Volumetric analysis of intracranial vessels: a novel tool for evaluation of cerebral vasospasm
- 48 Downloads
Together with other diagnostic modalities, computed tomography angiography (CTA) is commonly used to indicate endovascular vasospasm treatment after subarachnoid hemorrhage (SAH), despite the fact that objective, user-independent parameters for evaluation of CTA are lacking. This exploratory study was designed to investigate whether quantification of vasospasm by automated volumetric analysis of the middle cerebral artery M1 segment from CTA data could be used as an objective parameter to indicate endovascular vasospasm treatment.
We retrospectively identified SAH patients who underwent transcranial Doppler sonography (TCD), CTA, and CT perfusion (CTP), with or without subsequent endovascular treatment. We determined vessel volume/vessel length of the M1 segments from CTA data and used receiver operating characteristic curve analysis to determine the optimal threshold of vessel volume to predict vasospasm requiring endovascular treatment. In addition, blinded investigators independently analyzed TCD, CTA, and CTP data.
Of 45 CTA examinations with corresponding CTP and TCD examinations (24 SAH patients), nine indicated the need for endovascular vasospasm treatment during examination. In our patients, vessel volume < 5.8 µL/mm was moderately sensitive but fairly specific to detect vasospasm requiring endovascular treatment (sensitivity, 67%; specificity, 78%; negative predictive value (NPV), 89%; positive predictive value (PPV), 46%). For CTA, CTP, and TCD, we found NPVs of 96%, 92%, and 89%, PPVs of 40%, 35%, and 35%, sensitivities of 89%, 78%, and 67%, and specificities of 67%, 64%, and 69%, respectively.
Vessel volumes could provide a new objective parameter for the interpretation of CTA data and could thereby improve multimodal assessment of vasospasm in SAH patients.
KeywordsDelayed cerebral ischemia Posthemorrhagic cerebral vasospasm Subarachnoid hemorrhage Transcranial Doppler sonography Computed tomography angiography Computed tomography perfusion imaging
Parts of this study are part of the doctoral thesis of T. Pantel, presented to the Medical Faculty of the Johannes Gutenberg University of Mainz. The study was supported by a grant of the Medical Center of the Johannes Gutenberg University Mainz (Stufe I Foerderung, grant to A.N.). The funder had no role in the design or conduct of this research.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no competing interests.
- 2.Vergouwen MD, Vermeulen M, van Gijn J, Rinkel GJ, Wijdicks EF, Muizelaar JP, Mendelow AD, Juvela S, Yonas H, Terbrugge KG, Macdonald RL, Diringer MN, Broderick JP, Dreier JP, Roos YB (2010) Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group. Stroke 41(10):2391–2395. https://doi.org/10.1161/STROKEAHA.110.589275 CrossRefPubMedGoogle Scholar
- 6.Diringer MN, Bleck TP, Claude Hemphill J 3rd, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES Jr, Citerio G, Gress D, Hanggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MD, Wolf S, Zipfel G, Neurocritical Care S (2011) Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care 15(2):211–240. https://doi.org/10.1007/s12028-011-9605-9 CrossRefPubMedGoogle Scholar
- 7.Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P, American Heart Association Stroke Council, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Nursing, Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology (2012) Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 43(6):1711–1737. https://doi.org/10.1161/STR.0b013e3182587839 CrossRefPubMedGoogle Scholar
- 9.Westermaier T, Pham M, Stetter C, Willner N, Solymosi L, Ernestus RI, Vince GH, Kunze E (2014) Value of transcranial Doppler, perfusion-CT and neurological evaluation to forecast secondary ischemia after aneurysmal SAH. Neurocrit Care 20(3):406–412. https://doi.org/10.1007/s12028-013-9896-0 CrossRefPubMedGoogle Scholar
- 11.Chaudhary SR, Ko N, Dillon WP, Yu MB, Liu S, Criqui GI, Higashida RT, Smith WS, Wintermark M (2008) Prospective evaluation of multidetector-row CT angiography for the diagnosis of vasospasm following subarachnoid hemorrhage: a comparison with digital subtraction angiography. Cerebrovasc Dis 25(1–2):144–150. https://doi.org/10.1159/000112325 CrossRefPubMedGoogle Scholar
- 15.Neulen A, Pantel T, Kosterhon M, Kirschner S, Brockmann MA, Kantelhardt SR, Giese A, Thal SC (2017) A segmentation-based volumetric approach to localize and quantify cerebral vasospasm based on tomographic imaging data. PLoS ONE 12(2):e0172010. https://doi.org/10.1371/journal.pone.0172010 CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Greke C, Neulen A, Kantelhardt SR, Birkenmayer A, Vollmer FC, Thiemann I, Giese A (2013) Image-guided transcranial Doppler sonography for monitoring of defined segments of intracranial arteries. J Neurosurg Anesthesiol 25(1):55–61. https://doi.org/10.1097/ANA.0b013e31826b3d55 CrossRefPubMedGoogle Scholar
- 22.Neulen A, Kosterhon M, Pantel T, Kirschner S, Goetz H, Brockmann MA, Kantelhardt SR, Thal SC (2018) A volumetric method for quantification of cerebral vasospasm in a murine model of subarachnoid hemorrhage. J Vis Exp (Pending Publication) e57997 (In-press). https://doi.org/10.3791/57997
- 23.Wintermark M, Dillon WP, Smith WS, Lau BC, Chaudhary S, Liu S, Yu M, Fitch M, Chien JD, Higashida RT, Ko NU (2008) Visual grading system for vasospasm based on perfusion CT imaging: comparisons with conventional angiography and quantitative perfusion CT. Cerebrovasc Dis 26(2):163–170. https://doi.org/10.1159/000139664 CrossRefPubMedGoogle Scholar
- 25.Pickard JD, Murray GD, Illingworth R, Shaw MD, Teasdale GM, Foy PM, Humphrey PR, Lang DA, Nelson R, Richards P (1989) Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ 298(6674):636–642CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Dorhout Mees SM, Algra A, Vandertop WP, van Kooten F, Kuijsten HA, Boiten J, van Oostenbrugge RJ, Al-Shahi Salman R, Lavados PM, Rinkel GJ, van den Bergh WM, Group M-S (2012) Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebo-controlled trial. Lancet 380(9836):44–49. https://doi.org/10.1016/s0140-6736(12)60724-7 CrossRefPubMedGoogle Scholar
- 31.Aburto-Murrieta Y, Marquez-Romero JM, Bonifacio-Delgadillo D, Lopez I, Hernandez-Curiel B (2012) Endovascular treatment: balloon angioplasty versus nimodipine intra-arterial for medically refractory cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Vasc Endovasc Surg 46(6):460–465. https://doi.org/10.1177/1538574412454585 CrossRefGoogle Scholar