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

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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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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Volumetric quantification of aneurysmal subarachnoid hemorrhage independently predicts hydrocephalus and seizures

Journal of Neurosurgery ◽

10.3171/2020.8.jns201273 ◽

2021 ◽

pp. 1-9

Author(s):

Badih J. Daou ◽

Siri Sahib S. Khalsa ◽

Sharath Kumar Anand ◽

Craig A. Williamson ◽

Noah S. Cutler ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Characteristic Curve ◽

Volumetric Analysis ◽

Aneurysm Rupture ◽

Mean Difference ◽

Analysis Tool ◽

Volume Data ◽

Hemorrhage Volume ◽

The Mean

OBJECTIVEHydrocephalus and seizures greatly impact outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH); however, reliable tools to predict these outcomes are lacking. The authors used a volumetric quantitative analysis tool to evaluate the association of total aSAH volume with the outcomes of shunt-dependent hydrocephalus and seizures.METHODSTotal hemorrhage volume following aneurysm rupture was retrospectively analyzed on presentation CT imaging using a custom semiautomated computer program developed in MATLAB that employs intensity-based k-means clustering to automatically separate blood voxels from other tissues. Volume data were added to a prospectively maintained aSAH database. The association of hemorrhage volume with shunted hydrocephalus and seizures was evaluated through logistic regression analysis and the diagnostic accuracy through analysis of the area under the receiver operating characteristic curve (AUC).RESULTSThe study population comprised 288 consecutive patients with aSAH. The mean total hemorrhage volume was 74.9 ml. Thirty-eight patients (13.2%) developed seizures. The mean hemorrhage volume in patients who developed seizures was significantly higher than that in patients with no seizures (mean difference 17.3 ml, p = 0.01). In multivariate analysis, larger hemorrhage volume on initial CT scan and hemorrhage volume > 50 ml (OR 2.81, p = 0.047, 95% CI 1.03–7.80) were predictive of seizures. Forty-eight patients (17%) developed shunt-dependent hydrocephalus. The mean hemorrhage volume in patients who developed shunt-dependent hydrocephalus was significantly higher than that in patients who did not (mean difference 17.2 ml, p = 0.006). Larger hemorrhage volume and hemorrhage volume > 50 ml (OR 2.45, p = 0.03, 95% CI 1.08–5.54) were predictive of shunt-dependent hydrocephalus. Hemorrhage volume had adequate discrimination for the development of seizures (AUC 0.635) and shunted hydrocephalus (AUC 0.629).CONCLUSIONSHemorrhage volume is an independent predictor of seizures and shunt-dependent hydrocephalus in patients with aSAH. Further evaluation of aSAH quantitative volumetric analysis may complement existing scales used in clinical practice and assist in patient prognostication and management.

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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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Positron Emission Tomographic Cerebral Perfusion Disturbances and Transcranial Doppler Findings among Patients with Neurological Deterioration after Subarachnoid Hemorrhage

Neurosurgery ◽

10.1093/neurosurgery/52.5.1017 ◽

2003 ◽

Vol 52 (5) ◽

pp. 1017-1024 ◽

Cited By ~ 7

Author(s):

Pawan S. Minhas ◽

David K. Menon ◽

Piotr Smielewski ◽

Marek Czosnyka ◽

Peter J. Kirkpatrick ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Carotid Artery ◽

Cerebral Perfusion ◽

Internal Carotid ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Neurological Deficits ◽

Positron Emission Tomographic ◽

Positron Emission ◽

Arterial Vasospasm ◽

The Mean

Abstract OBJECTIVE After aneurysmal subarachnoid hemorrhage, approximately 30% of patients experience delayed neurological deficits, related in part to arterial vasospasm and dysautoregulation. Transcranial Doppler (TCD) ultrasonography is commonly used to noninvasively detect arterial vasospasm. We studied cerebral perfusion patterns and associated TCD indices for 25 patients who developed clinical signs of delayed neurological deficits. METHODS Patients were treated in a neurosurgical intensive care unit and were studied if they exhibited delayed focal or global neurological deterioration. Positron emission tomographic cerebral blood flow (CBF) studies and TCD studies measuring the mean flow velocity (FV) of the middle cerebral artery and the middle cerebral artery FV/internal carotid artery FV ratio (with the internal carotid artery FV being measured extracranially at the cranial base) were performed. Glasgow Outcome Scale scores were assessed at 6 months. RESULTS A markedly heterogeneous pattern of CBF distribution was observed, with hyperemia, normal CBF values, and reduced flow being observed among patients with delayed neurological deficits. TCD indices were not indicative of the cerebral perfusion findings. The mean CBF value was slightly lower for patients who did not survive (32.3 ml/100 g/min), compared with those who did survive (36.0 ml/100 g/min, P= 0.05). CONCLUSION Among patients who developed delayed neurological deficits after aneurysmal subarachnoid hemorrhage, a wide range of cerebral perfusion disturbances was observed, calling into question the traditional concept of large-vessel vasospasm. Commonly used TCD indices do not reflect cerebral perfusion values.

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Dynamic Change in Mean Platelet Volume and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Frontiers in Neurology ◽

10.3389/fneur.2020.571735 ◽

2020 ◽

Vol 11 ◽

Author(s):

Liuwei Chen ◽

Quanbin Zhang

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Mean Platelet Volume ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Dynamic Change ◽

Delayed Cerebral Ischemia ◽

Area Under The Curve ◽

Platelet Volume ◽

The Mean ◽

Change In Mean

Background: The mean platelet volume (MPV) has been shown to predict short-term outcomes in patients who have experienced aneurysmal subarachnoid hemorrhage (aSAH). The purpose of this study was to explore the temporal variation of MPV in patients with aSAH and its relationship to the development of delayed cerebral ischemia (DCI).Methods: Data from 197 consecutive aSAH patients who were treated at our institution between January 2017 and December 2019 were collected and analyzed. Blood samples to assess MPV were obtained at 1–3, 3–5, 5–7, and 7–9 d after the initial hemorrhage. Univariate and multivariate analyses were performed to investigate whether MPV was an independent predictor of DCI and the receiver operating characteristic (ROC) curve and area under the curve (AUC) were determined.Results: The MPV values in patients with DCI were significantly higher compared to those without DCI at 1–3, 3–5, 5–7, and 7–9 d after hemorrhage (P < 0.001). The trend for MPV in patients with DCI was increased at first and then decreased. The transition from increases to decreases occurred at 3–5 d after hemorrhage. The optimal cutoff value for MPV to accurately predict DCI was 10.35 fL at 3–5 d after aSAH in our cohort. Furthermore, the MPV observed at 3–5 d was an independent risk factor for DCI [odds ratio (OR) = 4.508, 95% confidence interval (CI): 2.665–7.626, P < 0.001].Conclusions: MPV is a dynamic variable that occurs during aSAH, and a high MPV at 3–5 days after hemorrhage is associated with the development of DCI.

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Characterization of perioperative seizures and epilepsy following aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2003.99.6.0978 ◽

2003 ◽

Vol 99 (6) ◽

pp. 978-985 ◽

Cited By ~ 99

Author(s):

Chih-Lung Lin ◽

Aaron S. Dumont ◽

Ann-Shung Lieu ◽

Chen-Po Yen ◽

Shiuh-Lin Hwang ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Predictive Factors ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Neurological Deficits ◽

Loss Of Consciousness ◽

Content Type ◽

Fisher Grade ◽

The Mean ◽

Fine Print

Object. The reported incidence, timing, and predictive factors of perioperative seizures and epilepsy after subarachnoid hemorrhage (SAH) have differed considerably because of a lack of uniform definitions and variable follow-up periods. In this study the authors evaluate the incidence, temporal course, and predictive factors of perioperative seizures and epilepsy during long-term follow up of patients with SAH who underwent surgical treatment. Methods. Two hundred seventeen patients who survived more than 2 years after surgery for ruptured intracranial aneurysms were enrolled and retrospectively studied. Episodes were categorized into onset seizures (≤ 12 hours of initial hemorrhage), preoperative seizures, postoperative seizures, and late epilepsy, according to their timing. The mean follow-up time was 78.7 months (range 24–157 months). Forty-six patients (21.2%) had at least one seizure post-SAH. Seventeen patients (7.8%) had onset seizures, five (2.3%) had preoperative seizures, four (1.8%) had postoperative seizures, 21 (9.7%) had at least one seizure episode after the 1st week postoperatively, and late epilepsy developed in 15 (6.9%). One (3.8%) of 26 patients with perioperative seizures (onset, preoperative, or postoperative seizure) had late epilepsy at follow up. The mean latency between the operation and the onset of late epilepsy was 8.3 months (range 0.3–19 months). Younger age (< 40 years old), loss of consciousness of more than 1 hour at ictus, and Fisher Grade 3 or greater on computerized tomography scans proved to be significantly related to onset seizures. Onset seizure was also a significant predictor of persistent neurological deficits (Glasgow Outcome Scale Scores 2–4) at follow up. Factors associated with the development of late epilepsy were loss of consciousness of more than 1 hour at ictus and persistent postoperative neurological deficit. Conclusions. Although up to one fifth of patients experienced seizure(s) after SAH, more than half had seizure(s) during the perioperative period. The frequency of late epilepsy in patients with perioperative seizures (7.8%) was not significantly higher than those without such seizures (6.8%). Perioperative seizures did not recur frequently and were not a significant predictor for late epilepsy.

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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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Clinical Use of a Portable Bedside Cerebral Blood Flow Machine in the Management of Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/00006123-198410000-00008 ◽

1984 ◽

Vol 15 (4) ◽

pp. 519-525 ◽

Cited By ~ 52

Author(s):

Jacob Rosenstein ◽

Mikio Suzuki ◽

Lindsay Symon ◽

Sheila Redmond

Keyword(s):

Blood Flow ◽

Cerebral Blood Flow ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Initial Slope ◽

Management Decision ◽

Mean Flow ◽

Management Decision Making ◽

Acute Subarachnoid Hemorrhage ◽

The Mean

Abstract Recent advances in electronics and microprocessors have enabled the development of a compact portable cerebral blood flow (CBF) machine capable of being transported to the patient's bedside. We have used such a device, the Novo Cerebrograph 2a, during the past 7 months on a regular basis in the day to day management of our patients with intracranial aneurysms. One hundred three studies were performed in 23 cases of suspected intracranial aneurysm. Twenty-two cases presented with acute subarachnoid hemorrhage. Patients were studied on admission, preoperatively, in the recovery room, on postoperative Days 1, 5, and 14, and whenever the clinical condition of the patient warranted. The preoperative admission grade was found to correlate well with the mean CBFisi (ISI: initial slope index). Grade III and IV patients had flows significantly lower than those of Grade I and II patients. Serial CBF measurements proved useful in the management of 18 of 22 cases admitted with acute subarachnoid hemorrhage. Delayed ischemic deficits secondary to vasospasm occurred in 6 cases, with a concomitant average fall in mean flow in the symptomatic hemispheres of 27.9%. After volume expansion, an average increase in flow of 29.7% was noted. Low preoperative flows influenced management decision-making in 8 cases. In a further 4 cases, serial CBF measurements were helpful in the differential diagnosis of new neurological signs.

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Trends in Mortality after Intensive Care of Patients with Aneurysmal Subarachnoid Hemorrhage in Finland in 2003–2019: A Finnish Intensive Care Consortium study

Neurocritical Care ◽

10.1007/s12028-021-01420-z ◽

2021 ◽

Author(s):

Jyri J. Virta ◽

Markus Skrifvars ◽

Matti Reinikainen ◽

Stepani Bendel ◽

Ruut Laitio ◽

...

Keyword(s):

Intensive Care ◽

Subarachnoid Hemorrhage ◽

Primary Outcome ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Simplified Acute Physiology Score ◽

World Federation ◽

Multivariable Logistic Regression Model ◽

Number Of Patients ◽

The Mean ◽

Case Mortality

Abstract Background Previous studies suggest that case mortality of aneurysmal subarachnoid hemorrhage (aSAH) has decreased during the last decades, but most studies have been unable to assess case severities among individual patients. We aimed to assess changes in severity-adjusted aSAH mortality in patients admitted to intensive care units (ICUs). Methods We conducted a retrospective, register-based study by using the prospectively collected Finnish Intensive Care Consortium database. Four out of five ICUs providing neurosurgical and neurointensive care in Finland participated in the Finnish Intensive Care Consortium. We extracted data on adult patients admitted to Finnish ICUs with aSAH between 2003 and 2019. The primary outcome was 12-month mortality during three periods: 2003–2008, 2009–2014, and 2015–2019. Using a multivariable logistic regression model—with variables including age, sex, World Federation of Neurological Surgeons grade, preadmission dependency, significant comorbidities, and modified Simplified Acute Physiology Score II—we analyzed whether admission period was independently associated with mortality. Results A total of 1,847 patients were included in the study. For the periods 2003–2008 and 2015–2019, the mean number of patients with aSAH admitted per year increased from 81 to 123. At the same time, the patients’ median age increased from 55 to 58 years (p = 0.001), and the proportion of patients with World Federation of Neurological Surgeons grades I–III increased from 42 to 58% (p < 0.001). The unadjusted 12-month mortality declined from 30% in 2003–2008 to 23% in 2015–2019 (p = 0.001), but there was no statistically significant change in severity-adjusted mortality. Conclusions Between 2003 and 2019, patients with aSAH admitted to ICUs became older and the proportion of less severe cases increased. Unadjusted mortality decreased but age and case severity adjusted–mortality remained unchanged.

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