Computed Tomography Perfusion Deficits during the Baseline Period in Aneurysmal Subarachnoid Hemorrhage Are Predictive of Delayed Cerebral Ischemia

Background Changes in cerebral perfusion occur in subarachnoid hemorrhage that possibly relate to clinical presentation and complications. Purpose To evaluate changes in computed tomography perfusion (CTP) parameters between the acute and subacute stage of subarachnoid hemorrhage. To analyze correlation of these parameters to SAH severity and delayed cerebral ischemia. Material and Methods Cerebral CT perfusion was assessed in a prospective cohort of 44 patients with acute subarachnoid hemorrhage at < 72 h (CTP1) and 8–10 days (CTP2), using the mean of all regions of interest. Regions of interest were located at arterial territories of the anterior, middle, and posterior cerebral artery and basal ganglia and midpons cerebellar hemispheres. Linear regression models (univariable and multivariable) were used to explore the association between changes in perfusion parameters (absolute and relative differences) and relevant clinical data. Results Worse perfusion parameters on the first 72 h were correlated with poor admission clinical scores: cerebral blood flow positively correlated with Glasgow Coma Scale (rS = 0.398, P = 0.008), and negatively correlated with Hunt & Hess scale (rS = −0.348, P = 0.020) and World Federation of Neurosurgeons scale (rS = −0.384, P = 0.010). Cerebral blood volume positively correlated with Glasgow Coma Scale (rS = 0.332, P = 0.028) and negatively correlated with World Federation of Neurosurgeons scale (rS = −0.353, P = 0.019). Mean transit time negatively correlated with Glasgow Coma Scale (rS = −0.415, P = 0.005) and positively correlated with Hunt & Hess scale (rS = 0.471, P = 0.001) and World Federation of Neurosurgeons scale (rS = 0.386, P = 0.010) scores. There were no differences between absolute CTP1/CTP2 parameters. Patients with delayed cerebral ischemia had ΔTmax mean decrease of 2.08 s (95% CI = −4.04–−0.12; P = 0.038). Conclusion Early cerebral hypoperfusion correlates with poor clinical grade at admission in subarachnoid hemorrhage and with higher amounts of blood. Tmax was decreased at 8–10 days, in patients with delayed cerebral ischemia, which may favor the application value of Tmax in signaling delayed cerebral ischemia.

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Computed tomography perfusion imaging after aneurysmal subarachnoid hemorrhage can detect cerebral vasospasm and predict delayed cerebral ischemia after endovascular treatment

Surgical Neurology International ◽

10.25259/sni_14_2020 ◽

2020 ◽

Vol 11 ◽

pp. 233

Author(s):

Koji Omoto ◽

Ichiro Nakagawa ◽

Fumihiko Nishimura ◽

Shuichi Yamada ◽

Yasushi Motoyama ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Endovascular Treatment ◽

Clinical Outcomes ◽

Cerebral Vasospasm ◽

Cerebral Blood Volume ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Mean Transit Time ◽

Delayed Cerebral Ischemia ◽

Computed Tomography Perfusion

Background: Endovascular treatment (ET) can improve angiographic cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage, but was unrelated to clinical outcomes in previous analyses. Appropriate detection of CV and precise indications for ET are required. This study investigated whether changes in computed tomography perfusion (CTP) parameter can determine indications for ET in CV and predict its effectiveness. Methods: Participants comprised 140 patients who underwent neck clipping or coil embolization. CTP was performed a week after aneurysmal treatment or when clinical deterioration had occurred. Patients were divided into ET and non-ET groups by propensity score matching. In addition, the ET group was divided into subgroups with and without new cerebral infarction (CI). All CTP images in the three groups were retrospectively investigated qualitatively and quantitatively. CI was diagnosed from CT at 3 months postoperatively. Results: Of the 121 patients examined, 15 patients (11%) needed ET. In qualitative analysis, all ET group patients displayed extension of time-to-peak (TTP) at the region of vasospastic change, regardless of the presence of CI. Quantitative analysis showed significant decreases in cerebral blood volume (P < 0.01), cerebral blood flow (CBF) (P < 0.001), and extension in TTP (P < 0.01) in the ET group compared with the non-ET group. A significant decrease in CBF (P < 0.001) and extension in mean transit time (P < 0.001) was seen in the ET with CI subgroup compared with the ET without CI subgroup. Conclusion: CTP in the vasospastic period may be an indication for ET and predict the effectiveness of ET for CV to improve clinical outcomes.

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Phase 1/2a Trial of ISPASM

Stroke ◽

10.1161/strokeaha.121.034578 ◽

2021 ◽

Author(s):

Mario Zanaty ◽

Lauren Allan ◽

Edgar A. Samaniego ◽

Anthony Piscopo ◽

Eleanor Ryan ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Intravenous Infusion ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Controlled Trial ◽

Phase 1 ◽

External Ventricular Drain ◽

Delayed Cerebral Ischemia ◽

Unique Identifier

Background and Purpose: Microthrombosis could play a role in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Tirofiban has shown promising results in reducing delayed cerebral ischemia in retrospective studies. However, the safety of using tirofiban in aneurysmal subarachnoid hemorrhage is not rigorously established. Methods: A phase 1/2a double-blinded randomized controlled trial (2:1 randomization) to assess the safety of a 7-day intravenous infusion of tirofiban compared with placebo, in patients with aneurysmal subarachnoid hemorrhage treated with ventriculostomy placed in the operative room and coiling was conducted. The primary end point was any intracranial hemorrhage during the hospital stay. The secondary end points were: incidence of radiographic and clinical vasospasm, incidence of delayed cerebral ischemia, and incidence of cerebral ischemic changes noted on magnetic resonance imaging or computed tomography. Results: Eighteen patients received intravenous tirofiban and 12 received placebo. There was no difference in baseline characteristics except for higher male proportions in the tirofiban group. There was no difference in death, in development of new or change in existing intracranial hemorrhages, in thrombocytopenia, and need for shunts in the two arms. However, the tirofiban arm had a lower incidence of delayed cerebral ischemia compared with placebo (6% [1/18] versus 33% [4/12]; P =0.04), and less radiographic vasospasm as detected by catheter angiogram or computed tomography angiography ( P =0.01) and computed tomography perfusion ( P =0.01). Conclusions: The above preliminary results support proceeding with further testing of the safety and efficacy of 7-day intravenous infusion of tirofiban in a pragmatic (placing external ventricular drain by the bedside), multicenter setting, and using a larger population. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03691727.

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