50% and non-severe vasospasm: <50%) for each artery. Best PCT predictors of the arteriographic score were tested using multiparametric logistic regression. RESULTS Among the 76 patients, PCT data were reliable in 65 patients. Twenty-seven patients had a severe vasospasm. Logistic regression showed that MTT was the best predictor of the arteriographic score. Using MTT, odds ratios having a vasospasm were superior to 3.1 and the occurrence of a vasospasm was accurately predicted in 78.5 to 100%, depending on the artery considered. However, no absolute value of the MTT could be identified to predict the occurrence of vasospasm. In fact, abnormal values of MTT ranged from 123 to 221% (m=146%) of the control values. DISCUSSION AND CONCLUSIONS PCT may accurately identify severe vasospasm and might be used as a convenient noninvasive imaging modality to monitor patients with SAH. When detected, severe vasospasm could be confirmed and managed using angiography and endovascular treatment, appropriately.
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Risk Factors and Medical Management of Vasospasm After Subarachnoid Hemorrhage. Neurosurg Clin N Am 2010; 21:353-64. [DOI: 10.1016/j.nec.2009.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Delgado Almandoz JE, Romero JM, Pomerantz SR, Lev MH. Computed Tomography Angiography of the Carotid and Cerebral Circulation. Radiol Clin North Am 2010; 48:265-81, vii-viii. [DOI: 10.1016/j.rcl.2010.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Semiquantitative software SPECT analysis in aneurysmal subarachnoid hemorrhage-related vasospasm. Nucl Med Commun 2010; 31:53-8. [DOI: 10.1097/mnm.0b013e328330db10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Rodríguez García P, Rodríguez Pupo L, Rodríguez García D. Diagnosis of delayed cerebral ischaemia and cerebral vasospasm in subarachnoid haemorrhage. NEUROLOGÍA (ENGLISH EDITION) 2010. [DOI: 10.1016/s2173-5808(10)70060-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Nogueira RG, Lev MH, Roccatagliata L, Hirsch JA, Gonzalez RG, Ogilvy CS, Halpern EF, Rordorf GA, Rabinov JD, Pryor JC. Intra-arterial nicardipine infusion improves CT perfusion-measured cerebral blood flow in patients with subarachnoid hemorrhage-induced vasospasm. AJNR Am J Neuroradiol 2008; 30:160-4. [PMID: 18945790 DOI: 10.3174/ajnr.a1275] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to determine the effects of intra-arterial (IA) nicardipine infusion on the cerebral hemodynamics of patients with aneurysmal subarachnoid hemorrhage (aSAH)-induced vasospasm by using first-pass quantitative cine CT perfusion (CTP). MATERIALS AND METHODS Six patients post-aSAH with clinical and transcranial Doppler findings suggestive of vasospasm were evaluated by CT angiography and CTP immediately before angiography for possible vasospasm treatment. CTP was repeated immediately following IA nicardipine infusion. Maps of mean transit time (MTT), cerebral blood volume (CBV), and cerebral blood flow (CBF) were constructed and analyzed in a blinded manner. Corresponding regions of interest on these maps from the bilateral middle cerebral artery territories and, when appropriate, the bilateral anterior or posterior cerebral artery territories, were selected from the pre- and posttreatment scans. Normalized values were compared by repeated measures analysis of variance. RESULTS Angiographic vasospasm was confirmed in all patients. In 5 of the 6 patients, both CBF and MTT improved significantly in affected regions in response to nicardipine therapy (mean increase in CBF, 41 +/- 43%; range, -9%-162%, P = .0004; mean decrease in MTT, 26 +/- 24%; range, 0%-70%, P = .0002). In 1 patient, we were unable to quantify improvement in flow parameters due to section-selection differences between the pre- and posttreatment examinations. CONCLUSIONS IA nicardipine improves CBF and MTT in ischemic regions in patients with aSAH-induced vasospasm. Our data provide a tissue-level complement to the favorable effects of IA nicardipine reported on prior angiographic studies. CTP may provide a surrogate marker for monitoring the success of treatment strategies in patients with aSAH-induced vasospasm.
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Affiliation(s)
- R G Nogueira
- Department of Interventional Neuroradiology and Endovascular Neurosurgery, Massachusetts General Hospital, 55 Fruit St, GRB-2-241, Boston, MA 02114, USA.
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Keyrouz SG, Diringer MN. Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage. Crit Care 2007; 11:220. [PMID: 17705883 PMCID: PMC2206512 DOI: 10.1186/cc5958] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Vasospasm is one of the leading causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Radiographic vasospasm usually develops between 5 and 15 days after the initial hemorrhage, and is associated with clinically apparent delayed ischemic neurological deficits (DID) in one-third of patients. The pathophysiology of this reversible vasculopathy is not fully understood but appears to involve structural changes and biochemical alterations at the levels of the vascular endothelium and smooth muscle cells. Blood in the subarachnoid space is believed to trigger these changes. In addition, cerebral perfusion may be concurrently impaired by hypovolemia and impaired cerebral autoregulatory function. The combined effects of these processes can lead to reduction in cerebral blood flow so severe as to cause ischemia leading to infarction. Diagnosis is made by some combination of clinical, cerebral angiographic, and transcranial doppler ultrasonographic factors. Nimodipine, a calcium channel antagonist, is so far the only available therapy with proven benefit for reducing the impact of DID. Aggressive therapy combining hemodynamic augmentation, transluminal balloon angioplasty, and intra-arterial infusion of vasodilator drugs is, to varying degrees, usually implemented. A panoply of drugs, with different mechanisms of action, has been studied in SAH related vasospasm. Currently, the most promising are magnesium sulfate, 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, nitric oxide donors and endothelin-1 antagonists. This paper reviews established and emerging therapies for vasospasm.
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Affiliation(s)
- Salah G Keyrouz
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, South Euclid Avenue, St Louis, MO 63110, USA
| | - Michael N Diringer
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, South Euclid Avenue, St Louis, MO 63110, USA
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Moftakhar R, Rowley HA, Turk A, Niemann DB, Kienitz BA, Van Gomple J, Başkaya MK. Utility of computed tomography perfusion in detection of cerebral vasospasm in patients with subarachnoid hemorrhage. Neurosurg Focus 2006; 21:E6. [PMID: 17029345 DOI: 10.3171/foc.2006.21.3.6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Digital subtraction (DS) angiography is the gold standard for detecting cerebral vasospasm after subarachnoid hemorrhage (SAH). Computed tomography (CT) perfusion is a recently developed modality for the evaluation of cerebral hemodynamics. This study was conducted to evaluate the potential of using CT perfusion to detect vasospasm in patients with SAH. METHODS Fourteen patients between the ages of 41 and 66 years with aneurysmal SAH underwent 23 CT perfusion scans for suspected vasospasm. All patients underwent DS angiography within 12 hours of the CT perfusion scans. The presence of vasospasm on CT perfusion images was determined based on qualitative reading using color maps of mean transit time, cerebral blood flow, and cerebral blood volume as criteria. The presence or absence of vasospasm as retrospectively determined using CT perfusion was compared with DS angiography findings. Of the 23 CT perfusion scans performed, 21 (91%) were concordant with angiography findings in predicting the presence or absence of vasospasm. In 15 of 23 scans, the presence of vasospasm was detected on CT perfusion scans and confirmed on DS angiography studies. In two cases, vasospasm was revealed on DS angiography but was not confirmed on CT perfusion. The degree of agreement between CT perfusion and DS angiography for detection of vasospasm was high (K = 0.8, p , 0.0001). CONCLUSIONS Computed tomography perfusion is an accurate, reliable, and noninvasive method to detect the presence or absence of vasospasm. It can be used as a tool to help guide the decision to pursue DS angiography with the intent to treat vasospasm.
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Affiliation(s)
- Roham Moftakhar
- Department of Neurosurgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
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