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Seyour M, Salvagno M, Rozenblum R, Macchini E, Anderloni M, Jodaitis L, Peluso L, Annoni F, Lolli V, Schuind S, Gaspard N, Taccone FS, Gouvea Bogossian E. The impact of perfusion computed tomography on the diagnosis and outcome of delayed cerebral ischemia after subarachnoid hemorrhage. Neurol Sci 2024; 45:1135-1144. [PMID: 37828386 DOI: 10.1007/s10072-023-07115-x] [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: 07/06/2023] [Accepted: 10/01/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is a preventable cause of poor neurological outcome in aneurysmal subarachnoid hemorrhage (aSAH). Advances in radiological methods, such as cerebral perfusion computed tomography (CTP), could help diagnose DCI earlier and potentially improve outcomes in aSAH. The objective of this study was to assess whether the use of CTP to diagnose DCI early could reduce the risk of infarction related to DCI. METHODS Retrospective cohort study of patients in the intensive care unit of Erasme Hospital (Brussels, Belgium) between 2004 and 2021 with aSAH who developed DCI. Patients were classified as: "group 1" - DCI diagnosed based on clinical deterioration or "group 2" - DCI diagnosed using CTP. The primary outcome was the development of infarction unrelated to the initial bleeding or surgery. RESULTS 211 aSAH patients were diagnosed with DCI during the study period: 139 (66%) in group 1 and 72 (34%) in group 2. In group 1, 109 (78%) patients developed a cerebral infarction, compared to 45 (63%) in group 2 (p = 0.02). The adjusted cumulative incidence of DCI over time was lower in group 2 than in group 1 [hazard ratio 0.65 (95% CI 0.48-0.94); p = 0.02]. The use of CTP to diagnose DCI was not independently associated with mortality or neurological outcome. CONCLUSIONS The use of CTP to diagnose DCI might help reduce the risk of developing cerebral infarction after aSAH, although the impact of such an approach on patient outcomes needs to be further demonstrated.
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Affiliation(s)
- Mohamed Seyour
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Raphael Rozenblum
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisabetta Macchini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Anderloni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lise Jodaitis
- Department of Neurology, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Valentina Lolli
- Department of Radiology, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
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Busse TL, Munthe S, Ketharanathan B, Bülow K, Jóhannsson B, Diaz A, Nielsen TH. Perfusion Computed Tomography as a Screening Tool for Pending Delayed Cerebral Ischemia in Comatose Patients After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study. Neurocrit Care 2023:10.1007/s12028-023-01855-6. [PMID: 37821720 DOI: 10.1007/s12028-023-01855-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is frequently complicated by delayed cerebral ischemia (DCI), leading to poor outcomes. Early diagnosis of DCI is crucial for improving survival and outcomes but remains challenging in comatose patients. In this study, we aimed to evaluate computed tomography with angiography and perfusion (P-CT) as a screening modality on postictal days four and eight for impending DCI after aSAH in comatose patients using vasospasm with hypoperfusion (hVS) as a surrogate and DCI-related infarction as an outcome measure. Two objectives were set: (1) to evaluate the screening's ability to accurately risk stratify patients and (2) to assess the validity of P-CT screening. METHODS We conducted a retrospective review of the records of comatose patients with aSAH from January 2019 to December 2021 who were monitored with P-CT scans on days four and eight. The event rates of DCI-related infarction, hVS, and endovascular rescue therapy (ERT) were analyzed, and the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for DCI were calculated. DCI-related infarction was defined as new secondary cerebral infarction > 48 h < 6 weeks post aSAH not attributable to other causes, and hVS was defined as arterial narrowing with corresponding hypoperfusion on P-CT. RESULTS Fifty-six comatose patients were included, and 98 P-CT scans were performed. The incidence of DCI-related infarction was 40%. Screening P-CT on days four and eight found vasospasm in 23% of all patients, including 11% with hVS. A positive hVS on day four or eight revealed a relative risk of 2.4 [95% confidence interval (CI) 1.13-5.11, p = 0.03], sensitivity of 23% (95% CI 8-45, p = 0.03), specificity of 95% (95% CI 36-100, p = 0.03), PPV of 0.83 (95% CI 0.36-1.00, p = 0.03), and NPV of 0.65 (95% CI 0.50-0.78). Six positive P-CT scans led to digital subtraction angiography in five patients, three of whom received ERT. All ERT-intervened patients developed DCI-related infarction. CONCLUSIONS P-CT resulted in few interventions and often resulted in late detection of DCI at an irreversible stage. Although a positive P-CT result accurately predicts impending DCI-related infarction, screening on days four and eight alone in comatose patients with aSAH often fails to timely detect impending DCI. Based on our analysis, we cannot recommend P-CT as a screening modality. P-CT is likely best used as a confirmatory test prior to invasive interventions when guided by continuous multimodal monitoring; however, prospective studies with comparison groups are warranted. The need for a reliable continuous screening modality is evident because of the high rate of deterioration and narrow treatment window.
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Affiliation(s)
- Thor Löwe Busse
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.
| | - Sune Munthe
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | - Karsten Bülow
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Bjarni Jóhannsson
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Anabel Diaz
- Department of Radiology, Odense University Hospital, Odense, Denmark
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Hofmann BB, Donaldson DM, Fischer I, Karadag C, Neyazi M, Piedade GS, Abusabha Y, Muhammad S, Rubbert C, Hänggi D, Beseoglu K. Blood Pressure Affects the Early CT Perfusion Imaging in Patients with aSAH Reflecting Early Disturbed Autoregulation. Neurocrit Care 2023; 39:125-134. [PMID: 36802010 PMCID: PMC10499698 DOI: 10.1007/s12028-023-01683-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/26/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early computed tomography perfusion (CTP) is frequently used to predict delayed cerebral ischemia following aneurysmatic subarachnoid hemorrhage (aSAH). However, the influence of blood pressure on CTP is currently controversial (HIMALAIA trial), which differs from our clinical observations. Therefore, we aimed to investigate the influence of blood pressure on early CTP imaging in patients with aSAH. METHODS We retrospectively analyzed the mean transit time (MTT) of early CTP imaging within 24 h after bleeding prior to aneurysm occlusion with respect to blood pressure shortly before or after the examination in 134 patients. We correlated the cerebral blood flow with the cerebral perfusion pressure in the case of patients with intracranial pressure measurement. We performed a subgroup analysis of good-grade (World Federation of Neurosurgical Societies [WFNS] I-III), poor-grade (WFNS IV-V), and solely WFNS grade V aSAH patients. RESULTS Mean arterial pressure (MAP) significantly correlated inversely with the mean MTT in early CTP imaging (R = - 0.18, 95% confidence interval [CI] - 0.34 to - 0.01, p = 0.042). Lower mean blood pressure was significantly associated with a higher mean MTT. Subgroup analysis revealed an increasing inverse correlation when comparing WFNS I-III (R = - 0.08, 95% CI - 0.31 to 0.16, p = 0.53) patients with WFNS IV-V (R = - 0.2, 95% CI - 0.42 to 0.05, p = 0.12) patients, without reaching statistical significance. However, if only patients with WFNS V are considered, a significant and even stronger correlation between MAP and MTT (R = - 0.4, 95% CI - 0.65 to 0.07, p = 0.02) is observed. In patients with intracranial pressure monitoring, a stronger dependency of cerebral blood flow on cerebral perfusion pressure is observed for poor-grade patients compared with good-grade patients. CONCLUSIONS The inverse correlation between MAP and MTT in early CTP imaging, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. Our results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Guilherme S Piedade
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Levinson S, Pendharkar AV, Gauden AJ, Heit JJ. Modern Imaging of Aneurysmal Subarachnoid Hemorrhage. Radiol Clin North Am 2023; 61:457-465. [PMID: 36931762 DOI: 10.1016/j.rcl.2023.01.004] [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] [Indexed: 02/21/2023]
Abstract
In this review, we discuss the imaging of aneurysmal subarachnoid hemorrhage (SAH). We discuss emergency brain imaging, aneurysm detection techniques, and the management of CTA-negative SAH. We also review the concepts of cerebral vasospasm and delayed cerebral ischemia that occurs after aneurysm rupture and their impact on patient outcomes. These pathologies are distinct, and the use of multimodal imaging modalities is essential for prompt diagnosis and management to minimize morbidity from these conditions. Lastly, new advances in artificial intelligence and advanced imaging modalities such as PET and MR imaging scans have been shown to improve the detection of aneurysms and potentially predict outcomes early in the course of SAH.
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Affiliation(s)
- Simon Levinson
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew J Gauden
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford School of Medicine, 453 Quarry Road, Palo Alto, CA 94304, USA.
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Faropoulos K, Tsolaki V, Georgakopoulou VE, Trakas I, Tarantinos K, Papalexis P, Spandidos DA, Aravantinou-Fatorou A, Mathioudakis N, Trakas N, Lavdas E, Fotakopoulos G. Value of sildenafil treatment for the prevention of vasospasm‑related delayed ischemic neurological deficits and delayed brain infarction following aneurysmal subarachnoid hemorrhage. MEDICINE INTERNATIONAL 2023; 3:19. [PMID: 37032716 PMCID: PMC10080186 DOI: 10.3892/mi.2023.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023]
Abstract
Cerebral vasospasm (CV) or delayed cerebral ischemia (DCI) constitutes the main reason for the unfavorable outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). The present retrospective cohort study, through an evaluation with computed tomography (CT) perfusion (CTP), aimed to examine the utility of an intravenous or oral administration of sildenafil in preventing DCI that develops due to vasospasm in these patients. A retrospective cohort study was conducted, which included 34 patients in a tertiary care hospital. Of these patients, 18 were males (52.9%), and the median age was 54.4 years. Of these patients, 18 (52.9%) had undergone surgery, and 16 (47.1%) had an endovascular procedure. CTP was performed on the 3rd to the 6th day. The clinical outcome was documented at 30 days using a CT scan and a complete neurological evaluation, including the Glasgow Coma Scale assessment. There was a statistically significant difference in the number of patients who developed an ischemic event at 1 month between those who did not receive sildenafil compared to those who received sildenafil (P<0.05). In addition, the multivariate analysis revealed that cerebral blood flow was an independent factor for detecting an ischemic event in 1 month (P=0.001). On the whole, the findings of the present study indicate that the intravenous or oral administration of sildenafil may be beneficial for the prevention of DCI.
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Affiliation(s)
| | - Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 11527 Athens, Greece
- Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Ilias Trakas
- Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 11527 Athens, Greece
| | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Aikaterini Aravantinou-Fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Eleftherios Lavdas
- Department of Medical Radiological Technologists, Technological Education Institute of Athens, 12243 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Bergin B, Ragulojan M, Trivedi A, Kesserwan M, Farrokhyar F, Sharma S. Computed Tomography Angiography Compared with Computed Tomography Perfusion in the Diagnosis of Cerebral Vasospasm: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 170:e340-e350. [PMID: 36368456 DOI: 10.1016/j.wneu.2022.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/04/2022] [Accepted: 11/05/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Cerebral vasospasm (CV) is a serious complication after subarachnoid hemorrhage; however, swift identification can be challenging. Computed tomography perfusion (CTP) directly measures tissue perfusion and may better screen for CV compared with other modalities. This systematic review summarizes studies assessing the diagnostic performance of computed tomography angiography (CTA) and CTP in identifying CV. METHODS The search strategy drew from English language publications in the PubMed, Embase, Medline, and Cochrane databases from January 1996 to September 2021. Diagnosis of CV by digital subtraction angiography was the reference standard. Pooled sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), positive likelihood ratios, negative likelihood ratios, and summary receiver operating characteristic curve were calculated. The methodological index for nonrandomized studies tool was employed to assess the quality of the studies. RESULTS The search generated 22 studies. Seven CTA studies and 6 CTP investigations provided sufficient data for meta-analysis. Following pooled estimates, CTA carried a sensitivity of 0.76 (95% confidence interval [CI], 0.72-0.80), specificity of 0.93 (95% CI, 0.92-0.95), PPV of 0.77 (95%, 0.76-0.79), and NPV of 0.81 (95%, 0.79-0.82). CTP carried a sensitivity of 0.86 (95%, 0.81-0.92), specificity of 0.97 (95%, 0.95-0.98), PPV of 0.94 (0.89-0.98), and NPV of 0.94 (0.91-0.97). Using the methodological index for nonrandomized studies tool, the evidence was rated as overall moderate quality. CONCLUSIONS This meta-analysis on the diagnostic performance of CTA and CTP in identifying CV suggests that CTP may carry greater diagnostic accuracy compared with CTA. The clinical significance of this difference should be delineated through future prospective studies.
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Affiliation(s)
- Brad Bergin
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; CRANI Group, McMaster University, Hamilton, Ontario, Canada
| | - Malavan Ragulojan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; CRANI Group, McMaster University, Hamilton, Ontario, Canada.
| | - Arunachala Trivedi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; CRANI Group, McMaster University, Hamilton, Ontario, Canada
| | - Mohamad Kesserwan
- CRANI Group, McMaster University, Hamilton, Ontario, Canada; Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- CRANI Group, McMaster University, Hamilton, Ontario, Canada; Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- CRANI Group, McMaster University, Hamilton, Ontario, Canada; Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Tsolaki V, Aravantinou-fatorou A, Georgakopoulou VE, Spandidos DA, Papalexis P, Mathioudakis N, Tarantinos K, Trakas N, Sklapani P, Fotakopoulos G. Early diagnosis of cerebral vasospasm associated with cerebral ischemia following subarachnoid hemorrhage: Evaluation of computed tomography perfusion and transcranial doppler as accurate methods. MEDICINE INTERNATIONAL 2022; 2:34. [PMID: 36699155 PMCID: PMC9829237 DOI: 10.3892/mi.2022.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
Cerebral vasospasm (CV) constitutes a major post-operative complication and source of morbidity in cases of subarachnoid hemorrhage (SAH). The early detection of CV in SAH may be difficult both clinically and radiographically. The present pilot study thus aimed to evaluate the practicability of the technique in a tertiary healthcare setting and to assess the diagnostic effectiveness of various diagnostic computed tomography (CT) perfusion (CTP) aspects in predicting the clinical outcome of patients with SAH (traumatic and aneurysmal). A retrospective study including 34 patients in a tertiary care hospital was thus conducted. The results revealed that of the 34 patients, 18 (52.9%) were males, and the mean age was 54.4±18.5 years (16-85 years old; range, 69 years). In total, 15 (44.1%) patients had traumatic SAH following traumatic brain injury (TBI), 11 (33.3%) had aneurysmal SAH, and 8 patients (23.6%) presented with TBI without SAH as controls. CTP was performed on the third to the sixth day, and 15-20 min prior to CPT, a transcranial Doppler ultrasound was performed. Clinical outcomes were documented at 30 days using a CT scan and a complete neurological evaluation, including Glasgow Coma Scale assessment. The results of a multivariate analysis revealed that cerebral blood flow (CBF) was an independent factor for detecting an ischemic event in 1 month (P=0.003). On the whole, the present study demonstrates that CTP, and consequently CBF, is a considerable index that may identify the onset of cerebral ischemia in patients with SAH.
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Affiliation(s)
- Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larisa, 41221 Larisa, Greece
| | - Aikaterini Aravantinou-fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece,Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece,Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | | | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Cytology, Mitera Hospital, 15123 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larisa, 41221 Larisa, Greece
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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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Subarachnoid Hemorrhage, Delayed Cerebral Ischemia and Milrinone Use in Canada. Can J Neurol Sci 2022; 50:380-388. [PMID: 35477442 DOI: 10.1017/cjn.2022.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. There is little high-quality evidence available to guide the management of DCI. The Canadian Neurosurgery Research Collaborative (CNRC) is comprised of resident physicians who are positioned to capture national, multi-site data. The objective of this study was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI. METHODS We performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. A 19-question electronic survey (Survey Monkey) was developed and validated by the CNRC following a DCI-related literature review (PubMed, Embase). The survey was distributed to members of the Canadian Neurosurgical Society and to Canadian members of the Neurocritical Care Society. Responses were analyzed using quantitative and qualitative methods. RESULTS The response rate was 129/340 (38%). Agreement among respondents was limited to the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for the prevention of DCI. Several inconsistencies were identified. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients who felt to require IV milrinone, IA vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI. CONCLUSION DCI is an important clinical entity for which no homogeneity and standardization exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the definition, identification, and treatment of DCI.
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Fung C, Heiland DH, Reitmeir R, Niesen WD, Raabe A, Eyding J, Schnell O, Rölz R, Z Graggen WJ, Beck J. Ultrasound Perfusion Imaging for the Detection of Cerebral Hypoperfusion After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2022; 37:149-159. [PMID: 35211837 PMCID: PMC9283360 DOI: 10.1007/s12028-022-01460-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/27/2022] [Indexed: 11/24/2022]
Abstract
Background Delayed cerebral ischemia increases mortality and morbidity after aneurysmal subarachnoid hemorrhage (aSAH). Various techniques are applied to detect cerebral vasospasm and hypoperfusion. Contrast-enhanced ultrasound perfusion imaging (UPI) is able to detect cerebral hypoperfusion in acute ischemic stroke. This prospective study aimed to evaluate the use of UPI to enable detection of cerebral hypoperfusion after aSAH. Methods We prospectively enrolled patients with aSAH and performed UPI examinations every second day after aneurysm closure. Perfusion of the basal ganglia was outlined to normalize the perfusion records of the anterior and posterior middle cerebral artery territory. We applied various models to characterize longitudinal perfusion alterations in patients with delayed ischemic neurologic deficit (DIND) across the cohort and predict DIND by using a multilayer classification model. Results Between August 2013 and December 2015, we included 30 patients into this prospective study. The left–right difference of time to peak (TTP) values showed a significant increase at day 10–12. Patients with DIND demonstrated a significant, 4.86 times increase of the left–right TTP ratio compared with a mean fold change in patients without DIND of 0.9 times (p = 0.032). Conclusions UPI is feasible to enable detection of cerebral tissue hypoperfusion after aSAH, and the left–right difference of TTP values is the most indicative result of this finding.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany. .,Medical Faculty, University of Freiburg, Freiburg, Germany.
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Raluca Reitmeir
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Wolf-Dirk Niesen
- Department of Neurology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Jens Eyding
- Department of Neurology, Gemeinschaftskrankenhaus Herdecke, University Witten/Herdecke, Herdecke, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Roland Rölz
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Werner J Z Graggen
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
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11
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Smith NM, Sweeney EM, Gupta A, Patsalides A, Sanelli P, Ivanidze J. Diagnostic accuracy of shuttle CT angiography (CTA) and helical CTA in the diagnosis of vasospasm. Clin Imaging 2021; 81:37-42. [PMID: 34598002 DOI: 10.1016/j.clinimag.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/14/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the diagnostic accuracy of computed tomography angiography (CTA) acquired with shuttle technique (CTAs) and helical CTA (CTAh) for vasospasm, using digital subtraction angiography (DSA) obtained within 24 h as reference standard. METHODS Thirty-six patients with suspected vasospasm in the setting of aneurysmal subarachnoid hemorrhage (ASAH, 30/36) or acute inflammatory/infectious conditions (6/36) who underwent CTAs (17/36) or CTAh (19/36) followed by DSA within 24 h were identified retrospectively. Presence of vasospasm in the proximal cerebral arterial segments was assessed qualitatively and semi-quantitatively on CTA and subsequent DSA. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated. Inter-rater variability was assessed using Cohen's kappa. RESULTS On CTAs, 35% of patients had low and 65% had high vasospasm burden. On CTAh, 37% had low and 63% had high vasospasm burden. ROC analysis demonstrated an AUC of 0.87 for CTAs (95%CI 0.67-1.00, p = 0.015) and 0.88 for CTAh (0.72-1.00, p = 0.028). Cohen's kappa was 0.843 (95%CI 0.548-1.000). Thresholding with Youden's J index, CTAs had a sensitivity of 85.71% (95%CI 48.69 to 99.27) and specificity of 66.67% (35.42 to 87.94). CTAh had sensitivity of 100% (56.55 to 100.00) and specificity of 78.57% (52.41 to 92.43). CONCLUSION CTAs and CTAh yielded similar sensitivity, specificity, and AUC values on ROC analysis for the detection of vasospasm using DSA as reference standard. Our findings suggest that CTAs is a promising alternative to CTAh especially in patients requiring serial imaging, given its potential advantages of decreased radiation exposure, contrast dose, and cost-effectiveness.
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Affiliation(s)
- Natasha M Smith
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
| | - Elizabeth M Sweeney
- Division of Biostatistics and Epidemiology, Department of Population Health Sciences, New York Presbyterian, Weill Cornell Medical College, 1300 York Ave., New York, NY 10065, USA.
| | - Ajay Gupta
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
| | - Athos Patsalides
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, 300 Community Drive, Manhasset, NY 11030, USA.
| | - Pina Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, 300 Community Drive, Manhasset, NY 11030, USA.
| | - Jana Ivanidze
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
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CT Perfusion for the Detection of Delayed Cerebral Ischemia in the Presence of Neurologic Confounders. Neurocrit Care 2021; 33:317-322. [PMID: 32472333 PMCID: PMC7259436 DOI: 10.1007/s12028-020-01005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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13
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Ivanidze J, Sanelli PC. Vasospasm: Role of Imaging in Detection and Monitoring Treatment. Neuroimaging Clin N Am 2021; 31:147-155. [PMID: 33902870 DOI: 10.1016/j.nic.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cerebral vasospasm (VS) and delayed cerebral ischemia (DCI) are important complications of aneurysmal subarachnoid hemorrhage (ASAH). Imaging approaches to VS monitoring include noninvasive bedside assessment with transcranial Doppler ultrasonography, angiographic evaluation with digital subtraction angiography, and computed tomography (CT) angiography. DCI is a clinical diagnosis and is not fully explained by the presence of angiographic VS. CT perfusion has shown clinical utility and implications for future research in the evaluation of DCI in patients with ASAH. This review article discusses the common approaches to diagnosis and monitoring of VS and DCI, current treatment strategies, and future research directions.
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Affiliation(s)
- Jana Ivanidze
- Department of Radiology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA.
| | - Pina C Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 300 Community Drive, Manhasset, NY 11030, USA
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14
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Amoo M, Henry J, Pender N, Brennan P, Campbell M, Javadpour M. Blood-brain barrier permeability imaging as a predictor for delayed cerebral ischaemia following subarachnoid haemorrhage. A narrative review. Acta Neurochir (Wien) 2021; 163:1457-1467. [PMID: 33404877 DOI: 10.1007/s00701-020-04670-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/01/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage is associated with significant morbidity and mortality due to the myriad of complications contributing to early brain injury and delayed cerebral ischaemia. There is increasing interest in the exploration of the association between blood-brain barrier integrity and risks of delayed cerebral ischaemia and poor outcomes. Despite recent advances in cerebral imaging, radiographic imaging of blood-brain barrier disruption, as a biomarker for outcome prediction, has not been adopted in clinical practice. METHODS We performed a narrative review by searching for articles describing molecular changes or radiological identification of changes in BBB permeability following subarachnoid haemorrhage (SAH) on MEDLINE. Preclinical studies were analysed if reported structural changes and clinical studies were included if they investigated for radiological markers of BBB disruption and its correlation with delayed cerebral ischaemia. RESULTS There is ample preclinical evidence to suggest that there are structural changes in BBB permeability following SAH. The available clinical literature has demonstrated correlations between permeability imaging and outcomes following aneurysmal subarachnoid haemorrhage (aSAH). CONCLUSION Radiological biomarkers offer a potential non-invasive prognostication tool and may also allow early identifications of patients who may be at risk of DCI.
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Darsaut TE, Derksen C, Farzin B, Keough MB, Fahed R, Boisseau W, Letourneau-Guillon L, Januel AC, Weill A, Roy D, Nguyen TN, Finitsis S, Gentric JC, Volders D, Carlson A, Chow MM, O'Kelly C, Rempel JL, Ashforth RA, Chagnon M, Zehr J, Findlay JM, Gevry G, Raymond J. Reliability of the Diagnosis of Cerebral Vasospasm Using Catheter Cerebral Angiography: A Systematic Review and Inter- and Intraobserver Study. AJNR Am J Neuroradiol 2021; 42:501-507. [PMID: 33509923 DOI: 10.3174/ajnr.a7021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the following: 1) to systematically review the literature on the reliability of the diagnosis of cerebral vasospasm using conventional angiography, and 2) to perform an agreement study among clinicians who perform endovascular treatment. MATERIALS AND METHODS Articles reporting a classification system on the degree of cerebral vasospasm on conventional angiography were systematically searched, and agreement studies were identified. We assembled a portfolio of 221 cases of patients with subarachnoid hemorrhage and asked 17 raters with different backgrounds (radiology, neurosurgery, or neurology) and experience (junior ≤10 and senior >10 years) to independently evaluate cerebral vasospasm in 7 vessel segments using a 3-point scale and to evaluate, for each case, whether findings would justify endovascular treatment. Nine raters took part in the intraobserver reliability study. RESULTS The systematic review showed a very heterogeneous literature, with 140 studies using 60 different nomenclatures and 21 different thresholds to define cerebral vasospasm, and 5 interobserver studies reporting a wide range of reliability (κ = 0.14-0.87). In our study, only senior raters reached substantial agreement (κ ≥ 0.6) on vasospasm of the supraclinoid ICA, M1, and basilar segments and only when assessments were dichotomized (presence or absence of ≥50% narrowing). Agreement on whether to proceed with endovascular management of vasospasm was only fair (κ ≤ 0.4). CONCLUSIONS Research on cerebral vasospasm would benefit from standardization of definitions and thresholds. Dichotomized decisions by experienced readers are required for the reliable angiographic diagnosis of cerebral vasospasm.
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Affiliation(s)
- T E Darsaut
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - C Derksen
- Stroke Program (C.D.), Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - B Farzin
- Research Center (B.F., G.G., J.R.)
| | - M B Keough
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - R Fahed
- Department of Medicine (R.F.), Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - W Boisseau
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - L Letourneau-Guillon
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - A-C Januel
- Service de Neuroradiologie (A.-C.J.), Hôpital Purpan, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - A Weill
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - D Roy
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - T N Nguyen
- Service of Interventional Neurology and Neuroradiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - S Finitsis
- Department of Radiology (S.F.), Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - J-C Gentric
- Department of Radiology (J.-C.G.), Division of Neuroradiology, Centre Hospitalier Universitaire Cavale Blanche, Brest, France
| | - D Volders
- Department of Radiology (D.V.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - A Carlson
- Department of Neurosurgery (A.C.), University of New Mexico, Albuquerque, New Mexico
| | - M M Chow
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - C O'Kelly
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - J L Rempel
- Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
| | - R A Ashforth
- Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Province du Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Province du Québec, Canada
| | - J M Findlay
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - G Gevry
- Research Center (B.F., G.G., J.R.)
| | - J Raymond
- Research Center (B.F., G.G., J.R.) .,Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
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Chen S, Xu P, Fang Y, Lenahan C. The Updated Role of the Blood Brain Barrier in Subarachnoid Hemorrhage: From Basic and Clinical Studies. Curr Neuropharmacol 2020; 18:1266-1278. [PMID: 32928088 PMCID: PMC7770644 DOI: 10.2174/1570159x18666200914161231] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke associated with high mortality and morbidity. The blood-brain-barrier (BBB) is a structure consisting primarily of cerebral microvascular endothelial cells, end feet of astrocytes, extracellular matrix, and pericytes. Post-SAH pathophysiology included early brain injury and delayed cerebral ischemia. BBB disruption was a critical mechanism of early brain injury and was associated with other pathophysiological events. These pathophysiological events may propel the development of secondary brain injury, known as delayed cerebral ischemia. Imaging advancements to measure BBB after SAH primarily focused on exploring innovative methods to predict clinical outcome, delayed cerebral ischemia, and delayed infarction related to delayed cerebral ischemia in acute periods. These predictions are based on detecting abnormal changes in BBB permeability. The parameters of BBB permeability are described by changes in computed tomography (CT) perfusion and magnetic resonance imaging (MRI). Kep seems to be a stable and sensitive indicator in CT perfusion, whereas Ktrans is a reliable parameter for dynamic contrast-enhanced MRI. Future prediction models that utilize both the volume of BBB disruption and stable parameters of BBB may be a promising direction to develop practical clinical tools. These tools could provide greater accuracy in predicting clinical outcome and risk of deterioration. Therapeutic interventional exploration targeting BBB disruption is also promising, considering the extended duration of post-SAH BBB disruption.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - PengLei Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - YuanJian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA,Center for Neuroscience Research, School of Medicine, Loma Linda University, Loma Linda, CA, USA
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17
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Shi D, Jin D, Cai W, Zhu Q, Dou X, Fan G, Shen J, Xu L. Serial low-dose quantitative CT perfusion for the evaluation of delayed cerebral ischaemia following aneurysmal subarachnoid haemorrhage. Clin Radiol 2020; 75:131-139. [DOI: 10.1016/j.crad.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
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18
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Li K, Strother CM, Chen GH. Statistical properties of cerebral CT perfusion imaging systems. Part I. Cerebral blood volume maps generated from nondeconvolution-based systems. Med Phys 2019; 46:4869-4880. [PMID: 31487396 DOI: 10.1002/mp.13806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/24/2019] [Accepted: 08/27/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The development and clinical employment of a computed tomography (CT) imaging system benefit from a thorough understanding of the statistical properties of the output images; cerebral CT perfusion (CTP) imaging system is no exception. A series of articles will present statistical properties of CTP systems and the dependence of these properties on system parameters. This Part I paper focuses on the signal and noise properties of cerebral blood volume (CBV) maps calculated using a nondeconvolution-based method. METHODS The CBV imaging chain was decomposed into a cascade of subimaging stages, which facilitated the derivation of analytical models for the probability density function, mean value, and noise variance of CBV. These models directly take CTP source image acquisition, reconstruction, and postprocessing parameters as inputs. Both numerical simulations and in vivo canine experiments were performed to validate these models. RESULTS The noise variance of CBV is linearly related to the noise variance of source images and is strongly influenced by the noise variance of the baseline images. Uniformly partitioning the total radiation dose budget across all time frames was found to be suboptimal, and an optimal dose partition method was derived to minimize CBV noise. Results of the numerical simulation and animal studies validated the derived statistical properties of CBV. CONCLUSIONS The statistical properties of CBV imaging systems can be accurately modeled by extending the linear CT systems theory. Based on the statistical model, several key signal and noise characteristics of CBV were identified and an optimal dose partition method was developed to improve the image quality of CBV.
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Affiliation(s)
- Ke Li
- Department of Medical Physics, University of Wisconsin-Madison, 1111 Highland Avenue, Madison, WI, 53705, USA.,Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Charles M Strother
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Guang-Hong Chen
- Department of Medical Physics, University of Wisconsin-Madison, 1111 Highland Avenue, Madison, WI, 53705, USA.,Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI, 53792, USA
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19
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Dundar TT, Aralasmak A, Kitiş S, Yılmaz FT, Abdallah A. Comparison of Subtracted Computed Tomography from Computed Tomography Perfusion and Digital Subtraction Angiography in Residue Evaluation of Treated Intracranial Aneurysms. World Neurosurg 2019; 132:e746-e751. [PMID: 31415894 DOI: 10.1016/j.wneu.2019.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/04/2019] [Accepted: 08/05/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Assessing clipped intracranial aneurysms for residues or incomplete occlusions is critical. Digital subtraction angiography (DSA) has been the gold standard for this. Previously, we presented subtracted computed tomography angiography (sub-CTA) from computed tomography perfusion as a more effective noninvasive technique for clipped aneurysms. The aim of this study was to compare effectiveness of sub-CTA with DSA in residue evaluation. METHODS A retrospective study of 17 patients with aneurysmal subarachnoid hemorrhage operated on at our institution between November 1, 2016, and December 31, 2018, was performed. Residue aneurysms were evaluated with both sub-CTA and DSA. Positive predictive value and negative predictive value were calculated. Correlation between techniques was determined by the McNemar test and κ value. RESULTS Sensitivity of sub-CTA in residue evaluation was low in aneurysms ≤3 mm (positive predictive value = 60%). DSA detected residue aneurysm in 29% (5/17) of patients, whereas sub-CTA detected residue aneurysm in 11% (2/17). Only 40% of aneurysms (2/5) were demonstrated by sub-CTA, all >3 mm; 60% (3/5) were missed, all ≤3 mm. CONCLUSIONS This is the first study comparing the effectiveness of sub-CTA from computed tomography perfusion with DSA in residue aneurysm evaluation. Our results were suggestive, but not conclusive. DSA is still the gold standard in residue evaluation. Sub-CTA from computed tomography perfusion can be a reliable method in evaluation of residual aneurysm >3 mm.
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Affiliation(s)
- Tolga Turan Dundar
- Department of Neurosurgery, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey.
| | - Ayse Aralasmak
- Department Radiology, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey
| | - Serkan Kitiş
- Department of Neurosurgery, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey
| | - Fatih Temel Yılmaz
- Department Radiology, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey
| | - Anas Abdallah
- Department of Neurosurgery, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey
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20
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Fragata I, Alves M, Papoila AL, Nunes AP, Ferreira P, Diogo M, Canto-Moreira N, Canhão P. Computed tomography perfusion as a predictor of delayed cerebral ischemia and functional outcome in spontaneous subarachnoid hemorrhage: A single center experience. Neuroradiol J 2019; 32:179-188. [PMID: 30777482 DOI: 10.1177/1971400919829048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Computed tomography (CT) perfusion has been studied as a tool to predict delayed cerebral ischemia (DCI) and clinical outcome in spontaneous subarachnoid hemorrhage (SAH). The purpose of the study was to determine whether quantitative CT perfusion performed within 72 hours after admission can predict the occurrence of DCI and clinical outcome as measured with a modified Rankin scale (mRS) at 3 months after ictus. METHODS Cerebral perfusion was assessed in a prospective cohort of patients with acute SAH. CT perfusion parameters at <72 h post SAH were quantitatively measured in the main vascular territories and represented as whole-brain means. Spearman rank correlation coefficient and generalized additive regression models for binary outcome were used. RESULTS A total of 66 patients underwent CT perfusion at <72 h. Poor clinical grade on admission was correlated with worse cerebral perfusion in all parameters. Multivariable analysis yielded an association of time to peak (TTP; odds ratio (OR) = 0.89; 95% confidence interval (CI): 0.77, 1.02; p = 0.083) with the occurrence of DCI. We also found an association of TTP values with poor outcome, with an 8% increase in the odds of mRS > 3 for each one second increase in TTP at admission (OR = 1.08; 95% CI: 1.00, 1.17; p = 0.061). CONCLUSIONS We identified an association of early TTP changes with DCI and poor clinical outcome. However, there were no associations with cerebral blood flow or mean transit time and DCI/clinical outcome. CT perfusion still remains to be validated as a tool in predicting outcome in SAH.
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Affiliation(s)
- Isabel Fragata
- 1 Department of Neuroradiology, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Marta Alves
- 2 Centro de Investigação, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Ana Luísa Papoila
- 3 Biostatistics Department, Faculdade Ciências Médicas, Nova University Lisbon, Lisbon, Portugal
| | - Ana Paiva Nunes
- 4 Unidade Cérebro-Vascular, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Patrícia Ferreira
- 4 Unidade Cérebro-Vascular, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Mariana Diogo
- 1 Department of Neuroradiology, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Nuno Canto-Moreira
- 5 Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patrícia Canhão
- 1 Department of Neuroradiology, Centro Hospitalar Lisboa Central, Lisbon, Portugal.,6 Instituto Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
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21
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Ivanidze J, Mackay M, Hoang A, Chi JM, Cheng K, Aranow C, Volpe B, Diamond B, Sanelli PC. Dynamic Contrast-Enhanced MRI Reveals Unique Blood-Brain Barrier Permeability Characteristics in the Hippocampus in the Normal Brain. AJNR Am J Neuroradiol 2019; 40:408-411. [PMID: 30733256 DOI: 10.3174/ajnr.a5962] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 12/17/2018] [Indexed: 11/07/2022]
Abstract
We report a prospective dynamic contrast-enhanced MR imaging analysis of region-specific blood-brain barrier permeability in 5 healthy subjects. By means of standardized postprocessing and ROI sampling methods, the hippocampi revealed significantly elevated area under the dynamic contrast-enhanced curve and significantly increased blood-brain barrier permeability metrics (volume transfer constant and volume in the extravascular extracellular space) from model-based quantitation. These findings suggest unique blood-brain barrier permeability characteristics in the hippocampus, which are concordant with previous animal studies, potentially laying the groundwork for future studies assessing patient populations in which hippocampal pathology plays a role.
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Affiliation(s)
- J Ivanidze
- From the Department of Radiology (J.I.), Weill Cornell Medicine, New York New York
| | - M Mackay
- The Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases (M.M., C.A., B.D.).,Donald and Barbara Zucker School of Medicine (M.M., A.H., J.M.C., K.C., C.A., B.V., B.D., P.C.S.), Hofstra/Northwell School of Medicine, Hempstead, New York
| | - A Hoang
- Department of Radiology (A.H., P.C.S.).,Donald and Barbara Zucker School of Medicine (M.M., A.H., J.M.C., K.C., C.A., B.V., B.D., P.C.S.), Hofstra/Northwell School of Medicine, Hempstead, New York
| | - J M Chi
- Department of Radiology (J.M.C., K.C.).,Donald and Barbara Zucker School of Medicine (M.M., A.H., J.M.C., K.C., C.A., B.V., B.D., P.C.S.), Hofstra/Northwell School of Medicine, Hempstead, New York
| | - K Cheng
- Department of Radiology (J.M.C., K.C.).,Donald and Barbara Zucker School of Medicine (M.M., A.H., J.M.C., K.C., C.A., B.V., B.D., P.C.S.), Hofstra/Northwell School of Medicine, Hempstead, New York
| | - C Aranow
- The Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases (M.M., C.A., B.D.).,Donald and Barbara Zucker School of Medicine (M.M., A.H., J.M.C., K.C., C.A., B.V., B.D., P.C.S.), Hofstra/Northwell School of Medicine, Hempstead, New York
| | - B Volpe
- The Center for Biomedical Science (B.V.), Feinstein Institute for Medical Research, Manhasset, New York.,Donald and Barbara Zucker School of Medicine (M.M., A.H., J.M.C., K.C., C.A., B.V., B.D., P.C.S.), Hofstra/Northwell School of Medicine, Hempstead, New York
| | - B Diamond
- The Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases (M.M., C.A., B.D.).,Donald and Barbara Zucker School of Medicine (M.M., A.H., J.M.C., K.C., C.A., B.V., B.D., P.C.S.), Hofstra/Northwell School of Medicine, Hempstead, New York
| | - P C Sanelli
- The Center for Health Innovations and Outcomes Research (P.C.S.).,Department of Radiology (A.H., P.C.S.).,Imaging Clinical Effectiveness and Outcomes Research Program (P.C.S.), Northwell Health, New Hyde Park, New York.,Donald and Barbara Zucker School of Medicine (M.M., A.H., J.M.C., K.C., C.A., B.V., B.D., P.C.S.), Hofstra/Northwell School of Medicine, Hempstead, New York
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22
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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: 0.7] [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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23
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Sun J, Liu Y, Zhang J, Chen X, Lin Z, Nie S, Shi M, Gao X, Huang Y. Electroacupuncture Improves Cerebral Vasospasm and Functional Outcome of Patients With Aneurysmal Subarachnoid Hemorrhage. Front Neurosci 2018; 12:724. [PMID: 30356696 PMCID: PMC6189302 DOI: 10.3389/fnins.2018.00724] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/20/2018] [Indexed: 11/13/2022] Open
Abstract
Cerebral vasospasm is the major cause of a poor outcome after aneurysmal subarachnoid hemorrhage (aSAH), and effective treatments for vasospasm are limited. The purpose of this study was to research the impact of electroacupuncture (EA) on cerebral vasospasm and the outcomes of patients with aSAH. A total of 60 age- and sex-matched aSAH patients were collected from Ningbo First Hospital between December 2015 and June 2017. All patients were given a basic treatment of nimodipine and randomized into two groups. The study group was treated with EA therapy on the Baihui (GV20) acupoint, and the control group was given mock transcutaneous electrical nerve stimulation. Cerebral vasospasm was measured by computed tomographic perfusion (CTP) and transcranial doppler (TCD). The mean flow velocity (MFV) in the middle cerebral artery (MCA), cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) of the patients were analyzed. The CBV and MTT exhibited significant differences between the study and control groups on the 1st (p = 0.026 and p = 0.001), 7th (p = 0.020 and p < 0.001), and 14th (p = 0.001 and p < 0.001) day after surgery, whereas CBF exhibited statistical significance only on the 14th day after surgery (p = 0.002). The MFV in MCA were significantly reduced after EA treatment in all patients (all p < 0.001). Additionally, the MFV in the MCA in patients treated with EA were considerably reduced compared with those of the control group (3rd day p = 0.046; 5th day, p = 0.010; 7th day, p < 0.001). Moreover, better outcomes were noted in the EA-treated group for the 1st month (p < 0.001) and 3rd month (p = 0.001) after surgery than in the control group. In conclusion, EA represents a potential method to treat cerebral vasospasm after aSAH and can improve the outcomes of patients with aSAH.
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Affiliation(s)
- Jie Sun
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
| | - Yuchun Liu
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
| | - Junjun Zhang
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
| | - Xiaosheng Chen
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
| | - Zhiqing Lin
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
| | - Sheng Nie
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
| | - Manhua Shi
- Department of Acupuncture, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
| | - Xiang Gao
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
| | - Yi Huang
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University School of Medicine, Ningbo, China
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24
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Blood-Brain Barrier Permeability in Aneurysmal Subarachnoid Hemorrhage: Correlation With Clinical Outcomes. AJR Am J Roentgenol 2018; 211:891-895. [DOI: 10.2214/ajr.17.18237] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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25
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The value of computed tomography perfusion & transcranial Doppler in early diagnosis of cerebral vasospasm in aneurysmal & traumatic subarachnoid hemorrhage. Future Sci OA 2018; 4:FSO313. [PMID: 30057790 PMCID: PMC6060394 DOI: 10.4155/fsoa-2018-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/02/2018] [Indexed: 02/04/2023] Open
Abstract
Early detection and diagnosis of cerebral vasospasm in subarachnoid hemorrhage may be challenging both on clinical and radiographic grounds. In this respect we conducted a pilot study in order to assess the feasibility of the technique in the everyday setting of a tertiary hospital and to evaluate the diagnostic performance of different diagnostic computed tomography perfusion aspects in diagnosing the clinical outcome of patients with subarachnoid hemorrhage. Receiver-operating characteristic analysis showed that a cerebral blood flow value of <24.5 presented 67% sensitivity and 100% specificity to diagnose adverse ischemic events at 1 month (p = 0.041). These case series data provide evidence that computed tomography perfusion-derived cerebral blood flow is a measurable index that may detect the degree of cerebral ischemia in a very early stage. Early detection and diagnosis of cerebral vasospasm in subarachnoid hemorrhage is important but may be challenging both on clinical or radiographic grounds. This article provides evidence that computed tomography perfusion-derived cerebral blood flow is a measurable index that could detect the degree of cerebral ischemia in a very early stage in patients suffering with subarachnoid hemorrhage. Larger studies are needed in order to better define the role of computed tomography perfusion in early diagnosis of cerebral vasospasm.
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26
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Afat S, Brockmann C, Nikoubashman O, Müller M, Thierfelder KM, Kunz WG, Haberland U, Brockmann MA, Nikolaou K, Wiesmann M, Othman AE. Diagnostic performance of different perfusion algorithms for the detection of angiographical spasm. J Neuroradiol 2018; 45:290-294. [PMID: 29412162 DOI: 10.1016/j.neurad.2017.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 06/16/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess the diagnostic utility of different perfusion algorithms for the detection of angiographical terial spasm. METHOD During a 2-year period, 45 datasets from 29 patients (54.2±10,75y, 20F) with suspected cerebral vasospasm after aneurysmal subarachnoid hemorrhage were included. Volume Perfusion CT (VPCT), Non-enhanced CT (NCT) and angiography were performed within 6hours post-ictus. Perfusion maps were generated using a maximum slope (MS) and a deconvolution-based approach (DC). Two blinded neuroradiologists independently evaluated MS and DC maps regarding vasospasm-related perfusion impairment on a 3-point Likert-scale (0=no impairment, 1=impairment affecting <50%, 2=impairment affecting >50% of vascular territory). A third independent neuroradiologist assessed angiography for presence and severity of arterial narrowing on a 3-point Likert scale (0=no narrowing, 1=narrowing affecting <50%, 2=narrowing affecting>50% of artery diameter). MS and DC perfusion maps were evaluated regarding diagnostic accuracy for angiographical arterial spasm with angiography as reference standard. Correlation analysis of angiography findings with both MS and DC perfusion maps was additionally performed. Furthermor, the agreement between MS and DC and inter-reader agreement was assessed. RESULTS DC maps yielded significantly higher diagnostic accuracy than MS perfusion maps (DC:AUC=.870; MS:AUC=.805; P=0.007) with higher sensitivity for DC compared to MS (DC:sensitivity=.758; MS:sensitivity=.625). DC maps revealed stronger correlation with angiography than MS (DC: R=.788; MS: R=694;=<0.001). MS and DC showed substantial agreement (Kappa=.626). Regarding inter-reader analysis, (almost) perfect inter-reader agreement was observed for both MS and DC maps (Kappa≥981). CONCLUSION DC yields significantly higher diagnostic accuracy for the detection of angiographic arterial spasm and higher correlation with angiographic findings compared to MS.
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Affiliation(s)
- Saif Afat
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Hospital Mainz, 55131 Mainz, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany; Department of Diagnostic and Interventional Radiology, RWTH Aachen University, 52074 Aachen, Germany
| | - Marguerite Müller
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany
| | - Kolja M Thierfelder
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Wolfgang G Kunz
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistr. 15, 81377 Munich, Germany
| | | | - Marc A Brockmann
- Department of Neuroradiology, University Hospital Mainz, 55131 Mainz, Germany
| | - Konstantin Nikolaou
- Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, 72076 Tübingen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany
| | - Ahmed E Othman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074 Aachen, Germany; Siemens Healthcare GmbH, 91052 Forchheim, Germany.
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27
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Afat S, Brockmann C, Nikoubashman O, Müller M, Thierfelder KM, Brockmann MA, Nikolaou K, Wiesmann M, Kim JH, Othman AE. Diagnostic Accuracy of Simulated Low-Dose Perfusion CT to Detect Cerebral Perfusion Impairment after Aneurysmal Subarachnoid Hemorrhage: A Retrospective Analysis. Radiology 2018; 287:643-650. [PMID: 29309735 DOI: 10.1148/radiol.2017162707] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose To evaluate diagnostic accuracy of low-dose volume perfusion (VP) computed tomography (CT) compared with original VP CT regarding the detection of cerebral perfusion impairment after aneurysmal subarachnoid hemorrhage. Materials and Methods In this retrospective study, 85 patients (mean age, 59.6 years; 62 women) with aneurysmal subarachnoid hemorrhage and who were suspected of having cerebral vasospasm at unenhanced CT and VP CT (tube voltage, 80 kVp; tube current-time product, 180 mAs) were included, 37 of whom underwent digital subtraction angiography (DSA) within 6 hours. Low-dose VP CT data sets at tube current-time product of 72 mAs were retrospectively generated by validated realistic simulation. Perfusion maps were generated from both data sets and reviewed by two neuroradiologists for overall image quality, diagnostic confidence and presence and/or severity of perfusion impairment indicating vasospasm. An interventional neuroradiologist evaluated 16 vascular segments at DSA. Diagnostic accuracy of low-dose VP CT was calculated with original VP CT as reference standard. Agreement between findings of both data sets was assessed by using weighted Cohen κ and findings were correlated with DSA by using Spearman correlation. After quantitative volumetric analysis, lesion volumes were compared on both VP CT data sets. Results Low-dose VP CT yielded good ratings of image quality and diagnostic confidence and classified all patients correctly with high diagnostic accuracy (sensitivity, 99.0%; specificity, 99.5%) without significant differences regarding presence and/or severity of perfusion impairment between original and low-dose data sets (Z = -0.447; P = .655). Findings of both data sets correlated significantly with DSA (original, r = 0.671; low dose, r = 0.667). Lesion volume was comparable for both data sets (relative difference, 5.9% ± 5.1 [range, 0.2%-25.0%; median, 4.0%]) with strong correlation (r = 0.955). Conclusion The results suggest that radiation dose reduction to 40% of original dose levels (tube current-time product, 72 mAs) may be performed in VP CT imaging of patients with aneurysmal subarachnoid hemorrhage without compromising the diagnostic accuracy regarding detection of cerebral perfusion impairment indicating vasospasm. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Saif Afat
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Carolin Brockmann
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Omid Nikoubashman
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Marguerite Müller
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Kolja M Thierfelder
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Marc A Brockmann
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Konstantin Nikolaou
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Martin Wiesmann
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Jong Hyo Kim
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Ahmed E Othman
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
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28
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Takahashi Y, Sasahara A, Yamazaki K, Inazuka M, Kasuya H. Disturbance of CT perfusion within 24 h after onset is associated with WFNS grade but not development of DCI in patients with aneurysmal SAH. Acta Neurochir (Wien) 2017; 159:2319-2324. [PMID: 29058091 DOI: 10.1007/s00701-017-3362-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/10/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is a serious complication following aneurysmal SAH (aSAH) and remains a leading cause of morbidity and mortality. We investigated whether data from CT perfusion (CTP) within 24 h after onset are associated with DCI and its outcome. METHODS We retrospectively examined plain CT, CTP, and CT angiography (CTA) of aSAH patients on arrival. We measured the average mean transit time (aMTT) and compared it with several clinical factors, such as the age, WFNS grade, Fisher group, delayed cerebral infarction, cerebral vasospasm, and modified Rankin scale (mRS), at 1 month. Regions of interest (ROIs) were quantitatively determined in cortical and two basal ganglia areas. RESULTS Delayed cerebral ischemia (DCI) developed in 11 patients and cerebral vasospasm in 28 patients out of a total of 86 aSAH patients scanned within 24 h after onset. The average MTT was correlated with the WFNS grade (p = 0.000), but not mRS (p = 0.128), age (p = 0.759), DCI (p = 0.669), or cerebral vasospasm (p = 0.306). On the other hand, DCI was associated with the Fisher group (p = 0.0056), mRS (p = 0.0052), and cerebral vasospasm (p = 0.000). Moreover, there were no significant differences in the average MTT within 24 h after onset between territories with and without DCI, or between patients with and without DCI. CONCLUSIONS The current findings suggest that disturbance of CT perfusion soon after the onset is associated with the WFNS grade but not with the development of DCI. Delayed cerebral ischemia may be solely caused by cerebral vasospasm due to a clot in the cistern, but not associated with early brain injury.
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Affiliation(s)
- Yuichi Takahashi
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Atsushi Sasahara
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan.
| | - Kei Yamazaki
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Mayuko Inazuka
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
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29
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Ene CI, Morton RP, Kelly CM, Levitt MR, Ghodke B. Angiographic perfusion imaging of intracranial stenting. J Clin Neurosci 2017; 48:100-102. [PMID: 29183679 DOI: 10.1016/j.jocn.2017.10.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
Abstract
Two-dimensional angiographic perfusion imaging (2DAP) is a new technique permitting perfusion imaging during angiography, and has been used to study cerebral vasospasm. Here we report our experience with this technique following angioplasty and stent placement in a patient with symptomatic and medically refractory stenosis of the right supraclinoid internal carotid artery. We found that intraprocedural angiographic perfusion imaging provided real-time and objective evidence of improved cerebral perfusion during intervention. Following treatment, the patient remains symptom-free at last follow-up.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurological Surgery, University of Washington, Seattle, WA United States.
| | - Ryan P Morton
- Department of Neurological Surgery, University of Washington, Seattle, WA United States
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, WA United States
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, WA United States; Department of Radiology, University of Washington, Seattle, WA, United States; Department of Mechanical Engineering, University of Washington, Seattle, WA, United States
| | - Basavaraj Ghodke
- Department of Neurological Surgery, University of Washington, Seattle, WA United States; Department of Radiology, University of Washington, Seattle, WA, United States
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30
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Ultra-early Detection of Microcirculatory Injury as Predictor of Developing Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Clin Neuroradiol 2017; 28:501-507. [DOI: 10.1007/s00062-017-0616-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
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31
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Donaldson C, O'Neill AH, Slater LA, Chong W, Lai LT, Chandra RV. Feasibility of Real-Time Angiographic Perfusion Imaging in the Treatment of Cerebral Vasospasm. INTERVENTIONAL NEUROLOGY 2017; 6:163-169. [PMID: 29118793 DOI: 10.1159/000468157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Objective assessment and quantification of the severity of cerebral vasospasm following aneurysmal subarachnoid hemorrhage is not routinely utilized. We investigated the feasibility of angiographic perfusion imaging derived from digital subtraction angiography (DSA) following endovascular vasospasm treatment procedures. Methodology Real-time blood flow analysis was performed using parametric color coding on pre- and postintervention DSA. Semiquantitative parenchymal perfusion parameters (arrival time [AT] of contrast, time to peak [TTP] opacification, and mean transit time [MTT] of contrast) were calculated across 3 vascular territories (anterior cerebral artery [ACA], middle cerebral artery [MCA], and lenticulostriate arteries) using standard 2-D angiographic perfusion software. The pre- and postintervention arterial vessel diameters were compared. Results Twelve endovascular vasospasm treatments in 6 patients were performed. All patients received intra-arterial vasodilator therapy with either nimodipine, milrinone, or both. Following intra-arterial intervention, parenchymal flow analysis showed improvement in TTP and MTT across all vascular territories (p < 0.002) and improvement in AT in the ACA and MCA territories (p < 0.03). Improvement in parenchymal perfusion parameters was associated with improvement in vessel diameters in all territories following treatment (p < 0.05). Conclusion Real-time parenchymal perfusion imaging during endovascular vasospasm treatment procedures is feasible and provides reliable semiquantitative measurement of angiographic treatment response.
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Affiliation(s)
- Christopher Donaldson
- Department of Neurosurgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Anthea H O'Neill
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Lee-Anne Slater
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Winston Chong
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ronil V Chandra
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, Victoria, Australia
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32
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Patet C, Quintard H, Zerlauth JB, Maibach T, Carteron L, Suys T, Bouzat P, Bervini D, Levivier M, Daniel RT, Eckert P, Meuli R, Oddo M. Bedside cerebral microdialysis monitoring of delayed cerebral hypoperfusion in comatose patients with poor grade aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2017; 88:332-338. [PMID: 27927702 DOI: 10.1136/jnnp-2016-313766] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 08/09/2016] [Accepted: 09/07/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Delayed cerebral ischaemia (DCI) is frequent after poor grade aneurysmal subarachnoid haemorrhage (SAH). Owing to the limited accuracy of clinical examination, DCI diagnosis is often based on multimodal monitoring. We examined the value of cerebral microdialysis (CMD) in this setting. METHODS 20 comatose SAH participants underwent CMD monitoring-for hourly sampling of cerebral extracellular lactate/pyruvate ratio (LPR) and glucose-and brain perfusion CT (PCT). Patients were categorised as DCI when PCT (8±3 days after SAH) showed cerebral hypoperfusion, defined as cerebral blood flow <32.5 mL/100 g/min with a mean transit time >5.7 s. Clinicians were blinded to CMD data; for the purpose of the study, only patients who developed cerebral hypoperfusion in anterior and/or middle cerebral arteries were analysed. RESULTS DCI (n=9/20 patients) was associated with higher CMD LPR (51±36 vs 31±10 in patients without DCI, p=0.0007) and lower CMD glucose (0.64±0.34 vs 1.22±1.05, p=0.0005). In patients with DCI, CMD changes over the 18 hours preceding PCT diagnosis revealed a pattern of CMD LPR increase (coefficient +2.96 (95% CI 0.13 to 5.79), p=0.04) with simultaneous CMD glucose decrease (coefficient -0.06 (95% CI -0.08 to -0.01), p=0.03, mixed-effects multilevel regression model). No significant CMD changes were noted in patients without DCI. CONCLUSIONS In comatose patients with SAH, delayed cerebral hypoperfusion correlates with a CMD pattern of lactate increase and simultaneous glucose decrease. CMD abnormalities became apparent in the hours preceding PCT, thereby suggesting that CMD monitoring may anticipate targeted therapeutic interventions.
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Affiliation(s)
- Camille Patet
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Hervé Quintard
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland.,Department of Anesthesia and Critical Care, University Hospital, Nice, France
| | - Jean-Baptiste Zerlauth
- Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | | | - Laurent Carteron
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Tamarah Suys
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Bouzat
- Department of Anesthesia and Critical Care, University Hospital, Grenoble, France.,Neuroscience Institute, Grenoble, France
| | - David Bervini
- Division of Neurosurgery, Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Marc Levivier
- Division of Neurosurgery, Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Roy T Daniel
- Division of Neurosurgery, Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Philippe Eckert
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Reto Meuli
- Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Mauro Oddo
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
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Sun H, Li W, Ma J, Liu Y, You C. CT perfusion diagnoses delayed cerebral ischemia in the early stage of the time-window after aneurysmal subarachnoid hemorrhage. J Neuroradiol 2017; 44:313-318. [PMID: 28237366 DOI: 10.1016/j.neurad.2016.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/21/2016] [Accepted: 12/30/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE It has been acknowledged that delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) can be diagnosed by CT perfusion (CTP) in the DCI time-window. We evaluated the diagnostic accuracy of CTP for DCI during the early stage of the time-window. MATERIALS AND METHODS We prospectively enrolled patients with aneurysmal SAH. DCI was defined as both new cerebral infarction and clinical deterioration after SAH. CTP was performed by using a standardized protocol with predefined regions of interest in 4 to 6 days after SAH. We quantitatively evaluated the diagnostic accuracy of eight CTP parameters (4 for absolute parameters and 4 for relative parameters). The receiver operator characteristic (ROC) curves of all parameters were generated and the optimal threshold values were derived for the calculation of sensitivities and specificities. RESULTS Fifty-three patients were enrolled and 20 patients were diagnosed with DCI. In the analysis of absolute CTP parameters, CBF and MTT had areas under the curve (AUC) >0.75 and the optimal threshold value was 40.4mL/100g/min and 3.78seconds, respectively. Through the evaluation of relative CTP parameters, all 4 parameters had AUC >0.75 and the optimal threshold value was 0.9 for CBV ratio, 0.85 for CBF ratio, 0.32seconds for MTT difference and 1.31seconds for TTP difference. CONCLUSIONS Besides two absolute CTP parameters (CBV and TTP), all six CTP parameters can be used as good diagnostic tests for DCI in the early stage of the time-window.
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Affiliation(s)
- Haogeng Sun
- Department of Neurosurgery, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China
| | - Wanjiang Li
- Department of Radiology, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China
| | - Junpeng Ma
- Department of Neurosurgery, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China.
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, 37, Guoxuexiang Street, Chengdu 610041, China
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34
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Abstract
For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.
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Affiliation(s)
- Charles L Francoeur
- Critical Care Division, Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, Québec, Canada
| | - Stephan A Mayer
- Department of Neurology (Neurocritical Care), Mount Sinai, New York, NY, USA.
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1522, New York, NY, 10029-6574, USA.
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35
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Sadahiro H, Shirao S, Yoneda H, Ishihara H, Oku T, Inamura A, Yamane A, Sugimoto K, Fujiyama Y, Suzuki M. Decreased Flow Velocity with Transcranial Color-Coded Duplex Sonography Correlates with Delayed Cerebral Ischemia due to Peripheral Vasospasm of the Middle Cerebral Artery. J Stroke Cerebrovasc Dis 2016; 25:2352-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/22/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022] Open
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36
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Abstract
Cerebral vasospasm is a potentially devastating complication in patients with aneurysmal subarachnoid hemorrhage. The purpose of this article is to review the use of computed tomogram (CT) angiography and CT perfusion in the diagnosis of cerebral vasospasm after aneurysmal subarachnoid hemorrhage and also assess their use in guiding treatment decisions. Both techniques are widely used for other indications but their use in cerebral vasospasm has not been well defined. Computed tomogram angiography can directly visualize arterial narrowing and CT perfusion is able to evaluate differences in perfusion parameters after aneurysmal subarachnoid hemorrhage with high sensitivity and specificity. CT perfusion is better at predicting which patients require endovascular treatment.
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37
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Ivanidze J, Kallas ON, Gupta A, Weidman E, Baradaran H, Mir D, Giambrone A, Segal AZ, Claassen J, Sanelli PC. Application of Blood-Brain Barrier Permeability Imaging in Global Cerebral Edema. AJNR Am J Neuroradiol 2016; 37:1599-603. [PMID: 27127002 DOI: 10.3174/ajnr.a4784] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 02/22/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Blood-brain barrier permeability is not routinely evaluated in the clinical setting. Global cerebral edema occurs after SAH and is associated with BBB disruption. Detection of global cerebral edema using current imaging techniques is challenging. Our purpose was to apply blood-brain barrier permeability imaging in patients with global cerebral edema by using extended CT perfusion. MATERIALS AND METHODS Patients with SAH underwent CTP in the early phase after aneurysmal rupture (days 0-3) and were classified as having global cerebral edema or nonglobal cerebral edema using established noncontrast CT criteria. CTP data were postprocessed into blood-brain barrier permeability quantitative maps of PS (permeability surface-area product), K(trans) (volume transfer constant from blood plasma to extravascular extracellular space), Kep (washout rate constant of the contrast agent from extravascular extracellular space to intravascular space), VE (extravascular extracellular space volume per unit of tissue volume), VP (plasmatic volume per unit of tissue volume), and F (plasma flow) by using Olea Sphere software. Mean values were compared using t tests. RESULTS Twenty-two patients were included in the analysis. Kep (1.32 versus 1.52, P < .0001), K(trans) (0.15 versus 0.19, P < .0001), VP (0.51 versus 0.57, P = .0007), and F (1176 versus 1329, P = .0001) were decreased in global cerebral edema compared with nonglobal cerebral edema while VE (0.81 versus 0.39, P < .0001) was increased. CONCLUSIONS Extended CTP was used to evaluate blood-brain barrier permeability in patients with SAH with and without global cerebral edema. Kep is an important indicator of altered blood-brain barrier permeability in patients with decreased blood flow, as Kep is flow-independent. Further study of blood-brain barrier permeability is needed to improve diagnosis and monitoring of global cerebral edema.
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Affiliation(s)
- J Ivanidze
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - O N Kallas
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - A Gupta
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - E Weidman
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - H Baradaran
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - D Mir
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - A Giambrone
- Healthcare Policy and Research (A.Giambrone)
| | - A Z Segal
- Neurology (A.Z.S.), Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - J Claassen
- Department of Neurology (J.C.), New York-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - P C Sanelli
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
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Lin CF, Hsu SPC, Lin CJ, Guo WY, Liao CH, Chu WF, Hung SC, Shih YS, Lin YT. Prolonged Cerebral Circulation Time Is the Best Parameter for Predicting Vasospasm during Initial CT Perfusion in Subarachnoid Hemorrhagic Patients. PLoS One 2016; 11:e0151772. [PMID: 26986626 PMCID: PMC4795708 DOI: 10.1371/journal.pone.0151772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 03/03/2016] [Indexed: 12/03/2022] Open
Abstract
Purpose We sought to imitate angiographic cerebral circulation time (CCT) and create a similar index from baseline CT perfusion (CTP) to better predict vasospasm in patients with subarachnoid hemorrhage (SAH). Methods Forty-one SAH patients with available DSA and CTP were retrospectively included. The vasospasm group was comprised of patients with deterioration in conscious functioning and newly developed luminal narrowing; remaining cases were classified as the control group. The angiography CCT (XA-CCT) was defined as the difference in TTP (time to peak) between the selected arterial ROIs and the superior sagittal sinus (SSS). Four arterial ROIs were selected to generate four corresponding XA-CCTs: the right and left anterior cerebral arteries (XA-CCTRA2 and XA-CCTLA2) and right- and left-middle cerebral arteries (XA-CCTRM2 and XA-CCTLM2). The CCTs from CTP (CT-CCT) were defined as the differences in TTP from the corresponding arterial ROIs and the SSS. Correlations of the different CCTs were calculated and diagnostic accuracy in predicting vasospasm was evaluated. Results Intra-class correlations ranged from 0.96 to 0.98. The correlations of XA-CCTRA2, XA-CCTRM2, XA-CCTLA2, and XA-CCTLM2 with the corresponding CT-CCTs were 0.64, 0.65, 0.53, and 0.68, respectively. All CCTs were significantly prolonged in the vasospasm group (5.8–6.4 s) except for XA-CCTLA2. CT-CCTA2 of 5.62 was the optimal cut-off value for detecting vasospasm with a sensitivity of 84.2% and specificity 82.4% Conclusion CT-CCTs can be used to interpret cerebral flow without deconvolution algorithms, and outperform both MTT and TTP in predicting vasospasm risk. This finding may help facilitate management of patients with SAH.
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Affiliation(s)
- Chun Fu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sanford P. C. Hsu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wan Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
| | - Chih Hsiang Liao
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei Fa Chu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sheng Che Hung
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yang Shin Shih
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen Tzu Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Serial Quantitative Computed Tomography Perfusion in Aneurysmal Subarachnoid Hemorrhage. Can J Neurol Sci 2016; 43:375-80. [PMID: 26757612 DOI: 10.1017/cjn.2015.351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Computed tomography perfusion (CTP) has been performed to predict which patients with aneurysmal subarachnoid hemorrhage are at risk of developing delayed cerebral ischemia (DCI). Patients with severe arterial narrowing may have significant reduction in perfusion. However, many patients have less severe arterial narrowing. There is a paucity of literature evaluating perfusion changes which occur with mild to moderate narrowing. The purpose of our study was to investigate serial whole-brain CTP/computed tomography angiography in aneurysm-related subarachnoid hemorrhage (aSAH) patients with mild to moderate angiographic narrowing. METHODS We retrospectively studied 18 aSAH patients who had baseline and follow-up whole-brain CTP/computed tomography angiography. Thirty-one regions of interest/hemisphere at six levels were grouped by vascular territory. Arterial diameters were measured at the circle of Willis. The correlation between arterial diameter and change in CTP values, change in CTP in with and without DCI, and response to intra-arterial vasodilator therapy in DCI patients was evaluated. RESULTS There was correlation among the overall average cerebral blood flow (CBF; R=0.49, p<0.04), mean transit time (R=-0.48, p=0.04), and angiographic narrowing. In individual arterial territories, there was correlation between changes in CBF and arterial diameter in the middle cerebral artery (R=0.53, p=0.03), posterior cerebral artery (R=0.5, p=0.03), and anterior cerebral artery (R=0.54, p=0.02) territories. Prolonged mean transit time was correlated with arterial diameter narrowing in the middle cerebral artery territory (R=0.52, p=0.03). Patients with DCI tended to have serial worsening of CBF compared with those without DCI (p=0.055). CONCLUSIONS Our preliminary study demonstrates there is a correlation between mild to moderate angiographic narrowing and serial changes in perfusion in patients with aSAH. Patients developing DCI tended to have progressively worsening CBF compared with those not developing DCI.
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C-arm flat detector computed tomography parenchymal blood volume imaging: the nature of parenchymal blood volume parameter and the feasibility of parenchymal blood volume imaging in aneurysmal subarachnoid haemorrhage patients. Neuroradiology 2015; 57:937-49. [PMID: 26022353 DOI: 10.1007/s00234-015-1545-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION C-arm flat detector computed tomography (FDCT) parenchymal blood volume (PBV) measurements allow assessment of cerebral haemodynamics in the neurointerventional suite. This paper explores the feasibility of C-arm computed tomography (CT) PBV imaging and the relationship between the C-arm CT PBV and the MR-PWI-derived cerebral blood volume (CBV) and cerebral blood flow (CBF) parameters in aneurysmal subarachnoid haemorrhage (SAH) patients developing delayed cerebral ischemia (DCI). METHODS Twenty-six patients with DCI following aneurysmal SAH underwent a research C-arm CT PBV scan using a biplane angiography system and contemporaneous MR-PWI scan as part of a prospective study. Quantitative whole-brain atlas-based volume-of-interest analysis in conjunction with Pearson correlation and Bland-Altman tests was performed to explore the agreement between C-arm CT PBV and MR-derived CBV and CBF measurements. RESULTS All patients received medical management, while eight patients (31%) underwent selective intra-arterial chemical angioplasty. Colour-coded C-arm CT PBV maps were 91% sensitive and 100% specific in detecting the perfusion abnormalities. C-arm CT rPBV demonstrated good agreement and strong correlation with both MR-rCBV and MR-rCBF measurements; the agreement and correlation were stronger for MR-rCBF relative to MR-rCBV and improved for C-arm CT PBV versus the geometric mean of MR-rCBV and MR-rCBF. Analysis of weighted means showed that the C-arm CT PBV has a preferential blood flow weighting (≈ 60% blood flow and ≈ 40% blood volume weighting). CONCLUSIONS C-arm CT PBV imaging is feasible in DCI following aneurysmal SAH. PBV is a composite perfusion parameter incorporating both blood flow and blood volume weightings. That PBV has preferential (≈ 60%) blood flow weighting is an important finding, which is of clinical significance when interpreting the C-arm CT PBV maps, particularly in the setting of acute brain ischemia.
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Ivanidze J, Kesavabhotla K, Kallas ON, Mir D, Baradaran H, Gupta A, Segal AZ, Claassen J, Sanelli PC. Evaluating blood-brain barrier permeability in delayed cerebral infarction after aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2015; 36:850-4. [PMID: 25572949 DOI: 10.3174/ajnr.a4207] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/05/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patients with SAH are at increased risk of delayed infarction. Early detection and treatment of delayed infarction remain challenging. We assessed blood-brain barrier permeability, measured as permeability surface area product, by using CTP in patients with SAH with delayed infarction. MATERIALS AND METHODS We performed a retrospective study of patients with SAH with delayed infarction on follow-up NCCT. CTP was performed before the development of delayed infarction. CTP data were postprocessed into permeability surface area product, CBF, and MTT maps. Coregistration was performed to align the infarcted region on the follow-up NCCT with the corresponding location on the CTP maps obtained before infarction. Permeability surface area product, CBF, and MTT values were then obtained in the location of the subsequent infarction. The contralateral noninfarcted region was compared with the affected side in each patient. Wilcoxon signed rank tests were performed to determine statistical significance. Clinical data were collected at the time of CTP and at the time of follow-up NCCT. RESULTS Twenty-one patients with SAH were included in the study. There was a statistically significant increase in permeability surface area product in the regions of subsequent infarction compared with the contralateral control regions (P < .0001). However, CBF and MTT values were not significantly different in these 2 regions. Subsequent follow-up NCCT demonstrated new delayed infarction in all 21 patients, at which time 38% of patients had new focal neurologic deficits. CONCLUSIONS Our study reveals a statistically significant increase in permeability surface area product preceding delayed infarction in patients with SAH. Further investigation of early permeability changes in SAH may provide new insights into the prediction of delayed infarction.
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Affiliation(s)
- J Ivanidze
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - K Kesavabhotla
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - O N Kallas
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - D Mir
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - H Baradaran
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | - A Gupta
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.)
| | | | - J Claassen
- Department of Neurology (J.C.), New York-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - P C Sanelli
- From the Departments of Radiology (J.I., K.K., O.N.K., D.M., H.B., A.G., P.C.S.) Public Health (P.C.S.), Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
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Beseoglu K, Etminan N, Hänggi D. The value of perfusion computed tomography (PCT) imaging after aneurysmal subarachnoid hemorrhage: a review of the current data. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:35-8. [PMID: 25366596 DOI: 10.1007/978-3-319-04981-6_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND PURPOSE The estimation of the extent of early brain injury (EBI) and sensitive detection of delayed cerebral ischemia (DCI) remains a major challenge in the context of aneurysmal subarachnoid hemorrhage (aSAH). Cerebral perfusion computed tomography (PCT) imaging is increasingly used as an additional diagnostic tool to monitor early brain injury as well as delayed cerebral ischemia after aSAH. Here, we review the current literature as well as the resulting implications and illustrate our institutional experience with PCT imaging in this context. METHODS The current literature on PCT imaging for SAH was identified based on a search of the PubMed database. Patient cohorts were dichotomized according to the time of PCT after ictus into early PCT (<72 h after ictus) and subsequent PCT (>72 h after ictus). The specific aspects and findings of PCT at different times are compared and discussed. RESULTS Sixteen relevant publications were identified, nine of which focused on early PCT and seven on subsequent PCT diagnostics after aSAH. Early PCT provided relevant details on the extent of EBI and identified patients at risk for developing DCI, whereas subsequent PCT imaging facilitated the monitoring and detection of DCI. CONCLUSIONS The present review demonstrates that PCT imaging is able to detect EBI as well as DCI in patients experiencing aSAH. As a consequence, this technique should be routinely implemented in monitoring strategies for this patient population.
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Affiliation(s)
- Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, Düsseldorf, 40225, Germany,
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de Oliveira Manoel AL, Mansur A, Murphy A, Turkel-Parrella D, Macdonald M, Macdonald RL, Montanera W, Marotta TR, Bharatha A, Effendi K, Schweizer TA. Aneurysmal subarachnoid haemorrhage from a neuroimaging perspective. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:557. [PMID: 25673429 PMCID: PMC4331293 DOI: 10.1186/s13054-014-0557-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Neuroimaging is a key element in the management of patients suffering from subarachnoid haemorrhage (SAH). In this article, we review the current literature to provide a summary of the existing neuroimaging methods available in clinical practice. Noncontrast computed tomography is highly sensitive in detecting subarachnoid blood, especially within 6 hours of haemorrhage. However, lumbar puncture should follow a negative noncontrast computed tomography scan in patients with symptoms suspicious of SAH. Computed tomography angiography is slowly replacing digital subtraction angiography as the first-line technique for the diagnosis and treatment planning of cerebral aneurysms, but digital subtraction angiography is still required in patients with diffuse SAH and negative initial computed tomography angiography. Delayed cerebral ischaemia is a common and serious complication after SAH. The modern concept of delayed cerebral ischaemia monitoring is shifting from modalities that measure vessel diameter to techniques focusing on brain perfusion. Lastly, evolving modalities applied to assess cerebral physiological, functional and cognitive sequelae after SAH, such as functional magnetic resonance imaging or positron emission tomography, are discussed. These new techniques may have the advantage over structural modalities due to their ability to assess brain physiology and function in real time. However, their use remains mainly experimental and the literature supporting their practice is still scarce.
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Dolatowski K, Malinova V, Frölich A, Schramm R, Haberland U, Klotz E, Mielke D, Knauth M, Schramm P. Volume perfusion CT (VPCT) for the differential diagnosis of patients with suspected cerebral vasospasm: Qualitative and quantitative analysis of 3D parameter maps. Eur J Radiol 2014; 83:1881-9. [DOI: 10.1016/j.ejrad.2014.06.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 06/24/2014] [Indexed: 11/16/2022]
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Sanelli PC, Pandya A, Segal AZ, Gupta A, Hurtado-Rua S, Ivanidze J, Kesavabhotla K, Mir D, Mushlin AI, Hunink MGM. Cost-effectiveness of CT angiography and perfusion imaging for delayed cerebral ischemia and vasospasm in aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2014; 35:1714-20. [PMID: 24812015 DOI: 10.3174/ajnr.a3947] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia and vasospasm are significant complications following SAH leading to cerebral infarction, functional disability, and death. In recent years, CTA and CTP have been used to increase the detection of delayed cerebral ischemia and vasospasm. Our aim was to perform comparative-effectiveness and cost-effectiveness analyses evaluating CTA and CTP for delayed cerebral ischemia and vasospasm in aneurysmal SAH from a health care payer perspective. MATERIALS AND METHODS We developed a decision model comparing CTA and CTP with transcranial Doppler sonography for detection of vasospasm and delayed cerebral ischemia in SAH. The clinical pathways were based on the "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association" (2012). Outcome health states represented mortality and morbidity according to functional outcomes. Input probabilities of symptoms and serial test results from CTA and CTP, transcranial Doppler ultrasound, and digital subtraction angiography were directly derived from an SAH cohort by using a multinomial logistic regression model. Expected benefits, measured as quality-adjusted life years, and costs, measured in 2012 US dollars, were calculated for each imaging strategy. Univariable, multivariable, and probabilistic sensitivity analyses were performed to determine the independent and combined effect of input parameter uncertainty. RESULTS The transcranial Doppler ultrasound strategy yielded 13.62 quality-adjusted life years at a cost of $154,719. The CTA and CTP strategy generated 13.89 quality-adjusted life years at a cost of $147,097, resulting in a gain of 0.27 quality-adjusted life years and cost savings of $7622 over the transcranial Doppler ultrasound strategy. Univariable and multivariable sensitivity analyses indicated that results were robust to plausible input parameter uncertainty. Probabilistic sensitivity analysis results yielded 96.8% of iterations in the right lower quadrant, representing higher benefits and lower costs. CONCLUSIONS Our model results suggest that CTA and CTP are the preferred imaging strategy in SAH, compared with transcranial Doppler ultrasound, leading to improved clinical outcomes and lower health care costs.
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Affiliation(s)
- P C Sanelli
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.) Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - A Pandya
- Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - A Z Segal
- Neurology (A.Z.S.), Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - A Gupta
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | | | - J Ivanidze
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - K Kesavabhotla
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - D Mir
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - A I Mushlin
- Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - M G M Hunink
- Departments of Radiology and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, the Netherlands
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Abstract
Critically ill neurologic patients are common in the hospital practice of neurology and are often in extreme states requiring accurate and specific information. Imaging, especially using advanced imaging techniques, can provide an important means of garnering this information. This article focuses on the clinical utilization of selective imaging methods that are commonly used in critically ill neurologic patients to render diagnoses, to monitor effects of treatment, or have contributed to a better understanding of pathophysiology in the intensive care unit.
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Affiliation(s)
- Paul M Vespa
- David Geffen School of Medicine at UCLA, 757 Westwood Boulevard, Room 6236A, Los Angeles, CA 90095, USA.
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Hana T, Iwama J, Yokosako S, Yoshimura C, Arai N, Kuroi Y, Koseki H, Akiyama M, Hirota K, Ohbuchi H, Hagiwara S, Tani S, Sasahara A, Kasuya H. Sensitivity of CT perfusion for the diagnosis of cerebral infarction. THE JOURNAL OF MEDICAL INVESTIGATION 2014; 61:41-5. [DOI: 10.2152/jmi.61.41] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Taijun Hana
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Junya Iwama
- Department of Neurosurgery, Toho University Ohashi Medical Center
| | - Suguru Yokosako
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Chika Yoshimura
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Naoyuki Arai
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Yasuhiro Kuroi
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Hirokazu Koseki
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Mami Akiyama
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Kengo Hirota
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Hidenori Ohbuchi
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Shinji Hagiwara
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Shigeru Tani
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Atsushi Sasahara
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women’s Medical University Medical Center East
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Shin BJ, Anumula N, Hurtado-Rúa S, Masi P, Campbell R, Spandorfer R, Ferrone A, Caruso T, Haseltine J, Robinson C, Gupta A, Sanelli PC. Does the location of the arterial input function affect quantitative CTP in patients with vasospasm? AJNR Am J Neuroradiol 2014; 35:49-54. [PMID: 23945228 DOI: 10.3174/ajnr.a3655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In recent years, there has been increasing use of CTP imaging in patients with aneurysmal SAH to evaluate for vasospasm. Given the critical role of the arterial input function for generation of accurate CTP data, several studies have evaluated the effect of varying the arterial input function location in patients with acute stroke. Our aim was to determine the effect on quantitative CTP data when the arterial input function location is distal to significant vasospasm in patients with aneurysmal SAH. MATERIALS AND METHODS A retrospective study was conducted of patients with aneurysmal SAH admitted from 2005 to 2011. Inclusion criteria were the presence of at least 1 anterior cerebral artery or MCA vessel with a radiologically significant vasospasm and at least 1 of these vessels without vasospasm. We postprocessed each CTP dataset 4 separate times by using standardized methods, only varying the selection of the arterial input function location in the anterior cerebral artery and MCA vessels. For each of the 4 separately processed examinations for each patient, quantitative data for CBF, CBV, and MTT were calculated by region-of-interest sampling of the vascular territories. Statistical analysis was performed by using a linear mixed-effects model. RESULTS One hundred twelve uniquely processed CTP levels were analyzed in 28 patients (mean age, 52 years; 24 women and 4 men) recruited from January 2005 to December 2011. The average Hunt and Hess scale score was 2.89 ± 0.79. The average time to CTP from initial presentation was 8.2 ± 5.1 days. For each vascular territory (right and left anterior cerebral artery, MCA, posterior cerebral artery), there were no significant differences in the quantitative CBF, CBV, and MTT generated by arterial input function locations distal to significant vasospasm compared with nonvasospasm vessels (P > .05). CONCLUSIONS Arterial input function placement distal to significant vasospasm does not affect the quantitative CTP data in the corresponding vascular territory or any other vascular territory in aneurysmal SAH.
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Izzy S, Muehlschlegel S. Cerebral vasospasm after aneurysmal subarachnoid hemorrhage and traumatic brain injury. Curr Treat Options Neurol 2013; 16:278. [PMID: 24347030 DOI: 10.1007/s11940-013-0278-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OPINION STATEMENT Cerebral vasospasm (cVSP) consists of the vasoconstriction of large and small intracranial vessels which can lead to cerebral hypoperfusion, and in extreme cases, delayed ischemic deficits with stroke. While most commonly observed after aneurysmal subarachnoid hemorrhage (aSAH), cVSP can also occur after traumatic brain injury (TBI) as we have described in detail in this review. For the past decades, the research attention has focused on cVSP because of its association with delayed cerebral ischemia, which is the largest contributor of morbidity and mortality after aSAH. New discoveries in the cVSP pathophysiology involving multifactorial complex cascades and pathways pose new targets for therapeutic interventions in the prevention and treatment of cVSP. The goal of this review is to demonstrate the commonalities and differences in epidemiology and pathophysiology of both aSAH and TBI-associated cVSP, and highlight the more recently discovered pathways of cVSP. Finally, the latest cVSP surveillance methods and treatment options are illustrated.
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Affiliation(s)
- Saef Izzy
- Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, 55 Lake Ave North, S-5, Worcester, MA, 01655, USA
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Mir DIA, Gupta A, Dunning A, Puchi L, Robinson CL, Epstein HAB, Sanelli PC. CT perfusion for detection of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. AJNR Am J Neuroradiol 2013; 35:866-71. [PMID: 24309123 DOI: 10.3174/ajnr.a3787] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia is a significant cause of morbidity and mortality after aneurysmal SAH, leading to poor outcomes. The purpose of this study was to evaluate the usefulness of CTP in determining delayed cerebral ischemia in patients with aneurysmal SAH. MATERIALS AND METHODS We conducted a systematic review evaluating studies that assessed CTP in patients with aneurysmal SAH for determining delayed cerebral ischemia. Studies using any of the following definitions of delayed cerebral ischemia were included in the systematic review: 1) new onset of clinical deterioration, 2) cerebral infarction identified on follow-up CT or MR imaging, and 3) functional disability. A random-effects meta-analysis was performed assessing the strength of association between a positive CTP result and delayed cerebral ischemia. RESULTS The systematic review identified 218 studies that met our screening criteria, of which 6 cohort studies met the inclusion criteria. These studies encompassed a total of 345 patients, with 155 (45%) of 345 patients classified as having delayed cerebral ischemia and 190 (55%) of 345 patients as not having delayed cerebral ischemia. Admission disease severity was comparable across all groups. Four cohort studies reported CTP test characteristics amenable to the meta-analysis. The weighted averages and ranges of the pooled sensitivity and specificity of CTP in the determination of delayed cerebral ischemia were 0.84 (0.7-0.95) and 0.77 (0.66-0.82), respectively. The pooled odds ratio of 23.14 (95% CI, 5.87-91.19) indicates that patients with aneurysmal SAH with positive CTP test results were approximately 23 times more likely to experience delayed cerebral ischemia compared with patients with negative CTP test results. CONCLUSIONS Perfusion deficits on CTP are a significant finding in determining delayed cerebral ischemia in aneurysmal SAH. This may be helpful in identifying patients with delayed cerebral ischemia before development of infarction and neurologic deficits.
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Affiliation(s)
- D I A Mir
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)
| | - A Gupta
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)
| | | | - L Puchi
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)
| | - C L Robinson
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)
| | - H-A B Epstein
- the Samuel J. Wood Library and C.V. Starr Biomedical Information Center (H.-A.B.E.), Weill Cornell Medical College, New York, NY
| | - P C Sanelli
- From the Departments of Radiology (D.I.A.M., A.G., L.P., C.L.R., P.C.S.)Public Health (A.D., P.C.S.)
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