Acute Anterior Circulation Stroke: Recanalization Using Clot Angioplasty

ABSTRACT:Background and Purpose:Different strategies have been employed to recanalize acutely occluded middle cerebral and internal carotid arteries (ICA) in the setting of acute stroke including intravenous and intra-arterial tPA. However, pharmaceutical thrombolysis alone, may not be effective in patients with a large amount of clot volume (complete M1, terminal internal carotid artery). We report our initial experience with endovascular clot disruption using a soft silicone balloon in addition to intravenous or intraarterial thrombolysis with tPA.Methods:This is a retrospective review of nine patients with symptoms of acute stroke from clot in the middle cerebral or internal carotid territories who were treated with intracranial balloon angioplasty. All patients presented with symptoms of acute anterior circulation stroke less than six hours from onset. Patients in whom computed tomography (CT) angiography confirmed the presence of large vessel clot (terminal ICA, M1 or proximal M2) were included in the study. A CT perfusion was performed providing maps of cerebral blood volume, flow and mean transit time. If the patient presented less than three hours from onset then intravenous tissue plasminogen activator (tPA) was also administered. Intra-arterial tPA was delivered into the clot. If the volume of clot was judged to be significant by the treating neurointerventionist, then a limited trial of tPA was administered intraarterially followed by balloon angioplasty of persistant clot. The time from imaging to vessel recanalization was recorded. Clinical outcomes were assessed using the modified Rankin scale and Barthel Index.Results:Diagnostic CT perfusion studies were performed in 7 (78%), all of which showed a significant amount of salvageable tissue as judged by the treating neurointerventionist and neurologist. Recanalization (TIMI 2 or 3) was possible in 8 (89%). There were no cases of symptomatic intracranial hemorrhage and 2 (22%) asymptomatic hemorrhages. The average time from performance of the initial emergency CT to vessel recanalization was 2.1 hours with mean time from symptom onset to vessel recanalization of 4.1 hours. Five (56%) patients had good outcomes, 1 (11%) had mild and 3 (33%) had moderate to severe disability.Conclusion:Clot angioplasty can potentially shorten recanalization times in well-selected patients and can be an effective complimentary procedure in patients with tPA resistant clot. Angioplasty can be performed with a very low complication rate using the technique described and may be associated with good outcomes.

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Abstract TP362: A Team Approach for Improving Door to needle Time for IV t-PA in Acute Stroke

Stroke ◽

10.1161/str.44.suppl_1.atp362 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Nili E Steiner ◽

Nicole Wolber ◽

Betty Robertson ◽

Paula Rosenfield ◽

Laurie Paletz

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Stroke Patient ◽

Ct Perfusion ◽

Team Approach ◽

Acute Stroke Patient ◽

Stroke Treatment ◽

Perfusion Studies ◽

Intravenous Tissue Plasminogen Activator ◽

Ct Angiogram

Background: Brain ischemia kills 2 million nerve cells per minute. As time elapses, the odds of favorable outcome become less likely. By providing treatment rapidly, patient outcome is markedly improved. We recognized an opportunity for improvement by shortening our door-to-needle time. The door-to-needle time is defined by the time the patient arrives in the emergency department to the time the patient receives intravenous tissue plasminogen activator (IV t-PA). Methods: We evaluated the system in place to look at opportunities for improvement. We met monthly to assess every acute stroke patient case, particularly to evaluate delays in acute stroke treatment. We analyzed the results of all the acute stroke patient cases from January 2008 to January 2012. We implemented the following interventions: staff education, reducing unnecessary CT angiogram and CT perfusion studies on patients, RN telephone triage for acute stroke patients. pre-hospital activation of the stroke team for patients exhibiting acute stroke symptoms, ED pharmacist at bedside upon patient arrival with t-PA, and placing patients on portable monitors immediately upon ED arrival. Conclusion: The average door-to-needle time from January 2008 to October 2011 was 1 hour and 32 minutes. After implementing the changes above, from November 2011 to January 2012, our average door-to-needle time was 38 minutes to 54 minutes, which is within the target of less than 60 minutes. By implementing these changes, we have successfully and safely reduced and improved our door-to-needle time. Monthly quality improvement meetings are on-going to assess continuing quality improvement.

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Abstract TP49: Irreversible Ischemic Lesion Characterization: Does CBV_ASPECTS Add to CT_ASPECTS?

Stroke ◽

10.1161/str.47.suppl_1.tp49 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Marina Padroni ◽

Pilar Coscojuela ◽

Sandra Boned ◽

Marc Ribó ◽

Jordi Cabero ◽

...

Keyword(s):

Acute Stroke ◽

Symptom Onset ◽

Cerebral Blood Volume ◽

Ct Perfusion ◽

Infarct Volume ◽

Relevant Information ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Anterior Circulation ◽

Ischemic Lesion

Introduction: The best technique for selecting acute stroke patients for reperfusion therapies is not defined yet. ASPECTS is a useful score for assessing the extent of early ischemic signs in the anterior circulation on non-contrast CT (CT). Cerebral blood volume (CBV) on CT perfusion (CTP) defines the core lesion assumed to be irreversibly damaged. Whether CBV provides additional information over CT in the initial ASPECTS assessment is unknown. We aim to explore the advantages of CBV_ASPECTS over CT_ASPECTS in the prediction of final infarct volume. Methods: Consecutive patients with middle cerebral or internal carotid artery occlusion who underwent endovascular reperfusion treatment according to initial CT_ASPECTS≥7 were studied. CBV_ASPECTS was assessed blindly later-on. Recanalization was defined as TICI2b3. Final infarct volumes were measured on follow-up imaging. We defined an irrelevant ASPECTS difference (IAD) as: CT_ASPECTS - CBV_ASPECTS≤1. Results: Sixty-five patients, mean age 67±14, median NIHSS:16(10-20) were studied. Recanalization rate was: 78.5%. Median CT_ASPECTS was 9(8-10), and CBV_ASPECTS 8(8-10). Mean time from symptom onset to CT was 219±143 min. 50 patients (76.9%) showed an IAD. The ASPECTS difference was inversely correlated to the time from symptom onset to CT (r:-0.36, p<0.01). A ROC curve defined 120 minutes as the best cut-off time point after which the ASPECTS difference becomes irrelevant. The rate of IAD was significantly higher after 120 minutes (89.5% Vs 37.5; p<0.01). CBV_ASPECTS but not CT_ASPECTS correlated to the final infarct (r:-0.33, p<0.01). However, if CT was done >2 hours after symptom onset, then CT_ASPECTS was correlated to final infarct (r:-0.39, p=0.01). No other variables were associated with CT-CBV_ASPECTS difference. Conclusions: In acute stroke patient CBV_ASPECTS correlates with final infarct volume. However, when CT is performed after 120 minutes from symptoms onset CBV_ASPECTS does not add relevant information to CT_ASPECTS.

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Abstract TP245: Prediction of Hemorrhagic Transformation in Patients With Acute Ischaemic Stroke and Atrial Fibrillation With Ct Perfusion Aspects Scores

Stroke ◽

10.1161/str.48.suppl_1.tp245 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Qiaoshu Wang ◽

Yanyan Cao ◽

Yongbo Zhao ◽

Louis Caplan

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Roc Analysis ◽

Cerebral Blood Volume ◽

Ct Perfusion ◽

Mean Transit Time ◽

Operating Characteristics ◽

Middle Cerebral Artery Infarction

Background and Purpose: Hemorrhage transformation (HT) is common in patients with acute cerebral infarction caused by atrial fibrillation. The prediction of HT is crucial after acute stroke, especially for the patients received vessel recanalization therapy. The Alberta Stroke program early CT score (ASPECTS) is used to estimate early ischemic changes within the MCA territory in the acute stroke setting. Several studies indicated that CT perfusion (CTP) and MR diffusion weighted imaging (DWI) ASPECTS scores was useful to quantify the degree of ischemic brain tissue. Hereby we did the study to explore the association of CT perfusion ASPECTS scores with HT in patients with acute ischemic stroke and atrial fibrillation. Methods: This was a single center retrospective study. All patients with middle cerebral artery infarction and atrial fibrillation from September 2008 to September 2013 were included. MR imaging including DWI and gradient echo sequence (GRE), and CTP were required to identify the HT and determine the scores of CTP- ASPECTS. Demographic and clinical characteristics of the HT positive and negative groups were explored. Results: Fifty-four patients were analyzed, among them twenty-four patients (44%) developed HT. According to logistic regression analysis, mean transit time (MTT), cerebral blood volume (CBV) and DWI-ASPECTS scores were associated with HT ( p = 0.035, 0.044, and 0.020 respectively). The following receiver operating characteristics (ROC) analysis revealed area under the curve of MTT, CBV, CBF and DWI were 0.588, 0.737, 0.687, and 0.841 respectively. CBV-ASPECTS score was found to have medium prediction value of HT among all CTP-ASPECTS parameters. ROC analysis also indicated that CBV-ASPECTS score < 7 was the optimal threshold. Conclusions: CTP-ASPECTS was useful to predict the HT of acute ischemic stroke caused by atrial fibrillation and CBV-ASPECTS score < 7 was the preferable parameter.

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CT perfusion and angiographic assessment of pial collateral reperfusion in acute ischemic stroke: the CAPRI study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-012155 ◽

2016 ◽

Vol 8 (12) ◽

pp. 1211-1216 ◽

Cited By ~ 6

Author(s):

Arturo Consoli ◽

Tommy Andersson ◽

Ake Holmberg ◽

Luca Verganti ◽

Andrea Saletti ◽

...

Keyword(s):

Multivariate Analysis ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Blood Volume ◽

Ct Perfusion ◽

Mean Transit Time ◽

Univariate Analysis ◽

Infarct Core ◽

Intravenous Tissue Plasminogen Activator ◽

Dichotomous Variable

BackgroundThe purpose of this study was to evaluate the correlation between a novel angiographic score for collaterals and CT perfusion (CTP) parameters in patients undergoing endovascular treatment for acute ischemic stroke (AIS).Methods103 patients (mean age 66.7±12.7; 48.5% men) with AIS in the anterior circulation territory, imaged with non-contrast CT, CT angiography, and CTP, admitted within 8 h from symptom onset and treated with any endovascular approach, were retrospectively included in the study. Clinical, neuroradiological data, and all time intervals were collected. Careggi Collateral Score (CCS) was used for angiographic assessment of collaterals and the Alberta Stroke Program Early CT Score (ASPECTS) for semiquantitative analysis of CTP maps. Two centralized core laboratories separately reviewed angiographic data, whereas CT findings were evaluated by an expert neuroradiologist. Univariate and multivariate analysis were performed considering CCS both as an ordinal and a dichotomous variable.Results37/103 patients (35.9%) received intravenous tissue plasminogen activator. Median (IQR) ASPECTS was 9 (6–10) for admission CT, 9 (5–10) for cerebral blood volume (CBV) maps, 3 (2–3) for mean transit time maps, 3 (2–4), for cerebral blood flow maps, and 5 (3–7) for CTP mismatch. Univariate analysis showed a significant correlation between CCS and ASPECTS for all CTP parameters. Multivariate analysis confirmed an independent association only between CCS and CBV (p=0.020 when CCS was considered as a dichotomous variable, p=0.026 with ordinal CCS).ConclusionsA correlation between angiographic assessment of the collateral circulation and CTP seems to be present, suggesting that CCS may provide an indirect evaluation of the infarct core volume to consider for patient selection in AIS.

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Preoperative computed tomography perfusion in pediatric moyamoya disease: a single-institution experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.10.peds19450 ◽

2020 ◽

Vol 25 (5) ◽

pp. 484-491

Author(s):

Vijay M. Ravindra ◽

Stephen F. Kralik ◽

Julius Griauzde ◽

Nisha Gadgil ◽

Melissa A. LoPresti ◽

...

Keyword(s):

Moyamoya Disease ◽

Cerebral Blood Volume ◽

Ct Perfusion ◽

Mean Transit Time ◽

Region Of Interest ◽

High Sensitivity ◽

Neurofibromatosis Type ◽

Predictive Values ◽

Perfusion Studies ◽

Preoperative Ct

OBJECTIVEMoyamoya disease is a progressive occlusive arteriopathy for which surgical revascularization is indicated. In this retrospective study, the authors investigated the use of preoperative CT perfusion with the aim of establishing pathological data references.METHODSThe authors reviewed the medical records of children with moyamoya disease treated surgically at one institution between 2016 and 2019. Preoperative CT perfusion studies were used to quantify mean transit time (MTT), cerebral blood volume (CBV), cerebral blood flow (CBF), and time to peak (TTP) for the anterior, middle, and posterior cerebral artery vascular territories for each patient. CT perfusion parameter ratios (diseased/healthy hemispheres) and absolute differences were compared between diseased and normal vascular territories (defined by catheter angiography studies). Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values for CT perfusion parameters for severe angiographic moyamoya were calculated.RESULTSNine children (89% female) had preoperative CT perfusion data; 5 of them had evidence of unilateral hemispheric disease and 4 had bilateral disease. The mean age at revascularization was 77 months (range 40–144 months). The etiology of disease was neurofibromatosis type 1 (3 patients), Down syndrome (2), primary moyamoya disease (2), cerebral proliferative angiopathy (1), and sickle cell disease (1). Five patients had undergone unilateral revascularization. Among these patients, pathological vascular territories demonstrated increased MTT in 66% of samples, increased TTP in 66%, decreased CBF in 47%, and increased CBV in 87%. Severe moyamoya (Suzuki stage ≥ 4) had diseased/healthy ratios ≥ 1 for MTT in 78% of cases, for TTP in 89%, for CBF in 67%, and for CBV in 89%. The MTT and TTP region of interest ratio ≥ 1 demonstrated 89% sensitivity, 67% specificity, 80% PPV, and 80% NPV for the prediction of severe angiographic moyamoya disease.CONCLUSIONSPathological hemispheres in these children with moyamoya disease demonstrated increased MTT, TTP, and CBV and decreased CBF. The authors’ results suggest that preoperative CT perfusion may, with high sensitivity, be useful in deciphering perfusion mismatch in brain tissue in children with moyamoya disease. More severe angiographic disease displays a more distinct correlation, allowing surgeons to recognize when to intervene in these patients.

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Abstract 3268: Ct Perfusion As A Tool To Predict The Risk Of Hemorrhagic Transformation In Ischemic Stroke Treated With Tissue Plasminogen Activator: A Single Center Experience.

Stroke ◽

10.1161/str.43.suppl_1.a3268 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Tareq Kass-Hout ◽

Maxim Mokin ◽

Omar Kass-Hout ◽

Emad Nourollahzadeh ◽

David Wack ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Brain Tissue ◽

Cerebral Blood Volume ◽

Ct Perfusion ◽

Intravenous Thrombolysis ◽

Hemorrhagic Transformation ◽

Stroke Therapy ◽

Two Phase ◽

The Mean

Objective: To use the Computed Tomography Perfusion (CTP) parameters at the time of hospital admission, including Cerebral Blood Volume (CBV) and Permeability Surface area product (PS), to identify patients with higher risk to develop hemorrhagic transformation in the setting of acute stroke therapy with intravenous thrombolysis. Methods: Retrospective study that compared admission CTP variables between patients with Hemorrhagic Transformation (HT) acute stroke and those with no hemorrhagic transformation. Both groups received standard of care intravenous thrombolysis with tPA. Twenty patients presented to our stroke center between the years 2007 - 2011 within 3 hours after stroke symptoms onset. All patients underwent two-phase 320 slice CTP which creates CBV and PS measurements. Patients were divided into two groups according to whether or not they had HT on a follow up CT head without contrast, done within 36 hours of the thrombolysis therapy. Clinical, demographic and CTP variables were compared between the HT and non-HT groups using logistic regression analyses. Results: HT developed in 8 (40%) patients. Patients with HT had lower ASPECT score ( P =.03), higher NIHSS on admission ( P= .01) and worse outcome ( P= .04) compared to patients who did not develop HT. Baseline blood flow defects were comparable between the two groups. The mean PS for the HT group was 0.53 mL/min/100g brain tissue, which was significantly higher than that for the non-HT group of 0.04 mL/min/100g brain tissue ( P <.0001). The mean area under the curve was 0.92 (95% CI). The PS threshold of 0.26 mL/min/100g brain tissue had a sensitivity of 80% and a specificity of 92% for detecting patients with high risk of hemorrhagic transformation after intravenous thrombolysis. Conclusions: Admission CTP measurements might be useful to predict patients who are at higher risk to develop hemorrhagic transformation after acute ischemic stroke therapy.

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Abstract 2619: Autoregulation of Cerebral Blood Flow is Preserved in Primary Intracerebral Hemorrhage

Stroke ◽

10.1161/str.43.suppl_1.a2619 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

E B Gould ◽

Rebecca McCourt ◽

Sana Vahidy ◽

Negar Asdaghi ◽

Michael D Hill ◽

...

Keyword(s):

Blood Flow ◽

Cerebral Blood Flow ◽

Intracerebral Hemorrhage ◽

Cerebral Autoregulation ◽

Cerebral Blood Volume ◽

Ct Perfusion ◽

Mean Transit Time ◽

Serial Ct ◽

Acute Intracerebral Hemorrhage ◽

Perfusion Maps

Background: Treatment of hypertension during acute intracerebral hemorrhage (ICH) is controversial. There are concerns that in the context of disrupted cerebral autoregulation, blood pressure (BP) reduction may cause decreased cerebral blood flow (CBF), particularly in the perihematoma region. CBF was assessed using serial CT perfusion (CTP) studies. We hypothesized that CBF would remain stable following BP reduction. Methods: Acute primary ICH patients were imaged pre and post BP treatment. Perfusion maps were calculated from CTP source images. Mean CBF was measured in a 1cm perihematoma region, contralateral homologous regions and in both hemispheres. Mean cerebral blood volume (CBV), mean transit time (MTT), and time to drain (TTD) were calculated in the same manner. Relative measures (i.e. rCBF) were calculated as ratios/differences between ipsilateral and contralateral regions. Results: Sixteen patients (median age 75 (54-91)) were imaged with CTP (median time from onset 19.4 (2.0-72.2) h) and re-imaged 2.0 (1.1-3.3) h later. Median NIHSS at baseline was 9 (2-24); this remained stable at the time of the second CTP (10 (2-24), P=0.14). Baseline hematoma volume was 24.8±19.9 ml and there was no change at the time of the second CTP (26.3±22.1 ml, P=0.16). Patients were recruited from an ongoing trial, in which they were randomly treated to a target systolic BP of <150mmHg (n=9) or <180mmHg (n=7). Four patients received no antihypertensives as BP was below target at the time of randomization. Mean systolic BP in treated patients (n=12) decreased significantly between the first (165±23 mmHg) and second (143±18 mmHg, P<0.0001) CTP scans. Mean perihematoma CBF in treated patients was stable with BP reduction (pre=35.1±7.1 vs. post=35.4±6.2 ml/100g/min, P=0.87). Ipsilateral hemispheric CBF was also stable (pre=47.3±7.2 vs. post=46.4±7.1 ml/100g/min, P=0.66). Although perihematoma CBF was lower than in contralateral homologous regions (rCBF=0.72±0.11), BP reduction did not decrease this further (0.74±0.14 post-treatment, P=0.58). Ipsilateral hemispheric rCBF (0.96±0.06) was also unaffected by BP treatment (0.95±0.08, P=0.64). Perihematoma rCBF decreased in 5 treated patients, but never by >12%. Linear regression showed no relationship between changes in systolic BP and perihematoma rCBF (R=-0.002, [-0.005, 0.001], P=0.18). Perihematoma rCBV (pre=0.77±0.11 vs. post=0.79±0.10, P=0.20), rMTT (pre=0.51±0.54s vs. post=0.70±0.65s, P=0.26) and rTTD (pre=0.71±1.01s vs. post=0.89±0.84s, P=0.42) also remained stable following BP treatment. Conclusions: Acute BP reduction does not appear to exacerbate perihematoma oligaemia. Stability of CBF following acute BP treatment suggests preservation of cerebral autoregulation in ICH, within the range of arterial pressures studied. These findings support the safety of early BP treatment in ICH.

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Collateral Circulation Predicts the Size of the Infarct Core and the Proportion of Salvageable Penumbra in Hyperacute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Cerebrovascular Diseases ◽

10.1159/000439064 ◽

2015 ◽

Vol 40 (3-4) ◽

pp. 182-190 ◽

Cited By ~ 18

Author(s):

Harri Rusanen ◽

Jukka T. Saarinen ◽

Niko Sillanpää

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Collateral Circulation ◽

Cerebral Blood Volume ◽

Treatment Time ◽

Ct Perfusion ◽

Mean Transit Time ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

The Impact

Background: We studied the impact of collateral circulation on CT perfusion (CTP) parametric maps and the amount of salvaged brain tissue, the imaging and clinical outcome at 24 h and at 3 months in a retrospective acute (<3 h) stroke cohort (105 patients) with anterior circulation thrombus treated with intravenous thrombolysis. Methods: Baseline clinical and imaging information were collected and groups with different collateral scores (CS) were compared. Binary logistic regression analyses using good CS (CS ≥2) as the dependent variable were calculated. Results: CTP Alberta Stroke Program Early CT Score (ASPECTS) was successfully assessed in 58 cases. Thirty patients displayed good CS. Poor CS were associated with more severe strokes according to National Institutes of Health Stroke Scale (NIHSS) at arrival (15 vs. 7, p = 0.005) and at 24 h (10 vs. 3, p = 0.003) after intravenous thrombolysis. Good CS were associated with a longer mean onset-to-treatment time (141 vs. 121 min, p = 0.009) and time to CTP (102 vs. 87 min, p = 0.047), better cerebral blood volume (CBV) ASPECTS (9 vs. 6, p < 0.001), better mean transit time (MTT) ASPECTS (6 vs. 3, p < 0.001), better noncontrast CT (NCCT) ASPECTS (10 vs. 8, p < 0.001) at arrival and with favorable clinical outcome at 3 months (modified Rankin Scale ≤2, p = 0.002). The fraction of penumbra that was salvageable at arrival and salvaged at 24 h was higher with better CS (p < 0.001 and p = 0.035, respectively). In multivariate analysis, time from the onset of symptoms to imaging (p = 0.037, OR 1.04 per minute, 95% CI 1.00-1.08) and CBV ASPECTS (p = 0.001, OR 2.11 per ASPECTS point, 95% CI 1.33-3.34) predicted good CS. In similar multivariable models, MTT ASPECTS (p = 0.04, OR 1.46 per ASPECTS point, 95% CI 1.02-2.10) and NCCT ASPECTS predicted good CS (p = 0.003, OR 4.38 per CT ASPECTS point, 95% CI 1.66-11.55) along with longer time from the onset of symptoms to imaging (p = 0.045, OR 1.03 per minute, 95% CI 1.00-1.06 and p = 0.02, OR 1.05 per minute, 95% CI 1.00-1.09, respectively). CBV ASPECTS had a larger area under the receiver operating characteristic curve for good CS (0.837) than NCCT ASPECTS (0.802) or MTT ASPECTS (0.752) at arrival. Conclusions: Favorable CBV ASPECTS, NCCT ASPECTS and MTT ASPECTS are associated with good CS along with more salvageable tissue and longer time from the onset of symptoms to imaging in ischemic stroke patients treated with intravenous thrombolysis.

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CT Perfusion and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/jcbfm.2013.208 ◽

2013 ◽

Vol 34 (2) ◽

pp. 200-207 ◽

Cited By ~ 59

Author(s):

Charlotte H P Cremers ◽

Irene C van der Schaaf ◽

Emerens Wensink ◽

Jacoba P Greving ◽

Gabriel J E Rinkel ◽

...

Keyword(s):

Systematic Review ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Blood Volume ◽

Cerebral Blood Volume ◽

Ct Perfusion ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Mean Transit Time ◽

Delayed Cerebral Ischemia ◽

Mean Difference

Delayed cerebral ischemia (DCI) is at presentation a diagnosis per exclusionem, and can only be confirmed with follow-up imaging. For treatment of DCI a diagnostic tool is needed. We performed a systematic review to evaluate the value of CT perfusion (CTP) in the prediction and diagnosis of DCI. We searched PubMed, Embase, and Cochrane databases to identify studies on the relationship between CTP and DCI. Eleven studies totaling 570 patients were included. On admission, cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-peak (TTP) did not differ between patients who did and did not develop DCI. In the DCI time-window (4 to 14 days after subarachnoid hemorrhage (SAH)), DCI was associated with a decreased CBF (pooled mean difference −11.9 mL/100 g per minute (95% confidence interval (CI): −15.2 to −8.6)) and an increased MTT (pooled mean difference 1.5 seconds (0.9–2.2)). Cerebral blood volume did not differ and TTP was rarely reported. Perfusion thresholds reported in studies were comparable, although the corresponding test characteristics were moderate and differed between studies. We conclude that CTP can be used in the diagnosis but not in the prediction of DCI. A need exists to standardize the method for measuring perfusion with CTP after SAH, and optimize and validate perfusion thresholds.

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