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CT perfusion during delayed cerebral ischemia after subarachnoid hemorrhage: distinction between reversible ischemia
Charlotte H P Cremers1,2, Pieter C Vos3, Irene C van der Schaaf4
1Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, Utrecht, The Netherlands. C.H.P.Cremers-2@umcutrecht.nl.
Insights
CT perfusion (CTP) can help differentiate between reversible delayed cerebral ischemia (DCI) and infarction after aneurysmal subarachnoid hemorrhage (aSAH). Qualitative CTP assessment showed higher accuracy than quantitative measures in predicting infarction.
Area of Science:
- Neurology
- Radiology
- Neurosurgery
Background:
- Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) presents a critical clinical challenge, with potential for reversible ischemia or progression to irreversible cerebral infarction.
- Early identification of DCI progression is crucial for timely intervention and improved patient outcomes.
Purpose of the Study:
- To investigate the utility of CT perfusion (CTP) in distinguishing between reversible DCI and DCI progressing to cerebral infarction in aSAH patients.
- To compare the diagnostic performance of qualitative (visual) and quantitative CTP analyses for predicting infarction.
Main Methods:
- A prospective cohort of aSAH patients with clinically diagnosed DCI, undergoing CTP at the time of deterioration and subsequent follow-up imaging, were included.
- Qualitative CTP analysis assessed the presence of perfusion deficits, calculating positive predictive value (PPV) and negative predictive value (NPV) for infarction.
- Quantitative CTP analysis compared perfusion values, determining a threshold for cerebral blood flow (CBF) and its PPV/NPV for infarction.
Main Results:
- In qualitative analysis (33 patients), a perfusion deficit was present in 88% of patients who developed infarction versus 38% without infarction (p=0.002).
- Qualitative assessment yielded a PPV of 71% and NPV of 83% for predicting infarction.
- Quantitative analysis identified a CBF threshold of 17.7 mL/100 g/min with a PPV of 63% and NPV of 78% for infarction.
Conclusions:
- CTP demonstrates potential in differentiating DCI patients who will develop infarction from those who will not.
- Qualitative CTP evaluation appears to offer marginally superior performance compared to quantitative analysis for this distinction.
Introduction:
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) can be reversible or progress to cerebral infarction. In patients with a deterioration clinically diagnosed as DCI, we investigated whether CT perfusion (CTP) can distinguish between reversible ischemia and ischemia progressing to cerebral infarction.
Methods:
From a prospectively collected series of aSAH patients, we included those with DCI, CTP on the day of clinical deterioration, and follow-up imaging. In qualitative CTP analyses (visual assessment), we calculated positive and negative predictive value (PPV and NPV) with 95% confidence intervals (95%CI) of a perfusion deficit for infarction on follow-up imaging. In quantitative analyses, we compared perfusion values of the least perfused brain tissue between patients with and without infarction by using receiver-operator characteristic curves and calculated a threshold value with PPV and NPV for the perfusion parameter with the highest area under the curve.
Results:
In qualitative analyses of 33 included patients, 15 of 17 patients (88%) with and 6 of 16 patients (38%) without infarction on follow-up imaging had a perfusion deficit during clinical deterioration (p = 0.002). Presence of a perfusion deficit had a PPV of 71% (95%CI: 48-89%) and NPV of 83% (95%CI: 52-98%) for infarction on follow-up. Quantitative analyses showed that an absolute minimal cerebral blood flow (CBF) threshold of 17.7 mL/100 g/min had a PPV of 63% (95%CI: 41-81%) and a NPV of 78% (95%CI: 40-97%) for infarction.
Conclusions:
CTP may differ between patients with DCI who develop infarction and those who do not. For this purpose, qualitative evaluation may perform marginally better than quantitative evaluation.
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