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CTP for the Screening of Vasospasm and Delayed Cerebral Ischemia in Aneurysmal SAH: A Systematic Review and
Amer Mitchelle1,2, Vineet V Gorolay3,4, Matthew Aitken5
1From the Department of Radiology (A.M., Y.R.H., I.T., M.V.C.), Concord Repatriation and General Hospital, Sydney, Australia amer@nhs.net.au.
Insights
This review found CT Perfusion (CTP) has over 80% sensitivity and 75% specificity for detecting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (SAH). CTP showed higher accuracy for vasospasm detection, suggesting its potential clinical utility.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Delayed cerebral ischemia and vasospasm are major causes of morbidity after aneurysmal subarachnoid hemorrhage (SAH).
- Diagnosis of these conditions is challenging, necessitating improved diagnostic tools.
Purpose of the Study:
- To systematically review and meta-analyze the diagnostic performance of CT Perfusion (CTP) for detecting delayed cerebral ischemia and vasospasm in patients with aneurysmal SAH.
Main Methods:
- A comprehensive literature search was conducted across multiple databases up to September 2023.
- Thirty studies involving 1786 patients and 2302 CTP scans were included.
- Bivariate random effects models were used to pool sensitivity, specificity, and likelihood ratios; QUADAS-2 tool assessed bias.
Main Results:
- For delayed cerebral ischemia, CTP showed pooled sensitivity of 82.1% and specificity of 79.6%.
- For vasospasm, CTP demonstrated higher pooled sensitivity of 85.6% and specificity of 87.9%.
- Negative likelihood ratios were low for both conditions (0.23 for ischemia, 0.16 for vasospasm).
Conclusions:
- CTP exhibits promising diagnostic accuracy for delayed cerebral ischemia and vasospasm following aneurysmal SAH.
- While CTP shows potential for clinical use, standardization of techniques and further high-quality trials are needed.
- Risk of bias varied across included studies, with 7 identified as high risk.
Background:
Delayed cerebral ischemia and vasospasm are the most common causes of late morbidity following aneurysmal SAH, but their diagnosis remains challenging.
Purpose:
This systematic review and meta-analysis investigated the diagnostic performance of CTP for detection of delayed cerebral ischemia and vasospasm in the setting of aneurysmal SAH.
Data Sources:
Studies evaluating the diagnostic performance of CTP in the setting of aneurysmal SAH were searched on the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Clinical Answers, Cochrane Methodology Register, Ovid MEDLINE, EMBASE, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, Health Technology Assessment, National Health Service Economic Evaluation Database, PubMed, and Google Scholar from their inception to September 2023.
Study Selection:
Thirty studies were included, encompassing 1786 patients with aneurysmal SAH and 2302 CTP studies. Studies were included if they compared the diagnostic accuracy of CTP with a reference standard (clinical or radiologic delayed cerebral ischemia, angiographic spasm) for the detection of delayed cerebral ischemia or vasospasm in patients with aneurysmal SAH. The primary outcome was accuracy for the detection of delayed cerebral ischemia or vasospasm.
Data Analysis:
Bivariate random effects models were used to pool outcomes for sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. Subgroup analyses for individual CTP parameters and early-versus-late study timing were performed. Bias and applicability were assessed using the modified QUADAS-2 tool.
Data Synthesis:
For assessment of delayed cerebral ischemia, CTP demonstrated a pooled sensitivity of 82.1% (95% CI, 74.5%-87.8%), specificity of 79.6% (95% CI, 73.0%-84.9%), positive likelihood ratio of 4.01 (95% CI, 2.94-5.47), and negative likelihood ratio of 0.23 (95% CI, 0.12-0.33). For assessment of vasospasm, CTP showed a pooled sensitivity of 85.6% (95% CI, 74.2%-92.5%), specificity of 87.9% (95% CI, 79.2%-93.3%), positive likelihood ratio of 7.10 (95% CI, 3.87-13.04), and negative likelihood ratio of 0.16 (95% CI, 0.09-0.31).
Limitations:
QUADAS-2 assessment identified 12 articles with low risk, 11 with moderate risk, and 7 with a high risk of bias.
Conclusions:
For delayed cerebral ischemia, CTP had a sensitivity of >80%, specificity of >75%, and a low negative likelihood ratio of 0.23. CTP had better performance for the detection of vasospasm, with sensitivity and specificity of >85% and a low negative likelihood ratio of 0.16. Although the accuracy offers the potential for CTP to be used in limited clinical contexts, standardization of CTP techniques and high-quality randomized trials evaluating its impact are required.
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