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Blood-brain barrier permeability imaging as a predictor for delayed cerebral ischaemia following subarachnoid haemorrhage. A narrative review

  • Review Article - Vascular Neurosurgery - Aneurysm
  • Published:
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Abstract

Background

Aneurysmal subarachnoid haemorrhage is associated with significant morbidity and mortality due to the myriad of complications contributing to early brain injury and delayed cerebral ischaemia. There is increasing interest in the exploration of the association between blood-brain barrier integrity and risks of delayed cerebral ischaemia and poor outcomes. Despite recent advances in cerebral imaging, radiographic imaging of blood-brain barrier disruption, as a biomarker for outcome prediction, has not been adopted in clinical practice.

Methods

We performed a narrative review by searching for articles describing molecular changes or radiological identification of changes in BBB permeability following subarachnoid haemorrhage (SAH) on MEDLINE. Preclinical studies were analysed if reported structural changes and clinical studies were included if they investigated for radiological markers of BBB disruption and its correlation with delayed cerebral ischaemia.

Results

There is ample preclinical evidence to suggest that there are structural changes in BBB permeability following SAH. The available clinical literature has demonstrated correlations between permeability imaging and outcomes following aneurysmal subarachnoid haemorrhage (aSAH).

Conclusion

Radiological biomarkers offer a potential non-invasive prognostication tool and may also allow early identifications of patients who may be at risk of DCI.

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Authors and Affiliations

  1. National Center for Neurosurgery, Beaumont Hospital, Dublin 9, Ireland

    Michael Amoo & Mohsen Javadpour

  2. Royal College of Surgeons in Ireland, Dublin, Ireland

    Michael Amoo, Niall Pender, Paul Brennan & Mohsen Javadpour

  3. School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland

    Jack Henry

  4. Department of Clinical Neuropsychology, Beaumont Hospital, Dublin 9, Ireland

    Niall Pender

  5. Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland

    Niall Pender & Mohsen Javadpour

  6. Department of Radiology, Beaumont Hospital, Dublin 9, Ireland

    Paul Brennan

  7. Department of Genetics, Trinity College Dublin, Dublin, Ireland

    Matthew Campbell

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  1. Michael Amoo
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Correspondence to Michael Amoo.

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Comments

The authors claim that the manuscript is a narrative review on the hypothesis that clinical imaging of the blood-brain barrier permeability may serve as a predictor for delayed cerebral ischaemia following subarachnoid haemorrhage.

They state that there has been limited use of BBB imaging in clinical practice for the prediction and prognostication of DCI following aSAH. Accordingly, they discuss some of the mechanisms involved in BBB disruption following aSAH and the potential role of BBB integrity imaging in prediction of DCI and outcome prognostication following aSAH.

The concept that detection of focal BBB damage following aneurysmal subarachnoid haemorrhage in the acute phase of the disease as shown by abnormal contrast enhancement may be an early indicator/biomarker of development of delayed vasospasm/focal DCI is rather old. The authors rightly point out that DCI, however, has now been shown to occur independent of cerebral vasospasm, i.e. the pathogenesis of DCI may not be fully a result of pathological vasoconstriction.

The authors performed an anecdotical search in the English literature looking for papers dealing with disruptions to the blood-brain barrier in SAH; BBB permeability imaging as a predictor of DCI. Based on their critical reading experiences, they conclude that there is sufficient evidence from preclinical and clinical studies to suggest that alterations to the permeability of the BBB play a crucial role in the complex pathophysiology of DCI following SAH.

Radiological biomarkers offer a potential non-invasive prognostication tool and may also allow early identifications of patients who may be at risk of DCI.

With the recent advances in permeability imaging, it is imperative that potential associations between BBB disruption and early and delayed brain injuries are investigated in patients with aSAH.

Tamas Peter Doczi

Pecs, Hungary

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This article is part of the Topical Collection on Vascular Neurosurgery – Aneurysm

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Amoo, M., Henry, J., Pender, N. et al. Blood-brain barrier permeability imaging as a predictor for delayed cerebral ischaemia following subarachnoid haemorrhage. A narrative review. Acta Neurochir 163, 1457–1467 (2021). https://doi.org/10.1007/s00701-020-04670-6

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