Potential mechanisms and clinical significance of global cerebral edema following aneurysmal subarachnoid hemorrhage

✓In an attempt to elucidate the pathophysiology and clinical significance of global cerebral edema (GCE) following aneurysmal subarachnoid hemorrhage (SAH), the authors explored potential mechanisms and reviewed findings associated with this phenomenon. Admission computed tomography (CT) scans show GCE in up to 20% of patients experiencing aneurysmal SAH. This edema is likely to have been initiated by transient global ischemia, as indicated by an association between ictal loss of consciousness and the development of edema. A further cascade of events, including a rise in intracranial pressure and compromise of the blood–brain barrier, are also likely contributors. Clinically, GCE on CT after aneurysmal SAH is predictive of a poor outcome. Further investigation is needed to gain a full understanding of edema development following SAH, with the hope that the knowledge can be used to influence treatment positively and improve outcome.

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Early ischemic lesion on computed tomography: predictor of poor outcome among survivors of aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns-07/12/1074 ◽

2007 ◽

Vol 107 (6) ◽

pp. 1074-1079 ◽

Cited By ~ 21

Author(s):

Jari Siironen ◽

Matti Porras ◽

Joona Varis ◽

Kristiina Poussa ◽

Juha Hernesniemi ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Independent Predictor ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Ct Scans ◽

Ischemic Lesion ◽

Poor Outcome ◽

Serial Ct ◽

Early Lesion

Object Identifying ischemic lesions after subarachnoid hemorrhage (SAH) is important because the appearance of these lesions on follow-up imaging correlates with a poor outcome. The effect of ischemic lesions seen on computed tomography (CT) scans during the first days of treatment remains unknown, however. Methods In 156 patients with SAH, clinical course and outcome, as well as the appearance of ischemic lesions on serial CT scans, were prospectively monitored for 3 months. At 3 months after SAH, magnetic resonance imaging was performed to detect permanent lesions that had not been visible on CT. Results Of the 53 patients with no lesions on any of the follow-up CT scans, four (8%) had a poor outcome. Of the 52 patients with a new hypodense lesion on the first postoperative day CT, 23 (44%) had a poor outcome. Among the remaining 51 patients with a lesion appearing later than the first postoperative morning, 10 (20%) had a poor outcome (p < 0.001). After adjusting for patient age; clinical condition on admission; amounts of subarachnoid, intracerebral, and intraventricular blood; and plasma glucose and D-dimer levels, a hypodense lesion on CT on the first postoperative morning was an independent predictor of poor outcome after SAH (odds ratio 7.27, 95% confidence interval 1.54–34.37, p < 0.05). Conclusions A new hypodense lesion on early postoperative CT seems to be an independent risk factor for poor outcome after SAH, and this early lesion development may be more detrimental to clinical outcome than a later lesion occurrence.

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Plasma glucose levels and outcome after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.1993.79.6.0885 ◽

1993 ◽

Vol 79 (6) ◽

pp. 885-891 ◽

Cited By ~ 87

Author(s):

Giuseppe Lanzino ◽

Neal F. Kassell ◽

Teresa Germanson ◽

Laura Truskowski ◽

Wayne Alves

Keyword(s):

Subarachnoid Hemorrhage ◽

Plasma Glucose ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Ct Scans ◽

Good Recovery ◽

Glucose Levels ◽

Poor Outcome ◽

Elevated Glucose ◽

Mean Glucose

✓ Plasma glucose levels were studied in 616 patients admitted within 72 hours after subarachnoid hemorrhage (SAH). Glucose levels measured at admission showed a statistically significant association with Glasgow Coma Scale scores, Botterell grade, deposition of blood on computerized tomography (CT) scans, and level of consciousness at admission. Elevated glucose levels at admission predicted poor outcome. A good recovery, as assessed by the Glasgow Outcome Scale at 3 months, occurred in 70.2% of patients with normal glucose levels (≤ 120 mg/dl) and in 53.7% of patients with hyperglycemia (> 120 mg/dl) (p = 0.002). The death rates for these two groups were 6.7% and 19.9%, respectively (p = 0.001). The association was still maintained after adjusting for age (> or ≤ 50 years) and thickness of clot on CT scans (thin or thick) in the subset of patients who were alert/drowsy at admission. Increased mean glucose levels between Days 3 and 7 also predicted a worse outcome; good recovery was observed in 132 (73.7%) of 179 patients who had normal mean glucose levels (≤ 120 mg/dl) and 160 (49.7%) of 322 who had elevated mean glucose levels (> 120 mg/dl) (p < 0.0001). Death occurred in 6.7% and 20.8% of the two groups, respectively (p < 0.0001). It is concluded that admission plasma glucose levels can serve as an objective prognostic indicator after SAH. Elevated glucose levels during the 1st week after SAH also predict a poor outcome. However, a causal link between hyperglycemia and outcome after delayed cerebral ischemia, although suggested by experimental data, cannot be established on the basis of this study.

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Serial Quantitative Computed Tomography Perfusion in Aneurysmal Subarachnoid Hemorrhage

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2015.351 ◽

2016 ◽

Vol 43 (3) ◽

pp. 375-380 ◽

Cited By ~ 2

Author(s):

Cheemun Lum ◽

Matthew J. Hogan ◽

John Sinclair ◽

Shane English ◽

Howard Lesiuk ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Transit Time ◽

Cerebral Artery ◽

Computed Tomography Angiography ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Mean Transit Time ◽

Arterial Diameter ◽

Computed Tomography Perfusion

AbstractPurpose: 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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Clot volume and clearance rate as independent predictors of vasospasm after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2004.101.2.0255 ◽

2004 ◽

Vol 101 (2) ◽

pp. 255-261 ◽

Cited By ~ 118

Author(s):

Christopher Reilly ◽

Chris Amidei ◽

Jocelyn Tolentino ◽

Babak S. Jahromi ◽

R. Loch Macdonald

Keyword(s):

Subarachnoid Hemorrhage ◽

Clearance Rate ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Quantitative Imaging ◽

Univariate Analysis ◽

Ct Scans ◽

Focal Neurological Deficit ◽

Content Type ◽

Fisher Grade ◽

Fine Print

Object. This study was conducted for two purposes. The first was to determine whether a combination of measurements of subarachnoid clot volume, clearance rate, and density could improve prediction of which patients experience vasospasm. The second was to determine if each of these three measures could be used independently to predict vasospasm. Methods. Digital files of the cranial computerized tomography (CT) scans obtained in 75 consecutive patients admitted within 24 hours of subarachnoid hemorrhage (SAH) were analyzed in a blinded fashion by an observer who used quantitative imaging software to measure the volume of SAH and its density. Clot clearance rates were measured by quantifying SAH volume on subsequent CT scans. Vasospasm was defined as new onset of a focal neurological deficit or altered consciousness 5 to 12 days after SAH in the absence of other causes of deterioration, diagnosed with the aid of or exclusively by confirmatory transcranial Doppler ultrasonography and/or cerebral angiography. Univariate analysis showed that vasospasm was significantly associated with the SAH grade as classified on the Fisher scale, the initial clot volume, initial clot density, and percentage of clot cleared per day (p < 0.05). In multivariate analysis, initial clot volume and percentage of clot cleared per day were significant predictors of vasospasm (p < 0.05), whereas Fisher grade and initial clot density were not. Conclusions. Quantitative analysis of subarachnoid clot shows that vasospasm is best predicted by initial subarachnoid clot volume and the percentage of clot cleared per day.

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Early prediction of clinical outcomes in patients with aneurysmal subarachnoid hemorrhage using computed tomography texture analysis

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2019.08.098 ◽

2020 ◽

Vol 71 ◽

pp. 144-149 ◽

Cited By ~ 1

Author(s):

Tokunori Kanazawa ◽

Satoshi Takahashi ◽

Yasuhiro Minami ◽

Masahiro Jinzaki ◽

Masahiro Toda ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Texture Analysis ◽

Clinical Outcomes ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Early Prediction

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Dynamic perfusion computerized tomography in cerebral vasospasm following aneurysmal subarachnoid hemorrhage: a comparison with technetium-99m–labeled ethyl cysteinate dimer–single-photon emission computerized tomography

Journal of Neurosurgery ◽

10.3171/jns.2006.104.3.404 ◽

2006 ◽

Vol 104 (3) ◽

pp. 404-410 ◽

Cited By ~ 15

Author(s):

Gill E. Sviri ◽

Ali H. Mesiwala ◽

David H. Lewis ◽

Gavin W. Britz ◽

Andrew Nemecek ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Computerized Tomography ◽

Single Photon ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Brain Regions ◽

Perfusion Ct ◽

Ct Scans ◽

Ethyl Cysteinate Dimer ◽

The Mean ◽

Spect Images

Object The aim of this study was to correlate cerebral blood flow (CBF) and mean transient time (MTT) measured on dynamic perfusion computerized tomography (CT) with CBF using 99mTc ethyl cysteinate dimer–single-photon emmision computerized tomography (SPECT) in patients with cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). Methods Thirty-five patients with vasospasm following aneurysmal SAH (12 men and 23 women with a mean age of 49.3 ± 10.1 years) underwent imaging studies; thus, 35 perfusion CT scans and 35 SPECT images were available for comparison. The CBF and MTT values in 12 different brain regions were defined relative to the interhemispheric occipital cortex values using perfusion CT scans and were compared with qualitative relative (rel)CBF estimated on SPECT images. In brain regions with normal, mild (relCBF 71–85%), moderate (relCBF 50–70%), and severe (relCBF < 50%) hypoperfusion on SPECT, the mean relCBF values measured on perfusion CT were 1.01 ± 0.08, 0.82 ± 0.22, 0.6 ± 0.15, and 0.32 ± 0.08, respectively (p < 0.0001); the mean relMTT values were 1.04 ± 0.14, 1.4 ± 0.31, 2.16 ± 0.46, and 3.3 ± 0.54, respectively (p < 0.0001). All but one brain region (30 regions) with severe hypoperfusion on SPECT images demonstrated relCBF values less than 0.6 and relMTT values greater than 2.5 on perfusion CT scans. Conclusions Relative CBF and MTT values on perfusion CT showed a high concordance rate with estimated relCBF on SPECT in patients with vasospasm following aneurysmal SAH. Given its logistical advantages, perfusion CT may be a valuable method of assessing perfusion abnormality in the acute setting of vasospasm and in patients with an unstable condition following aneurysmal SAH.

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