Diagnosing Delayed Cerebral Ischemia With Different CT Modalities in Patients With Subarachnoid Hemorrhage With Clinical Deterioration

Dankbaar, Jan Willem; Rooij, Nicolien K. de; Velthuis, Birgitta K.; Frijns, Catharina J.M.; Rinkel, Gabriël J.E.; Schaaf, Irene C. van der

doi:10.1161/strokeaha.109.559013

Cited by 107 publications

(96 citation statements)

References 19 publications

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“…CTP had a sensitivity of 84% and a specificity of 79% for the diagnosis of new focal neurological deficit due to vasospasm at the time point of clinical deterioration. 4 All of these studies have significant limitations. One of them is validating parameter.…”

Section: Discussionmentioning

confidence: 99%

“…This is reflected by available studies, in which CTP was performed once between Days 5 and 14, which represent the days with the highest probability of vasospasm occurrence. 1,4,12,15,17,18,23,28,29,35,36 A correlation between hypoperfusion in CTP and vasospastic infarction was found. However, the retrospective design of these studies, with inappropriate imaging time points and perfusion measurements in preselected regions instead of global brain perfusion, failed to show a therapeutically relevant correlation between hypoperfusion and tissue at risk for stroke development.…”

mentioning

confidence: 84%

“…18,30 Computed tomography perfusion (CTP) allows visualization of brain perfusion and has been applied in brain tumors, ischemic stroke, and aSAH. 1,4,10,12,14,15,[17][18][19]23,25,28,33,[36][37][38] A disadvantage of CTP is the exposure to radiation, which precludes its frequent use. This is reflected by available studies, in which CTP was performed once between Days 5 and 14, which represent the days with the highest probability of vasospasm occurrence.…”

mentioning

confidence: 99%

“…However, the retrospective design of these studies, with inappropriate imaging time points and perfusion measurements in preselected regions instead of global brain perfusion, failed to show a therapeutically relevant correlation between hypoperfusion and tissue at risk for stroke development. 4,12,15,17,18,23,29,35,36 Recently, whole-brain CTP became available, which might at least overcome the problem of focal perfusion measurement. 10,25,37,38 The aim of this prospective study was to evaluate the role of whole-brain CTP for the identification of tissue at risk for DCI and, thereby, of patients at risk for developing DIND and/or vasospasm-associated infarction, either 1) early after aSAH, prior to the vasospasm period; 2) during rapidly progressive TCD-confirmed vasospasm with or without symptoms; and/or 3) on Day 7 in patients who were comatose or sedated and could not be neurologically assessed.…”

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confidence: 99%

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Early whole-brain CT perfusion for detection of patients at risk for delayed cerebral ischemia after subarachnoid hemorrhage

Malinova¹,

Dolatowski

Schramm

et al. 2016

JNS

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C erebral infarction with permanent vasospasminduced delayed ischemic neurological deficits (DIND) after aneurysmal subarachnoid hemorrhage (aSAH) is a feared and unfortunately frequent complication, responsible for poor functional and overall outcome. 2 The pathophysiology of DIND and vasospasminduced delayed cerebral infarction (DCI) after aSAH is multifactorial and still not fully understood. It is well accepted that vasospasm is a major contributor to DIND and DCI, but it is also assumed that processes already initiated shortly after aSAH render some brain areas more vulnerable for vasospasm than others. 20,27,33 In up to 15% of patients, cerebral infarction and a fixed neurological deficit (including death) are irreversible end points of a dynamic process starting with tissue predisposition and asymptomatic vasospasm, followed by symptomatic vasospasm and transient DIND. For the successful prevention of infarction by antivasospastic therapy, timely recognition of abbreviatioNs aSAH = aneurysmal subarachnoid hemorrhage; BFV = blood flow velocity; CBF = cerebral blood flow; CBV = cerebral blood volume; CTA = CT angiography; CTP = CT perfusion; DCI = delayed cerebral infarction; DIND = delayed ischemic neurological deficits; DSA = digital subtraction angiography; MIP = maximum-intensity projection; MTT = mean transit time; NPV = negative predictive value; PPV = positive predictive value; ROI = region of interest; TCD = transcranial Doppler sonography; TTP = time to peak; TTS = time to start. obJective This prospective study investigated the role of whole-brain CT perfusion (CTP) studies in the identification of patients at risk for delayed ischemic neurological deficits (DIND) and of tissue at risk for delayed cerebral infarction (DCI). methods Forty-three patients with aneurysmal subarachnoid hemorrhage (aSAH) were included in this study. A CTP study was routinely performed in the early phase (Day 3). The CTP study was repeated in cases of transcranial Doppler sonography (TCD)-measured blood flow velocity (BFV) increase of > 50 cm/sec within 24 hours and/or on Day 7 in patients who were intubated/sedated. results Early CTP studies revealed perfusion deficits in 14 patients, of whom 10 patients (72%) developed DIND, and 6 of these 10 patients (60%) had DCI. Three of the 14 patients (21%) with early perfusion deficits developed DCI without having had DIND, and the remaining patient (7%) had neither DIND nor DCI. There was a statistically significant correlation between early perfusion deficits and occurrence of DIND and DCI (p < 0.0001). A repeated CTP was performed in 8 patients with a TCD-measured BFV increase > 50 cm/sec within 24 hours, revealing a perfusion deficit in 3 of them (38%). Two of the 3 patients (67%) developed DCI without preceding DIND and 1 patient (33%) had DIND without DCI. In 4 of the 7 patients (57%) who were sedated and/or comatose, additional CTP studies on Day 7 showed perfusion deficits. All 4 patients developed DCI. coNclusioNs Whole-brain CTP on Day 3 after aSAH allows early and rel...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 84%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Early whole-brain CT perfusion for detection of patients at risk for delayed cerebral ischemia after subarachnoid hemorrhage

Malinova¹,

Dolatowski

Schramm

et al. 2016

JNS

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“…First, other pathological conditions, like edema and infection, might also affect cerebral perfusion (3,4). If the author did not carefully identify the perfusion changes causing by other pathology, the results of CT perfusion could be blurred and false-positive findings were produced.…”

Section: Discussionmentioning

confidence: 99%

Evaluating the diagnostic accuracy of CT perfusion in patients with cerebral vasospasm after aneurysm rupture: a meta-analysis

Sun¹,

Zhang²,

Ma³

et al. 2014

Turkish Neurosurgery

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AIm: Computed tomography perfusion (CTP) has recently been used to identify regions of potential ischemia due to cerebral vasospasm, and CTP parameters are able to quantitatively evaluate brain parenchymal perfusion. We performed a meta-analysis as an update of a previous paper published in 2010 and aimed at evaluating the diagnostic accuracy of CTP and CTP parameters for vasospasm after aneurysm rupture. mATERIAL and mETHods: Relevant articles published between January 2005 and May 2013 were systematically searched for analysis without language restrictions from the PubMed/MEDLINE, Embase, and Cochrane databases. The data of CTP parameters, including CBV, CBF, MTT and TTP, were extracted for analysis, and the pooled sensitivity, specificity, PLR, NLR, DOR and the sROC curve were determined. REsuLTs:Three relevant articles and a total of 98 patients were finally involved in the analysis. The pooled sensitivity, specificity, PLR, NLR, DOR, and AUC of CTP for diagnosing cerebral vasospasm were 94%, 90%, 8.22, 0.06, 141.09, and 0.9802, respectively. Through the evaluation of CTP parameters, MTT had a higher sensitivity (91%) while CBF had a higher specificity (93%). CoNCLusIoN:CT perfusion has a great diagnostic value to detect cerebral vasospasm compared with DSA in patients with aneurysmal subarachnoid hemorrhage (aSAH). As CTP parameters, CBF and MTT quantitatively evaluate brain parenchymal perfusion. soNuÇ: BTP testinin anevrizmal subaraknoid hemorajili (aSAK) hastalarda serebral vazospazmı belirlemede anjiyografiye kıyasla önemli diyagnostik değeri vardır. BTP parametreleri olan CBF ve MTT beyin parankimi perfüzyonunu kantitatif olarak değerlendirirler.ANAHTAR sÖZCÜKLER: BTP, BT perfüzyon, BTP parametreleri, Vazospazm, Serebral vazospazm ABBREVIATIoNs: CTP: computed tomography perfusion, CBV: cerebral blood volume, CBF: cerebral blood flow, mTT: mean transit time, TTP: time to peak, PLR: positive likelihood ratio, NLR: negative likelihood ratio, doR: diagnostic odds ratio, CIs: confidence intervals, sRoC: summary receiver-operating characteristic, dsA: digital substraction angiography, asAH: aneurysmal subarachnoid hemorrhage.

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The role of TLR4 and HO‐1 in neuroinflammation after subarachnoid hemorrhage

Akamatsu

Pagan

Hanafy

2019

J of Neuroscience Research

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This review on the mechanisms of neuroinflammation following subarachnoid hemorrhage will focus mainly on toll‐like receptor 4 (TLR4), Heme Oxygenase‐1 (HO‐1), and the role of microglia and macrophages in this process. Vasospasm has long been the focus of research in SAH; however, clinical trials have shown that amelioration of vasospasm does not lead to an improved clinical outcome. This necessitates the need for novel avenues of research. Our work has demonstrated that microglial TLR4 and microglial HO‐1, not only affects cognitive dysfunction, but also circadian dysrhythmia in a mouse model of SAH. To attempt to translate these findings, we have also begun investigating macrophages in the cerebrospinal fluid of SAH patients. The goal of this review is to provide an update on the role of TLR4, HO‐1, and other signal transduction pathways in SAH‐induced neuroinflammation.

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Diagnosing Delayed Cerebral Ischemia With Different CT Modalities in Patients With Subarachnoid Hemorrhage With Clinical Deterioration

Cited by 107 publications

References 19 publications

Early whole-brain CT perfusion for detection of patients at risk for delayed cerebral ischemia after subarachnoid hemorrhage

Early whole-brain CT perfusion for detection of patients at risk for delayed cerebral ischemia after subarachnoid hemorrhage

Evaluating the diagnostic accuracy of CT perfusion in patients with cerebral vasospasm after aneurysm rupture: a meta-analysis

The role of TLR4 and HO‐1 in neuroinflammation after subarachnoid hemorrhage

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