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The value of perfusion computed tomography in predicting clinically relevant vasospasm in patients with aneurysmal subarachnoid hemorrhage

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Abstract

Delayed cerebral ischemia remains a severe potential complication of aneurysmal subarachnoid hemorrhage (SAH) possibly leading to death and disability. We evaluated a semiquantitative and visual analysis of perfusion computed tomography (PCT) as a predictor of clinically relevant vasospasm (CRV) in patients with aneurysmal SAH. Thirty-eight patients with aneurysmal SAH were analyzed yielding 145 PCT scans. PCT, clinical examination, and transcranial Doppler ultrasound (TCD) were performed on days 3, 7, 10, and 14 after hemorrhage. Cerebral blood flow, cerebral blood volume, and time to peak (TTP) were analyzed semiquantitatively using six regions of interest, and visually for signs of cerebral hypoperfusion. CRV was defined as secondary cerebral infarction (CI) seen on cranial computed tomography scans and/or delayed neurological deterioration (DND). CI occurred in 13 (34.2 %) and DND in 11 patients (28.9 %). With TCD as pretest, TTP had a sensitivity of 90 % and a specificity of 72 % (cutoff value, 0.963) as predictor for CI. TTP’s sensitivity as predictor for DND was 90 % with a specificity of 61.1 % (cutoff value, 0.983). Visual analysis of TTP showed a negative predictive value of 100 % with a positive predictive value of 52 %. TTP is a sensitive and specific perfusion parameter in predicting CI in patients with SAH. Its use in the clinical setting may optimize the early treatment of patients at risk for vasospasm before the onset of clinical deterioration, especially when applying TCD as pretest. Further investigation in a larger patient population is required.

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Acknowledgments

We thank A. Bleiss and E. Radloff for their generous help and technical support in performing the transcranial Doppler ultrasound as well as M. Matthes for his generous help in formatting the artwork. We also very much appreciate Dr. C. Teo’s editorial assistance.

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Authors and Affiliations

  1. Department of Neurosurgery, Klinikum Stuttgart “Katharinenhospital”, Stuttgart, Baden-Württemberg, Germany

    Anne-Katrin Hickmann

  2. Department of Neuroradiology, Universitätsmedizin Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany

    Sönke Langner & Michael Kirsch

  3. Department of Neurosurgery, Universitätsmedizin Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany

    Jörg Baldauf, Cornelia Müller & Henry W. S. Schroeder

  4. Department of Neurology, Universitätsmedizin Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany

    Alexander Khaw

  5. Department of Neurosurgery, Klinikum Stuttgart, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany

    Anne-Katrin Hickmann

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  1. Anne-Katrin Hickmann
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  2. Sönke Langner
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Kazuya Kanemaru, Hiroyuki Kinouchi, Yamanashi, Japan

The authors prospectively collected and analyzed a total of 145 perfusion computed tomography (PCT) data from 38 patients with aneurysmal subarachnoid hemorrhage (SAH). This is one of the largest reports in this topic, and the authors made a detailed assessment of PCT as a predictor of clinically relevant vasospasm (CRV). PCT and transcranial Doppler ultrasound (TCD) were performed on days 3, 7, 10 and 14 after SAH. Time to peak (TTP), cerebral blood flow (CBF), and cerebral blood volume (CBV) were analyzed semiquantitatively using only simple six regions of interest (ROIs), and visually by an experienced neuroradiologist. In this cohort, cerebral infarction (CI) occurred in 13 (34.2 %) and delayed neurological deterioration (DND) in 11 (28.9 %) patients.

This study provides clinical benefits in the prediction of CRV. First, the authors simplified PCT examination by decreasing the number of ROIs (only six ROIs were employed) using simple true circle-shaped ROIs, employing semiquantitative evaluation instead of quantitative analysis, which minimize variability due to age, gender, and CT settings; furthermore, they adopted visual analysis which can save time for analysis without losing the predictive value of the PCT. Second, detailed evaluation showed that the mean TTP ratio in ROI 2 (middle cerebral artery territory) on day 7 was significantly greater in patients with secondary CI than without CI. This result was in accordance with previous reports and reinforced that TTP is the most reliable parameter in predicting CRV. Third, a combination of PCT and TCD gives further high predictive value. Mean TTP ratio in ROI 2 on day 7 combined with more than 50 cm/s increase of peak systolic velocity in the middle cerebral artery by TCD exhibited highest sensitivity of 90 % and specificity of 72 %. And TCD could serve as a pretest to reduce the number of PCT examinations.

The authors’ approach could possibly allow optimizing the intensity of the care. For example, the application and duration of prophylactic treatment of CRV in the intensive care unit can be adjusted on the basis of PCT. Further study of PCT determining whether PCT can improve clinical results or reduce medical care cost will be of great interest.

Veit Rohde, Göttingen, Germany

The authors aimed to predict clinically relevant vasospasm by perfusion computed tomography (PCT). The measured parameters in regions of interest in both cerebral hemispheres were time to peak (TTP), cerebral blood flow (CBF), and cerebral blood volume (CBV). On day 3, 7, 10, and 14, PCT was obtained. On the same day, TCD and clinical examination were performed. The study population consisted of 38 patients.

Cerebral infarction was found in 34.2 % of the patients. These patients had greater interhemispheric TTP differences than the patients without infarction. The TTP was considered to be a predictor of infarction. In 53.8 %, the TTP difference preceded the stroke. A delayed ischemic neurological deficit (DIND) developed in 28.9 % of the patients and progressed to stroke in half of this population. Again, interhemispheric TTP differences were higher in patients with DIND. In only one patient, TTP differences were detected before DIND. In both groups, CBV and CBF were not significantly different in both hemispheres.

Many attempts had been made to identify patients at risk to develop symptomatic vasospasm. Initiation of antivasospastic therapy (from mere elevation of blood pressure to endovascular procedures) in the symptomatic vasospasm candidates before progression to completed stroke was the underlying idea in earlier and, I guess, in this study. In this respect, the study unfortunately is not very helpful due to its immature study design with parallel clinical, transcranial Doppler sonographic (TCD), and PCT studies. Such a design only allows to correlate PCT parameters with cerebral infarctions and DIND, but not to answer the question if PCT could be a tool to avoid these ischemic events by timely start of antivasospastic therapy.

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Hickmann, AK., Langner, S., Kirsch, M. et al. The value of perfusion computed tomography in predicting clinically relevant vasospasm in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 36, 267–278 (2013). https://doi.org/10.1007/s10143-012-0430-1

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