Computed tomography perfusion as a predictor of delayed cerebral ischemia and functional outcome in spontaneous subarachnoid hemorrhage: A single center experience

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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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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Prognostic Value of Cerebral Perfusion Computed Tomography in the Acute Stage after Subarachnoid Hemorrhage for the Development of Delayed Cerebral Ischemia

Neurosurgery ◽

10.1227/01.neu.0000310155.08735.97 ◽

2006 ◽

Vol 58 (2) ◽

pp. 397

Author(s):

Irene van der Schaaf ◽

Marieke Wermer ◽

Birgitta Velthuis ◽

Yolanda van der Graaf ◽

Gabriel Rinkel

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Cerebral Perfusion ◽

Prognostic Value ◽

Delayed Cerebral Ischemia ◽

Acute Stage ◽

Perfusion Computed Tomography

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Diagnostic Threshold Values of Cerebral Perfusion Measured With Computed Tomography for Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/strokeaha.109.574392 ◽

2010 ◽

Vol 41 (9) ◽

pp. 1927-1932 ◽

Cited By ~ 71

Author(s):

Jan Willem Dankbaar ◽

Nicolien Karen de Rooij ◽

Mienke Rijsdijk ◽

Birgitta K. Velthuis ◽

Catharine J.M. Frijns ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Cerebral Perfusion ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Threshold Values ◽

Diagnostic Threshold

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Body mass index and leptin levels in serum and cerebrospinal fluid in relation to delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage

Neurosurgical Review ◽

10.1007/s10143-021-01541-1 ◽

2021 ◽

Author(s):

Michael Veldeman ◽

Miriam Weiss ◽

Tim Philipp Simon ◽

Anke Hoellig ◽

Hans Clusmann ◽

...

Keyword(s):

Body Mass Index ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Clinical Outcome ◽

Body Mass ◽

Ct Perfusion ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Overweight And Obesity ◽

Protective Effects

AbstractAneurysmal subarachnoid hemorrhage (SAH) is associated with a high mortality rate and may leave surviving patients severely disabled. After the initial hemorrhage, clinical outcome is further compromised by the occurrence of delayed cerebral ischemia (DCI). Overweight and obesity have previously been associated with protective effects in the post-bleeding phase. The aim of this study was to assess the effects of a patient’s body mass index (BMI) and leptin levels on the occurrence of DCI, DCI-related cerebral infarction, and clinical outcome. In total, 263 SAH patients were included of which leptin levels were assessed in 24 cases. BMI was recorded along disease severity documented by the Hunt and Hess and modified Fisher scales. The occurrence of clinical or functional DCI (neuromonitoring, CT Perfusion) was assessed. Long-term clinical outcome was documented after 12 months (extended Glasgow outcome scale). A total of 136 (51.7%) patients developed DCI of which 72 (27.4%) developed DCI-related cerebral infarctions. No association between BMI and DCI occurrence (P = .410) or better clinical outcome (P = .643) was identified. Early leptin concentration in serum (P = .258) and CSF (P = .159) showed no predictive value in identifying patients at risk of unfavorable outcomes. However, a significant increase of leptin levels in CSF occurred from 326.0 pg/ml IQR 171.9 prior to DCI development to 579.2 pg/ml IQR 211.9 during ongoing DCI (P = .049). In our data, no association between obesity and clinical outcome was detected. After DCI development, leptin levels in CSF increased either by an upsurge of active transport or disruption of the blood-CSF barrier. This trial has been registered at ClinicalTrials.gov (NCT02142166) as part of a larger-scale prospective data collection. BioSAB: https://clinicaltrials.gov/ct2/show/NCT02142166

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Body Mass Index and Leptin Levels in Serum and Cerebrospinal Fluid in Relation to Delayed Cerebral Ischemia and Outcome after Aneurysmal Subarachnoid Hemorrhage

10.21203/rs.3.rs-190557/v1 ◽

2021 ◽

Author(s):

Michael Veldeman ◽

Miriam Weiss ◽

Tim Philipp Simon ◽

Anke Hoellig ◽

Hans Clusmann ◽

...

Keyword(s):

Body Mass Index ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Clinical Outcome ◽

Body Mass ◽

Ct Perfusion ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Overweight And Obesity ◽

Protective Effects

Abstract ObjectiveAneurysmal subarachnoid hemorrhage (SAH) is associated with a high mortality rate and may leave surviving patients severely disabled. After the initial hemorrhage, clinical outcome is further compromised by the occurrence of delayed cerebral ischemia (DCI). Overweight and obesity have previously been associated with protective effects in the post-bleeding phase. The aim of this study was to assess the effects of patient’s body mass index (BMI) and leptin levels on the occurrence of DCI, DCI-related cerebral infarction and clinical outcome. METHODS263 SAH patients were included of which leptin levels were assessed in 24 cases. BMI was recorded along disease severity documented by the Hunt and Hess and modified Fisher scales. The occurrence of clinical or functional DCI (neuromonitoring, CT Perfusion) was assessed. Long-term clinical outcome was documented after 12 months (extended Glasgow outcome scale). RESULTSA total of 136 (51.7%) patients developed DCI of which 72 (27.4%) developed DCI-related cerebral infarctions. No association between BMI and DCI occurrence (P=.410) or better clinical outcome (P=.643) was identified. Early leptin concentration in serum (P=.258) and CSF (P=.159) showed no predictive value in identifying patients at risk of unfavorable outcome. However, a significant increase of leptin levels in CSF occurred from 326.0 pg/ml IQR 171.9 prior to DCI development to 579.2 pg/ml IQR 211.9 during ongoing DCI (P =.049). CONCLUSIONSIn our data, no association between obesity and clinical outcome was detected. After DCI-development, leptin levels in CSF increased either by an upsurge of active transport or disruption of the blood-CSF barrier.Trial registration: This trial has been registered at ClinicalTrials.gov (NCT02142166) as part of a larger scale prospective data collection. BioSAB: https://clinicaltrials.gov/ct2/show/NCT02142166

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The Updated Role of the Blood Brain Barrier in Subarachnoid Hemorrhage: From Basic and Clinical Studies

Current Neuropharmacology ◽

10.2174/1570159x18666200914161231 ◽

2020 ◽

Vol 18 (12) ◽

pp. 1266-1278

Author(s):

Sheng Chen ◽

PengLei Xu ◽

YuanJian Fang ◽

Cameron Lenahan

Keyword(s):

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Cerebral Ischemia ◽

Clinical Outcome ◽

Blood Brain Barrier ◽

Ct Perfusion ◽

Delayed Cerebral Ischemia ◽

Early Brain Injury ◽

Brain Barrier ◽

Blood Brain

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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