Brain Injury Visible on Early MRI After Subarachnoid Hemorrhage Might Predict Neurological Impairment and Functional Outcome
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In subarachnoid hemorrhage (SAH), brain injury visible within 48 h of onset may impact on admission neurological disability and 3-month functional outcome. With volumetric MRI, we measured the volume of brain injury visible after SAH, and assessed the association with admission clinical grade and 3-month functional outcome.
Retrospective cohort study conducted in the Neurocritical Care Division, Columbia University Medical Center, New York, USA. On brain MRI acquired within 48 h of SAH-onset and before aneurysm-securing (n = 27), two blinded readers measured DWI and FLAIR-lesion volumes using semi-automated, computer segmentation software.
Compared to post-resuscitation Hunt–Hess grade 1–3 (70 %), high-grade patients (30 %) had higher lesion volumes on DWI (34 ml [IQR: 0–64] vs. 2 ml [IQR: 0.5–7], P = 0.02) and on FLAIR (81 ml [IQR: 24–127] vs. 3 ml [IQR: 0–27], P = 0.02). On DWI, each 10 ml increase in lesion volume was associated with a 101 %-increase in the odds of presenting with 1 grade more in the Hunt–Hess scale (aOR 2.01, 95 % CI 1.10–3.68, P = 0.02), but was not significantly associated with 3-month outcome. On FLAIR, each 10 ml increase in lesion volume was associated with 34 % higher odds of a 1-point increase on the Hunt–Hess scale (aOR 1.34, 95 % CI 1.06–1.68, P = 0.01) and 139 % higher odds of a 1-point increase on the 3-month mRS (aOR 2.39, 95 % CI 1.13–5.07, P = 0.02).
The volume of brain injury visible on DWI and FLAIR within 48 h after SAH is proportional to neurological impairment on admission. Moreover, FLAIR-imaging implicates chronic brain injury—predating SAH—as potentially relevant cause of poor functional outcome.
KeywordsSubarachnoid hemorrhage Brain injury MRI Biomarker Neurological disability Outcome
Gian Marco De Marchis was supported by the following Grants: Career Development Grant for junior investigators (PBBEP3_139388) by the Swiss National Science Foundation; Swisslife Jubiläumsstiftung for Medical Research; Swiss Neurological Society; Fondazione Dr. Ettore Balli (Switzerland); peer reviewed De Quervain research Grant for young clinical investigators of the Clinical Trial Unit, University of Bern (Switzerland).
Conflict of interest
Christopher G. Filippi, Xiaotao Guo, Deborah Pugin, Christopher D. Gaffney, Neha S. Dangayach, Sureerat Suwatcharangkoon, M. Cristina Falo, Michael Schmidt, Sachin Agarwal, E. Sander Connolly Jr., Jan Claassen, Binsheng Zhao, Stephan A. Mayer declare that they have no conflict of interest.
Video: Example of Computed Aided Volumetry (CAV). On an axial slice of DWI, the reader is manually contouring a region of injured brain in the bilateral, parasagittal region of the frontal and parietal lobes. In a second step, the CAV software automatically localizes the boundaries of injured brain within the contoured region, excluding the surrounding non-injured brain. After contouring all injured brain regions on all slices, the software computes the total volume of injured brain. The video file format is mp4. (MP4 1,673 kb)